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Abstracts

Vitamin D: 266 Research Abstracts

134. Endocrinology. 1999 Oct;140(10):4779-88.

Vitamin D analogs, 20-Epi-22-oxa-24a,26a,27a,-trihomo-1alpha,25(OH)2-vitamin D3, 1,24(OH)2-22-ene-24-cyclopropyl-vitamin D3 and 1alpha,25(OH)2-lumisterol3 prime NB4 leukemia cells for monocytic differentiation via nongenomic signaling pathways, involving calcium and calpain.

Berry DM, Meckling-Gill KA.

Department of Human Biology and Nutritional Sciences, University of Guelph, Ontario, Canada.

Side-chain modified vitamin D analogs including 20-Epi-22-oxa-24a,26a,27a-trihomo-1alpha,2 5-dihydroxyvitamin D3 (KH1060), and 1,24-dihydroxy-22-ene-24-cyclopropyl-vitamin D3 (MC903) were originally designed to aid in the treatment of hyperproliferative disorders including psoriasis and cancer. Here we demonstrate that these analogs, as well as the 6-cis-locked conformer, 1alpha,25-dihydroxy-lumisterol3 (JN) prime NB4 cells for monocytic differentiation. Previously, the action of MC903 and KH1060 was presumed to be mediated by the nuclear vitamin D receptor (VDRnuc). Differentiation in response to all analogs was shown to be inhibited by 1beta,25-dihydroxyvitamin D3 (HL), the antagonist to the nongenomic activities of 1,25D3. These data suggest that although MC903 and KH1060 may bind the VDRnuc, that the differentiative activities of these agents requires nongenomic signaling pathways. Here we show that 1alpha,25(OH)2-d5-previtamin D3 (HF), JN, KH1060, and MC903 induce expression of PKC alpha and PKC delta and translocation of both isoforms to the particulate fraction, and PKC alpha to the nuclear fraction. The full differentiation response with combinations of analogs and TPA was inhibited 50% by the membrane permeable Ca2+ chelator, 1,2-bis(o-aminophenoxy)-ethane-N,N,N',N'-tetraacetic acid (BAPTA-AM) or calpain inhibitor I. These data demonstrate that intracellular free calcium and the calcium-dependent protease, calpain play critical roles in monocytic differentiation. Intracellular calcium appears to be most critical in the 1,25D3-priming stage of differentiation, while calpain is essential in the TPA maturation response.

135. Gen Pharmacol. 1999 Jan;32(1):143-54.

Leukemia cell differentiation: cellular and molecular interactions of retinoids and vitamin D.

James SY, Williams MA, Newland AC, Colston KW.

Division of Gastroenterology, Endocrinology, and Metabolism, St. George's Hospital Medical School, London.

1. The conventional approach to treatment of acute myeloid leukemia has been the use of chemotherapy, which although being cytotoxic to malignant clones, is also cytodestructive to normal cells. In addition, some leukemia cells develop resistance to chemotherapy and are therefore difficult to eradicate. 2. Differentiation therapy, whereby immature cells are induced to attain a mature phenotype by differentiation agents, has provided an alternative strategy in the treatment of hyperproliferative disorders. This has been highlighted by the use of all-trans retinoic acid (ATRA) in the treatment of acute promyelocytic leukemia (APL). 3. Another differentiation agent, 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), directs monocytic maturation of normal and leukemic cells. Cellular studies have revealed that combinations of vitamin D derivatives and retinoids such as ATRA and 9-cis retinoic acid (9-cis RA) exhibit cooperative effects on differentiation in established leukemia cell lines such as HL-60, U937, and NB4. Furthermore, vitamin D compounds, although not able to induce apoptosis when used alone, potentiate apoptosis induced by 9-cis RA in HL-60 cells and differentially regulate the expression of the apoptosis-related gene products bcl-2 and bax. The molecular mechanisms involved in regulating differentiation and apoptosis by these agents are mediated through the interactions of the nuclear receptors for vitamin D (VDR), ATRA (RAR), and 9-cis RA (RXR), which are able to form homo- or heterodimeric complexes and transcriptionally activate or repress target gene expression. 4. There is evidence to suggest that nitric oxide may also play a role in leukemic cell differentiation and that 1,25(OH)2D3 may influence endogenous nitric oxide production either by directly increasing tumor necrosis factor-alpha (TNF-alpha) or through a secondary mediator such as the C-type lectin CD23.

136. Leuk Lymphoma. 1998 Oct;31(3-4):279-84.

Vitamin D analogs, leukemia and WAF1.

Munker R, Zhang W, Elstner E, Koeffler HP.

Medizinische Klinik III der LMU (Klinikum Grosshadern) Munich, Germany. munker@gsf.de

Vitamin D compounds induce differentiation of human leukemic cells and have potential for the treatment of leukemia. In this review we summarize some of the basic mechanisms underlying the action of vitamin D compounds. A variety of vitamin D analogues were synthesized until now, some of which have enhanced antileukemic activity and a decreased propensity to cause hypercalcemia. Most actions of vitamin D compounds are mediated by nuclear receptors. In vivo, vitamin D binding protein interacts with free vitamin D compounds. Both in normal and leukemic cells, vitamin D compounds cause a differentiation to monocytes and macrophages. A variety of genes are regulated by vitamin D compounds. Recently, the cell cycle inhibitory gene p21/WAF-1/CIP-1 was characterized. The expression de novo of WAF-1 in blasts of acute myelogenous leukemia is an independent factor of unfavorable prognosis. In HL-60 leukemic cells treated with vitamin D analogs, WAF-1 can be induced by nano- or picomolar concentrations of vitamin D analogs and correlates with the induction of a differentiated phenotype. When vitamin D analogs are combined in-vitro with retinoids, an irreversible differentiation is observed. Clinical trials of vitamin D analogs are indicated in the situation of minimal residual disease and in combination with standard chemotherapy.

137. Blood. 1998 Oct 1;92(7):2441-9.

19-nor vitamin-D analogs: a new class of potent inhibitors of proliferation and inducers of differentiation of human myeloid leukemia cell lines.

Asou H, Koike M, Elstner E, Cambell M, Le J, Uskokovic MR, Kamada N, Koeffler HP.

Division of Hematology/Oncology, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA 90048, USA.

We have studied the in vitro biological activities and mechanisms of action of 1,25-dihydroxyvitamin D3 (1,25D3) and nine potent 1,25D3 analogs on proliferation and differentiation of myeloid leukemia cell lines (HL-60, retinoic acid-resistant HL-60 [RA-res HL-60], NB4 and Kasumi-1). The common novel structural motiff for almost all the analogs included removal of C-19 (19-nor); each also had unsaturation of the side chain. All the compounds were potent; for example, the concentration of analogs producing a 50% clonal inhibition (ED50) ranged between 1 x 10(-9) to 4 x 10(-11) mol/L when using the HL-60 cell line. The most active compound [1, 25(OH)2-16,23E-diene-26-trifluoro-19-nor-cholecalciferol (Ro 25-9716)] had an ED50 of 4 x 10(-11) mol/L; in contrast, the 1,25D3 produced an ED50 of 10(-9) mol/L with the HL-60 target cells. Ro 25-9716 (10(-9) mol/L, 3 days) was a strong inducer of myeloid differentiation because it caused 92% of the HL-60 cells to express CD11b and 75% of these cells to reduce nitroblue tetrazolium (NBT). This compound (10(-8) mol/L, 4 days) also caused HL-60 cells to arrest in the G1 phase of the cell cycle (88% cells in G1 v 48% of the untreated control cells). The p27(kip-1), a cyclin-dependent kinase inhibitor which is important in blocking the cell cycle, was induced more quickly and potently by Ro 25-9716 (10(-7) mol/L, 0 to 5 days) than by 1,25D3, suggesting a possible mechanism by which these analogs inhibit proliferation of leukemic growth. The NB4 promyelocytic leukemia cells cultured with the Ro 25-9716 were also inhibited in their clonal proliferation (ED50, 5 x 10(-11) mol/L) and their expression of CD11b was enhanced (80% positive [10(-9) mol/L, 4 days] v 27% untreated NB4 cells). Moreover, the combination of Ro 25-9716 (10(-9) mol/L) and all-trans retinoic acid (ATRA, 10(-7) mol/L) induced 92% of the NB4 cells to reduce NBT, whereas only 26% of the cells became NBT positive after a similar exposure to the combination of 1,25D3 and ATRA. Surprisingly, Ro 25-9716 also inhibited the clonal growth of poorly differentiated leukemia cell lines (RA-res HL-60 [ED50, 4 x 10(-9) mol/L] and Kasumi-1 [ED50, 5 x 10(-10) mol/L]). For HL-60 cells, Ro 25-9716 markedly decreased the percent of the cells in S phase of the cell cycle and increased the expression of the cyclin-dependent kinase inhibitor, p27(kip-1). In summary, 19-nor vitamin D3 compounds strongly induced differentiation and inhibited clonal proliferation of various myeloid leukemia cell lines, suggesting a therapeutic niche for their use in myeloid leukemia.

138. Leuk Res. 1997 Apr;21(4):321-6.

CB1093, a novel vitamin D analog; effects on differentiation and clonal growth on HL-60 and de novo leukemia cells.

Pakkala I, Savli H, Knuutila S, Binderup L, Pakkala S.

Transplantation Laboratory, University of Helsinki, and Helsinki University Central Hospital, Finland.

We studied the effects of a novel vitamin D analog CB1093, EB1089 (one of the most antileukemic analogs yet) and 1 alpha,25(OH)2D3 both on HL-60 cells and cells from 13 AML patients. Differentiation was measured both by induction of superoxide production and non-specific esterase. Cell proliferation was assessed by colony assay and 3H-thymidine incorporation. The effect on serum calcium was measured in rats. The CB1093 proved to be the most efficient of the analogs tested so far, both in inducing differentiation and in inhibiting proliferation. This, combined with its low hypercalcemic effect shown here, makes it a promising candidate for preclinical animal studies.

139. Blood. 1996 Sep 15;88(6):2201-9.

A new series of vitamin D analogs is highly active for clonal inhibition, differentiation, and induction of WAF1 in myeloid leukemia.

Munker R, Kobayashi T, Elstner E, Norman AW, Uskokovic M, Zhang W, Andreeff M, Koeffler HP.

Division of Hematology/Oncology, Cedars-Sinai Medical Center/UCLA School of Medicine 90048, USA.

The active form of vitamin D3 [1 alpha, 25-dihydroxyvitamin-D3 (1 alpha, 25(OH)2D3)] modulates the proliferation and differentiation of hematopoietic cells. Analogs of 1 alpha, 25(OH)2D3 that have greater potency may have the potential as adjuvant therapy for high-risk patients in remission for acute myelogenous leukemia (AML) and myelodysplastic syndromes. A new generation of 11 analogs of 1 alpha, 25(OH)2D3 has been synthesized, and we examined their effects on the human leukemic cell line HL-60. This cell line provides a sensitive monitor of activity of the 1 alpha, 25(OH)2D3 analogs. All the compounds were potent, producing a 50% clonal inhibition (ED50) in the range of 10(-8) to 10(-11) mol/L; nine of the 11 analogs had ED50s at concentrations that were at least 10-fold lower than those for the parental 1,25(OH)2D3. The most active compound [cmpd LA, (22R)-1 alpha, 25-(OH)2-16,22,23-triene-D3] had an ED50 of 2 x 10(-11) mol/L; it was also tested on clonogenic cells from patients with AML, and it achieved an ED50 of approximately 6 x 10(-11) mol/L, while 1 alpha, 25(OH)2D3 produced an ED50 of approximately 10(-8) mol/L on the same population of cells. Five different cell surface markers were examined on HL-60 cells exposed to the 1 alpha, 25(OH)2D3 analogs: HLA-DR and CD11b were induced by all of the compounds; CD13 was induced by six of the 12 compounds, including 1,25(OH)2D3; CD14 was strongly induced by all compounds; and CD38 was induced rather weakly by nine of 12 analogs. WAF1/CIP1/p21, a cyclin-dependent kinase inhibitor (CDKI), which is important in blocking the cell cycle, was examined by Western blot and was found to be induced by all of the compounds, suggesting a possible mechanism by which these analogs inhibit leukemic growth. The induction of WAF1 occurred at concentrations of vitamin D analogs as low as 10(-10) mol/L. This structure-function study showed that a new series of 1 alpha, 25(OH)2D3 analogs was active in clonal inhibition, as well as induction of differentiation and WAF1 expression of HL-60 cells. The key structural motifs included C-16 double bond, double and/or triple bonds in the side chain, lengthening of the side chain, 20-epi-conformation of the side chain, replacement of six hydrogens at the end of the side chain with fluorines, and the removal of C-19. Consideration should be given to further in vivo testing of toxicity and efficacy to move toward a clinical trial, especially in a setting of minimal residual disease.

140. Exp Cell Res. 1996 May 25;225(1):143-50.

Differential regulation of vitamin D receptors in clonal populations of a chronic myelogenous leukemia cell line.

Iwata K, Kouttab N, Ogata H, Morgan JW, Maizel AL, Lasky SR.

Roger Williams Medical Center, Experimental Pathology Section, Department of Pathology and Laboratory, Brown University School of Medicine, Providence, RI 02908, USA. stephen_lasky@brown.edu

RWLeu4 is a chronic myelogenous leukemia cell line that is sensitive to the antiproliferative and differentiation-inducing actions of 1alpha,25(OH)2-vitamin D3 (VD3). The JMRD3 cell line is a VD3-resistant variant of RWLeu4 that was selected by continuous passage of RWLeu4 in the presence of VD3. The isolation of a spontaneous VD3-resistant variant suggests that phenotypically different cells exist within the RWLeu4 cell population. Therefore, single-cell clones of RWLeu4 cells were isolated and characterized. Four clonal cell populations that fall into three groups differing in response to the antiproliferative and differentiation-inducing actions of VD3 were examined. Surprisingly, the extent of response of the clones to VD3 does not show a correlation with the basal level of the vitamin D receptor (VDR). RWLeu4-3 and RWLeu4-4 are the clones most sensitive to the antiproliferative actions of VD3 (ED50 approximately equal to 1 nM); however, RWLeu4-3 expresses basal levels of VDRs similar to those found in the parental cells and the RWLeu4-2 clone, while in RWLeu4-4, VD3 binding and VDR protein are below the limits of detection. Furthermore, RWLeu4-10 expresses the highest basal level of VDR protein but is relatively resistant to the antiproliferative actions of VD3 (ED50 > or = 30 nM). Like JMRD3, RWLeu4-10 is still capable of differentiating in response to VD3, as judged by the induction of biochemical processes and cell-surface antigen expression. Although VD3 treatment increases VDR protein levels and DNA-binding activity in all clones, altered DNA-protein complexes are detected in RWLeu4-4. Our results suggest that sensitivity to the antiproliferative and differentiation-inducing actions of VD3 is not dependent solely upon the level of VDR expressed, but may also require posttranslational modification of the VDR or complex interactions with other nuclear transcription factors.

141. Cancer Lett. 1995 Apr 14;90(2):225-30.

Induction of differentiation in murine erythroleukemia cells by 1 alpha,25-dihydroxy vitamin D3.

Radhika S, Choudhary SK, Garg LC, Dixit A.

Department of Zoology, University of Delhi, India.

The Friend murine erythroleukemia (MEL) cells can be stimulated to differentiate in response to a variety of chemical inducing agents. In the present study, the effect of 1 alpha,25-dihydroxyvitamin D3 on differentiation of MEL cells was investigated. Vitamin D3 induced differentiation of MEL cells in culture as determined by elevated hemoglobin content, a rise in the number of benzidine-positive cells and increase in acetylcholine esterase activity. The optimum concentration of the vitamin required to induce differentiation of MEL cells was found to be 750 nM. The pattern of induction of differentiation was similar to that observed with DMSO and the induction of differentiation by vitamin D3 was inhibited by dexamethasone.

142. Leuk Res. 1994 Jun;18(6):453-63.

1,25(OH)2-16ene-vitamin D3 is a potent antileukemic agent with low potential to cause hypercalcemia.

Jung SJ, Lee YY, Pakkala S, de Vos S, Elstner E, Norman AW, Green J, Uskokovic M, Koeffler HP.

Pusan Women's Junior College, Korea.

Compounds that induce cancer cells to differentiate are clinically effective for several types of malignancies. The 1,25-dihydroxyvitamin D3[1,25(OH)2D3(C)] induces leukemic cells, including HL-60, to differentiate and/or no longer proliferate, but it causes hypercalcemia. Development of vitamin D analogs that are more potent in their abilities to affect leukemic cells without causing greater hypercalcemia, may be useful therapeutically. A novel analog [1,25(OH)2-16ene-D3(HM)] has a double bond between C-16 and C-17; it appears to be an extremely effective antileukemic agent with the same or fewer effects on serum calciums. We define the potency of this compound and compare it with seven, previously reported, potent analogs of 1,25(OH)2D3. HM inhibited clonal growth of HL-60 cells by 50% at 1.5 x 10(-11) M. This was about equipotent to 1,25(OH)2-16ene-23yne-D3(V), about 100-fold more potent than many of the other analogs, and 1000-fold more potent than 1,25(OH)2D3. The rank order of leukemic inhibitory activity was: 1,25(OH)2-16ene-D3(HM) > or = 1,25(OH)2- 16ene-23yne-D3(V) > 1,25(OH)2-23ene-D3(EX) = 1,24(OH)2-22ene-24-cyclopropyl-D3(BT) = 22-oxa- 1,25(OH)2D3(EU) = 1,25(OH)2-24-homo-D3(ER) > 1,25(OH)2D3(C) > 1,25(OH)2-24- dihomo-D3(ES). The rank order of their effects on induction of differentiation of HL-60 cells, as measured by superoxide production and nonspecific esterase activity, was similar to their antiproliferative activities. In contrast, each analog slightly stimulated proliferation of normal human myeloid clonal growth. Serum calcium levels were the same or slightly less when either 1,25(OH)2-16ene-D3(HM) or 1,25(OH)2D3 (0.0625, 0.125, or 0.25 microgram) was given intraperitoneally to mice for 5 weeks. HM bound to 1,25(OH)2D3 receptors about 1.5-fold more avidly than 1,25(OH)2D3. In fact, this vitamin D3 appears to be the most avid binder to 1,25(OH)2D3 receptors that has been identified to date. In contrast, HM had a greater than 50-fold lower affinity for the D-binding proteins as compared with 1,25(OH)2D3, thus increasing the availability of the compound for target tissues. Further differentiation experiments showed that HM was more potent than 1,25(OH)2D3 in the presence of serum, but was equipotent in serum-free conditions. Taken together, our experiments suggest that 1,25(OH)2-16ene-D3(HM) may be more potent than 1,25(OH)2D3(C) because of its higher affinity to the 1,25(OH)2D3 receptors and its low affinity to the D-binding protein present in serum. HM is an ideal compound for clinical studies including patients with preleukemia and other neoplasia, as well as several skin disorders, such as psoriasis.

143. J Biol Chem. 1988 Nov 5;263(31):16039-44.

Ca2+ priming during vitamin D-induced monocytic differentiation of a human leukemia cell line.

Hruska KA, Bar-Shavit Z, Malone JD, Teitelbaum S.

Department of Medicine, Jewish Hospital, Washington University Medical Center, St. Louis, Missouri 63110.

1,25-Dihydroxyvitamin D3 (1,25-(OH)2D3) induces monocytic differentiation of the human promyelocytic leukemia line, HL-60, and enhances Ca2+ transport in target cells of the mineral metabolism system. Hence, we determined whether the steroid's maturational effect on HL-60 involves alterations of intracellular calcium [( Ca2+]i). We found that, as detected by indo-1 fluorescence, [Ca2+]i increases in a slow tonic manner from 99 +/- 11 nM in virgin HL-60 to 182 +/- 19 nM (p less than 0.001) in those treated with 1,25-(OH)2D3 for 24 h. The first apparent rise in [Ca2+]i occurs at between 6 and 12 h and parallels expression of alpha-thrombin and N-formyl-methionyl-leucyl-phenylalanine (fMLP) receptors. This increase in [Ca2+]i is derived from extracellular calcium as its reduction abolishes the effect. The increase in [Ca2+]i is associated with an increase in inositol trisphosphate-stimulated Ca2+ flux from intracellular stores. Interestingly, 1,25-(OH)2D3-mediated HL-60 differentiation as manifest by expression of the macrophage-specific antigen, 63D3, is not blocked by low extracellular calcium. In contrast, the fMLP-induced superoxide ion generation is diminished if the increase in [Ca2+]i is prevented. Furthermore, fMLP-stimulated signal transduction is also reduced by limiting the stimulation of [Ca2+]i during 1,25-(OH)2D3 treatment. Thus, although differentiation of HL-60 to the monocytic phenotype by 1,25-(OH)2D3 is Ca2+-independent, expression of response to regulatory stimuli requires priming of cellular Ca2+ stores. The latter appears to be induced by 1,25-(OH)2D3 via stimulated Ca2+ entry through the plasma membrane.

144. Arch Biochem Biophys. 1987 Nov 1;258(2):421-5.

Biological activity of fluorinated vitamin D analogs at C-26 and C-27 on human promyelocytic leukemia cells, HL-60.

Inaba M, Okuno S, Nishizawa Y, Yukioka K, Otani S, Matsui-Yuasa I, Morisawa S, DeLuca HF, Morii H.

Second Department of Internal Medicine, Osaka City University Medical School, Japan.

Vitamin D compounds added to the culture medium induce HL-60 cells to differentiate into macrophage/monocytes via a receptor mechanism. This system provides a biologically relevant assay for the study of biopotency of vitamin D analogs. Using this system, the biological activity of various fluorinated derivatives of vitamin D3 was compared with that of 1,25-dihydroxyvitamin D3 (1,25-(OH)2D3). As assessed by cell morphology, nitroblue tetrazolium reduction and nonspecific esterase activity, 26,26,26,27,27,27-hexafluoro-1,25-dihydroxyvitamin D3 (26,27-F6-1,25-(OH)2D3) and 26,26,26,27,27,27-hexafluoro-1,24-dihydroxyvitamin D3 (26,27-F6-1,24-(OH)2D3) were about 10 times as potent as 1,25-(OH)2D3 in suppressing HL-60 cell proliferation and inducing cell differentiation. The biological activity of 26,26,26,27,27,27-hexafluoro-1-hydroxyvitamin D3 (26,27-F6-1-OH-D3) was equal to that of 1,25-(OH)2D3 in this system. 1,25-(OH)2D3 and its fluorinated analogs exerted their effects on HL-60 cells in a dose-dependent manner. HL-60 cells have a specific receptor for 1,25-(OH)2D3 with an apparent Kd of 0.25 nM, identical with that of chick intestinal receptor. While the binding affinities of 26,27-F6-1,25-(OH)2D3 and 26,27-F6-1,24-(OH)2D3 for chick intestinal receptor were lower than that of 1,25-(OH)2D3 by factors of 3 and 1.5, respectively, they were as competent as 1,25-(OH)2D3 in binding to HL-60 cell receptor. The ability of 26,27-F6-1-OH-D3 to compete for receptor protein from HL-60 cells and chick intestine was about 1/70 that of 1,25-(OH)2D3. These results indicate that trifluorination of carbons 26 and 27 of vitamin D3 can markedly enhance the effect on HL-60 cells.

145. Endocrinology. 1986 Feb;118(2):679-86.

Reversibility of vitamin D-induced human leukemia cell-line maturation.

Bar-Shavit Z, Kahn AJ, Stone KR, Trial J, Hilliard T, Reitsma PH, Teitelbaum SL.

HL-60 cells are induced to differentiate along a monocytic pathway by the active metabolites of vitamin D3, e.g. 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3]. All such differentiated cells share a number of features in common but are heterogeneous in their ability to adhere to solid substrates and to resorb devitalized bone matrix. Here, we show that, in addition, as compared to the nonadherent, adherent cells are smaller, less likely to be in the S phase, more enriched in the human monocyte-specific cell surface antigen, 63D3, and contain less cmyc messenger RNA (mRNA). In addition, we document that removal of the hormone leads to dedifferentiation. For these susceptible mononuclear cells, removal of 1,25-(OH)2D3 results in a reversion to a more myeloblastic phenotype, renewed cell proliferation, and the rapid appearance of elevated levels of cmyc mRNA. Finally, we report that the cells that do not revert upon 1,25-(OH)2D3 removal are those that became multinucleated during treatment.

146. J Med Chem. 1985 Sep;28(9):1148-53.

Syntheses and differentiating action of vitamin D endoperoxides. Singlet oxygen adducts of vitamin D derivatives in human myeloid leukemia cells (HL-60).

Yamada S, Yamamoto K, Naito H, Suzuki T, Ohmori M, Takayama H, Shiina Y, Miyaura C, Tanaka H, Abe E, et al.

Singlet oxygen adducts of various vitamin D derivatives, 6,19-dihydro-6,19-epidioxyvitamin D (vitamin D endoperoxides, 2 and 2'), were chemically synthesized, and their biological activity in inducing differentiation of a human myeloid leukemia cell line (HL-60 cells) was examined. The potency of the endoperoxides derived from vitamin D derivatives possessing the 1 alpha-hydroxyl group such as 1 alpha, 25-dihydroxyvitamin D3 endoperoxides (2b and 2b') was markedly (10(-2)) diminished relative to the respective parent vitamin D compounds. In contrast, 25-hydroxyvitamin D3 endoperoxides [25-(OH)D3 endoperoxides, 2a and 2a'] and their analogues fluorinated at the 24- or 26- and 27-positions were 2.5-10 times more potent than 25-hydroxyvitamin D3 (1a) in spite of the absence of the conjugated triene structure typical of vitamin D compounds. The potency of these vitamin D endoperoxides (2 and 2'), especially those lacking the 1 alpha-hydroxyl group, in inducing differentiation of HL-60 cells was not correlated with their activity in binding to the cytosol receptor for 1 alpha, 25-dihydroxyvitamin D3 (1b). The binding efficiency to the receptor was relatively lower than the differentiating activity. To examine the action of vitamin D endoperoxides, carbon analogues of 25-(OH)D3 endoperoxides, two C-6 epimers of 25-hydroxy-6,19-dihydro-6,19-ethanovitamin D3 (6 and 6'), were synthesized. The carbon analogues (6 and 6') had no potential to induce differentiation of HL-60 cells. These results suggest that vitamin D endoperoxides (2 and 2') express their biological activity probably after being converted to some other compounds.

Neuroblastoma

147. Biochem Pharmacol. 2003 Jun 15;65(12):1943-55.

Effect of 20-epi-1alpha,25-dihydroxyvitamin D3 on the proliferation of human neuroblastoma: role of cell cycle regulators and the Myc-Id2 pathway.

Gumireddy K, Ikegaki N, Phillips PC, Sutton LN, Reddy CD.

Department of Pediatrics, Brown University School of Medicine, Providence, RI 02905, USA.

The antiproliferative effects of 1alpha,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)] and its epimer, 20-epi-1alpha,25-dihydroxyvitamin D(3) [20-epi-1,25(OH)(2)D(3)], in six human neuroblastoma (NB) cell lines (SH-SY5Y, NB69, SK-N-AS, IMR5, CHP134, and NGP) were investigated. We determined the ability of 1,25(OH)(2)D(3) and 20-epi-1,25(OH)(2)D(3) to influence cell viability by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, cell proliferation by bromodeoxyuridine (BrdU) incorporation, and their antineoplastic effect on colony formation in a soft agar assay. A concentration-dependent decrease in cell viability, inhibition of DNA synthesis, and suppression of clonal proliferation was observed with both compounds. 20-epi-1,25(OH)(2)D(3) was more potent in suppressing the proliferation of all six NB cell lines. To understand the mechanisms of action, we examined the effect of 20-epi-1,25(OH)(2)D(3) on the Myc-Id2 cell proliferative network and also on key regulators of the cell cycle. For the first time, we show that 20-epi-1,25(OH)(2)D(3) down-regulated Myc and Id2 expression by western blot analysis. Semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) analysis revealed that 20-epi-1,25(OH)(2)D(3) induced the expression of retinoic acid receptor-beta and p21(Cip1), and down-regulated the expression of cyclin D1 resulting in decreased phosphorylation of retinoblastoma protein (pRB). In sum, we show that 20-epi-1,25(OH)(2)D(3) exerts strong antiproliferative effects by regulating key growth control networks (Myc-Id2-pRB) in NB cells.

148. Brain Res. 2002 Aug 2;945(2):181-90.

Calretinin and calbindin D-28k, but not parvalbumin protect against glutamate-induced delayed excitotoxicity in transfected N18-RE 105 neuroblastoma-retina hybrid cells.

D'Orlando C, Celio MR, Schwaller B.

Institute of Histology and General Embryology, University of Fribourg, CH-1705 Fribourg, Switzerland.

Excitotoxic effects leading to neuronal cell degeneration are often accompanied by a prolonged increase in the intracellular level of Ca(2+) ions and L-glutamate-induced toxicity is assumed to be mediated via a Ca(2+)-dependent mechanism. Due to their buffering properties, EF-hand Ca(2+)-binding proteins (CaBPs) can affect intracellular Ca(2+) homeostasis and a neuroprotective role has been attributed to some of the family members including calretinin, calbindin D-28k and parvalbumin. We have stably transfected N18-RE 105 neuroblastoma-retina hybrid cells with the cDNAs for the three CaBPs and investigated the effect of these proteins on the L-glutamate-induced, Ca(2+)-dependent cytotoxicity. Several clones for each CaBP were selected according to immunocytochemical staining and characterization of the overexpressed proteins by Western blot analysis. In calretinin- and parvalbumin-expressing clones, expression levels were quantitatively determined by ELISA techniques. Cytotoxicity of transfected clones was quantified by measurement of the activity of lactate dehydrogenase (LDH) that was released into the medium after L-glutamate (10 mM) exposure as a result of necrotic cell death. In untransfected and parvalbumin-transfected cells, LDH released into the medium progressively increased (starting from the 20th hour) reaching maximum levels after 28-30 h of glutamate application. In contrast, LDH release in both, calretinin and calbindin D-28k-transfected clones, was not significantly different from unstimulated transfected or untransfected cells over the same period of time. The results indicate that the 'fast' Ca(2+)-buffers calretinin and calbindin D-28k, but not the 'slow' buffer parvalbumin can protect N18-RE 105 cells from this type of Ca(2+)-dependent L-glutamate-induced delayed cytotoxicity.

149. J Steroid Biochem Mol Biol. 2001 Jun;77(4-5):213-22.

Synergistic anti-proliferative effects of vitamin D derivatives and 9-cis retinoic acid in SH-SY5Y human neuroblastoma cells.

Stio M, Celli A, Treves C.

Department of Biochemical Sciences, University of Florence, Viale Morgagni 50, 50134 Florence, Italy.

This study examines the effect of 1,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)], 24,25-dihydroxyvitamin D(3) [24,25(OH)(2)D(3)], two vitamin D analogues (KH 1060 and EB 1089, which are 20-epi-22-oxa and 22,24-diene-analogues, respectively), 9-cis retinoic acid and all-trans retinoic acid on proliferation of SH-SY5Y human neuroblastoma cells, after treatment for 7 days. Cell number did not change when the cells were incubated with 1, 10 or 100 nM 1,25(OH)(2)D(3) or its derivatives, but significantly decreased in the presence of the two retinoids (0.001--10 microM final concentration). A synergistic inhibition was observed, when SH-SY5Y cells were treated combining 0.1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or 10 nM KH 1060, and 1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or 10 nM EB 1089. Acetylcholinesterase activity showed a significant increase, in comparison with controls, after treatment of the cells for 7 days with 0.1 or 1 microM 9-cis retinoic acid, alone or combined with 10 nM 1,25(OH)(2)D(3) or 10 nM KH 1060 or 10 nM EB 1089. This increase was synergistic, combining 1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or EB 1089. The levels of the c-myc encoded protein remarkably decreased after treatment of SH-SY5Y cells for 1, 3, 7 days with 0.1 and 1 microM 9-cis retinoic acid, alone or combined with 10 nM 1,25(OH)(2)D(3) or 10 nM KH 1060 or 10 nM EB 1089. In particular, the association of 1 microM 9-cis retinoic acid and 10 nM 1,25(OH)(2)D(3) or 10 nM EB 1089 resulted in a synergistic c-myc inhibition, in comparison with that obtained in the presence of the retinoid alone. These findings may have therapeutic implications in human neuroblastoma.

150. Biochem Biophys Res Commun. 1997 Jun 9;235(1):15-8.

1,25-dihydroxyvitamin D3 regulates the expression of N-myc, c-myc, protein kinase C, and transforming growth factor-beta2 in neuroblastoma cells.

Veenstra TD, Windebank AJ, Kumar R.

Nephrology Research Unit, Mayo Clinic Foundation, Rochester, Minnesota 55905, USA.

1alpha,25-Dihydroxyvitamin D3 (1,25(OH)2D3) alters the proliferation of neuroblastoma cells in culture in part via a nerve growth factor (NGF)-mediated pathway. This suggests that factors other than NGF also play a role in the growth arrest induced by 1,25(OH)2D3. To more fully characterize the effect of 1,25(OH)2D3 on neuroblastoma cells, we treated the cells with 10(-8) M 1,25(OH)2D3 and examined the cells for changes in the expression of N-myc, c-myc, transforming growth factor-beta2 (TGF-beta2), and protein kinase C (PKC) activity. Our results show that 1,25(OH)2D3 causes a decrease in the expression of N-myc and c-myc, as well as a two-fold increase in total PKC activity and a dose-dependent increase in TGF-beta2 expression. These results show that 1,25(OH)2D3 regulates the expression of growth-regulatory factors other than NGF in neuroblastoma cells and that 1,25(OH)2D3 influences the growth of neural cells via multiple growth regulatory pathways.

151. Brain Res Dev Brain Res. 1997 Mar 17;99(1):53-60. (Animal Study)

Effects of 1,25-dihydroxyvitamin D3 on growth of mouse neuroblastoma cells.

Veenstra TD, Londowski JM, Windebank AJ, Brimijoin S, Kumar R.

Nephrology Research Unit, Mayo Clinic Foundation, Rochester, MN 55905, USA.

Epitopes of the 1,25-dihydroxyvitamin D(1,25(OH)2D3) receptor have been shown in developing dorsal root ganglia in fetal mice, as well as in cells maintained in culture [Johnson, J.A., Grande, J.P., Windebank, A.J. and Kumar, R., 1,25-Dihydroxyvitamin D3 receptors in developing dorsal root ganglia of fetal rats, Dev. Brain Res., 92 (1996) 120-124]. To investigate a possible role for 1,25(OH)2D3 in neural cell growth and development, a murine neuroblastoma cell line that expresses 1,25(OH)2D3 receptors, was treated with 1,25(OH)2D3. Treatment with 1,25(OH)2D3 resulted in a decrease in cell proliferation, a change in cell morphology, and the expression of protein markers of mature neuronal cells. The decrease in cell proliferation was accompanied by an increase in the expression of nerve growth factor (NGF). Anti-NGF monoclonal antibody added to the growth medium blocked the decrease in cell proliferation caused by 1,25(OH)2D3 treatment. Our results show that the sterol hormone 1,25(OH)2D3, causes a decrease in the proliferation of mouse neuroblastoma cells through alterations in the expression of NGF.

152. Clin Exp Metastasis. 1996 May;14(3):239-45.

Vitamin D3 analogs inhibit growth and induce differentiation in LA-N-5 human neuroblastoma cells.

Moore TB, Koeffler HP, Yamashiro JM, Wada RK.

Department of Pediatrics, Division of Hematology/Oncology, UCLA School of Medicine, Los Angeles, CA 90024, USA.

The physiologically active metabolite of vitamin D3, 1,25-dihydroxycholecalciferol (D3), plays an important role in embryonic development and cell differentiation. Previously, we have demonstrated that D3 significantly induces differentiation and inhibits growth of LA-N-5 human neuroblastoma cells at concentrations of 24 nm and higher. In this study, we compared two D3 analogs, 20-epi-22oxa-25a,26a,27a-tri-homo-1,25-D3 (KH 1060) and 1,25-dihydroxy-22,24-diene, 24,26,27-trihomo (EB 1089), with D3 with respect to their effects on differentiation and growth inhibition. We report an inhibition of growth by 45-55% in cells treated with 0.24 nm EB 1089 and 0.24 nM KH 1060, similar to that seen in cells treated with 24 nM D3. At these concentrations, both EB 1089 and KH 1060 stimulate the differentiation of LA-N-5 neuroblastoma cells as shown by increased neurite outgrowth, decreased N-myc expression and decreased invasiveness in vitro. An increase in acetylcholinesterase activity, a functional measure of differentiation, was also exhibited. Previous reports have shown that treatment doses needed to achieve 24 nM serum concentrations of D3 in patients would result in hypercalcemia. EB 1089 and KH 1060 can cause the same in vitro effects on LA-N-5 human neuroblastoma cells at 1/100 of the concentration required of D3. These data suggest a potential clinical efficacy of EB 1089 and KH 1060 as biological response modifiers.

153. J Pediatr Hematol Oncol. 1995 Nov;17(4):311-7.

Differentiating effects of 1,25-dihydroxycholecalciferol (D3) on LA-N-5 human neuroblastoma cells and its synergy with retinoic acid.

Moore TB, Sidell N, Chow VJ, Medzoyan RH, Huang JI, Yamashiro JM, Wada RK.

Division of Pediatric Hematology/Oncology, UCLA School of Medicine 90095, USA.

PURPOSE: 1,25-Dihydroxycholecalciferol (D3) plays an important role in embryonic development and cell differentiation. It has previously been reported to decrease c-myc expression by HL-60 cells and downregulate c-myc expression by breast and ovarian cancer cells. We report the results of our investigations into the differentiating effects of D3 on LA-N-5 human neuroblastoma cells. METHODS: LA-N-5 human neuroblastoma cell line was treated with D3, retinoic acid (RA), D3 and RA, or solvent control. Growth inhibitory effects, neurite extension, acetylcholinesterase activity, invasiveness, motility, and N-myc protein expression were examined following treatment. RESULTS: Growth inhibition was observed at concentrations of > 24 nM. D3 stimulated the differentiation of LA-N-5 cells as demonstrated by increased neurite outgrowth, increased acetylcholinesterase activity, and decreased invasiveness. A decrease in N-myc expression was observed in immunostained cells treated with either agent alone, with a more profound effect appreciated with the combination. CONCLUSION: Vitamin D3 decreases N-myc expression in LA-N-5 human neuroblastoma cells, with extended treatment causing growth inhibition and differentiation. When used in combination with RA, these effects are more profound than with either agent alone. The therapeutic use of differentiating agent combinations such as D3 and RA may provide a relatively nontoxic means of treating susceptible tumor types.

154. Pediatr Hematol Oncol. 1994 Mar-Apr;11(2):173-9.

Effects of 1,25-dihydroxyvitamin D3 and retinoic acid on the proliferation and cell cycle phase distribution of neuroblastoma SK-N-SH cells.

Goplen DP, Brackman D, Aksnes L.

Institute of Pediatrics, University of Bergen, Norway.

The hormone 1,25-(OH)2D3 has been shown to modulate cell proliferation and induce differentiation in several normal and malignant cell lines. In this work, we examined the effect of the hormone on the neuroblastoma SK-N-SH cell line. The steroid did not influence cell growth and cell cycle distribution, while retinoic acid inhibited proliferation and induced an accumulation of the cells in the G0/G1 phase of the cell cycle. 1,25-(OH)2D3 did not alter cell morphology. The activities of the 1-alpha- and 24-hydroxylases were low and not regulated by the hormone. The level of the total 1,25-(OH)2D3 receptor was low. We conclude that the lack of effect of 1,25-(OH)2D3 on the SK-N-SH cell line is related to the low level of the 1,25-(OH)2D3 receptor.

Pancreatic Cancer

155. Endocrinology. 2003 May;144(5):1832-41.

Molecular pathways involved in the antineoplastic effects of calcitriol on insulinoma cells.

Galbiati F, Polastri L, Thorens B, Dupraz P, Fiorina P, Cavallaro U, Christofori G, Davalli AM.

Division of General Medicine, Unit of Endocrinology and Metabolic Disease, San Raffaele Scientific Institute, 20132 Milan, Italy.

We have previously reported that in tumorigenic pancreatic beta-cells, calcitriol exerts a potent antitumorigenic effect by inducing apoptosis, cell growth inhibition, and reduction of solid beta-cell tumors. Here we have studied the molecular pathways involved in the antineoplastic activity of calcitriol on mouse insulinoma beta TC(3) cells, mouse insulinoma beta TC expressing or not expressing the oncogene p53, and beta TC-tet cells overexpressing or not the antiapoptotic gene Bcl2. Our results indicate that calcitriol-induced apoptosis was dependent on the function of p53 and was associated with a biphasic increase in protein levels of transcription factor nuclear factor-kappa B. Calcitriol decreased cell viability by about 40% in p53-retaining beta TC and in beta TC(3) cells; in contrast, beta TC p53(-/-) cells were only minimally affected. Calcitriol-induced cell death was regulated by members of the Bcl-2 family of apoptosis regulatory proteins, as shown by calcitriol-induced up-regulation of proapoptotic Bax and Bak and the lack of calcitriol-induced cytotoxicity in Bcl-2-overexpressing insulinoma cells. Moreover, calcitriol-mediated arrest of beta TC(3) cells in the G(1) phase of the cell cycle was associated with the abnormal expression of p21 and G(2)/M-specific cyclin B2 genes and involved the DNA damage-inducible factor GADD45. Finally, in beta TC(3) cells, calcitriol modulated the expression of IGF-I and IGF-II genes. In conclusion, these findings contribute to the understanding of the antitumorigenic effects of calcitriol on tumorigenic pancreatic beta-cells and further support the rationale of its utilization in the treatment of patients with malignant insulinomas.

156. Pancreatology. 2003;3(1):41-6.

Vitamin d receptor is expressed in pancreatic cancer cells and a vitamin d(3) analogue decreases cell number.

Albrechtsson E, Jonsson T, Moller S, Hoglund M, Ohlsson B, Axelson J.

Department of Surgery, Lund University, Lund, Sweden.

BACKGROUND AND AIM: The vitamin D-receptor (VDR) has been detected in both normal and malignant cells of different tissues. Treatment with vitamin D(3) has been suggested as a possible therapy in malignant diseases such as pancreatic cancer. Synthetic analogues of vitamin D(3) have a less hypercalcemic effect than native vitamin D(3). The aim was to study the expression of the VDR in human pancreatic cancers and to study the in vitro effect of an analogue to vitamin D(3) on cell lines established from these cancers. METHODS: The pancreatic cancer cell lines were established from primary cultures with only cancer cells. A probe specific for the human VDR was used. After reverse-transcriptase PCR and Northern blotting, the expression of the VDR in normal pancreas and in pancreatic cancers was compared. The cell lines were incubated with EB 1089, a synthetic analogue vitamin of D(3), in dose-response studies. The cell number was measured by the XTT colorimetric method. RESULTS: The VDR was expressed in all cancers and in six of the cell lines the expression was increased more than 3-fold compared to normal pancreas. All cell lines developed from human pancreatic cancers responded with a decreased cell number to the vitamin D(3) analogue at concentrations of 10(-5) M or higher. CONCLUSION: The VDR was expressed in all pancreatic cancers studied. Cell lines derived from these cancers responded with a decrease in cell number to high concentrations of a vitamin D(3) analogue. These results, and the doses to use, have to be confirmed with in vivo studies. Copyright 2003 S. Karger AG, Basel and IAP

157. Endocrinology. 2002 Oct;143(10):4018-30.

Antitumorigenic and antiinsulinogenic effects of calcitriol on insulinoma cells and solid beta-cell tumors.

Galbiati F, Polastri L, Gregori S, Freschi M, Casorati M, Cavallaro U, Fiorina P, Bertuzzi F, Zerbi A, Pozza G, Adorini L, Folli F, Christofori G, Davalli AM.

Department of Medicine, San Raffaele Scientific Institute, Milan 20132, Italy.

Malignant insulinoma is a rare form of cancer with a poor prognosis because of metastatic dissemination and untreatable hypoglycemia. Effective chemotherapy of patients who are not cured by surgery is needed. Calcitriol has known anticancer properties on different neoplastic cell lines, but no data are available regarding its activity on tumorigenic pancreatic beta-cells. We analyzed the in vitro effects of calcitriol on the murine insulinoma cell line betaTC(3) and primary cultures of human isolated islets and benign insulinoma. The effect of in vivo calcitriol administration on insulinoma of recombinant insulin/Simian virus 40 oncogene-expressing transgenic mice was also investigated. In betaTC(3), calcitriol induced growth inhibition; apoptosis; down-regulation of insulin gene expression; and nongenomic activation of the MAPK pathway. MAPK kinase inhibitor (UO126) and staurosporine reduced calcitriol-mediated betaTC(3) death, and down-regulation of insulin gene transcription was prevented by staurosporine but not UO126. Calcitriol significantly decreased insulin release and mRNA levels of human islets and insulinoma cells. Finally, recombinant insulin/Simian virus 40 oncogene-expressing transgenic mice treated with calcitriol showed reduced insulinoma volumes because of increased apoptosis of adenomatous cells. Together, these findings provide the rationale for testing the efficacy of calcitriol in the treatment of patients with solid beta-cell tumors.

158. Br J Cancer. 2000 Jul;83(2):239-45.

Differential and antagonistic effects of 9-cis-retinoic acid and vitamin D analogues on pancreatic cancer cells in vitro.

Pettersson F, Colston KW, Dalgleish AG.

Department of Oncology, Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London, UK.

Retinoids and vitamin D are known to exert important anti-tumour effects in a variety of cell types. In this study the effects of 9-cis-retinoic acid (9cRA) the vitamin D analogues EB1089 and CB1093 on three pancreatic adenocarcinoma cell lines were investigated. All compounds caused inhibition of in vitro growth but the vitamin D analogues were generally the more potent growth inhibitors. They were also more effective on their own than in combination with 9cRA. Growth arrest correlated with an increased proportion of cells in the G0/G1 phase. Apoptosis was induced in the three cell lines by 9cRA, whereas neither EB1089 nor CB1093 had this effect. Furthermore, addition of EB1089 or CB1093 together with 9cRA resulted in significantly reduced apoptosis. Our results show that retinoic acids as well as vitamin D analogues have inhibitory effects on pancreatic tumour cells but different and antagonistic mechanisms seem to be employed.

159. Br J Cancer. 1997;76(8):1017-20. (Animal Study)

Vitamin D receptors and anti-proliferative effects of vitamin D derivatives in human pancreatic carcinoma cells in vivo and in vitro.

Colston KW, James SY, Ofori-Kuragu EA, Binderup L, Grant AG.

Division of Gastroenterology, Endocrinology and Metabolism, St George's Hospital Medical School, London, UK.

The GER human pancreatic carcinoma cell line possesses receptors for 1,25-dihydroxyvitamin D3. We report that the vitamin D analogue EB 1089 inhibits the growth of these cells in vitro and when grown as tumour xenografts in immunodeficient mice. Tumour-bearing mice were given EB 1089 at a dose of 5 microg kg(-1) body weight i.p. thrice weekly for 4-6 weeks. Tumour growth was significantly inhibited in treated animals compared with controls in the absence of hypercalcaemia. These findings may have therapeutic implications in pancreatic cancer.

160. Br J Cancer. 1997;76(7):884-9.

Vitamin D analogues up-regulate p21 and p27 during growth inhibition of pancreatic cancer cell lines.

Kawa S, Nikaido T, Aoki Y, Zhai Y, Kumagai T, Furihata K, Fujii S, Kiyosawa K.

The Second Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan.

To obtain information regarding the growth-inhibitory effect of 1,25-dihydroxyvitamin D3 and its non-calcaemic analogue 22-oxa-1,25-dihydroxyvitamin D3 on pancreatic cancer cell lines, differences in the effects of G1-phase cell cycle-regulating factors were studied in vitamin D-responsive and non-responsive cell lines. Levels of expression of cyclins (D1, E and A), cyclin-dependent kinases (2 and 4) and cyclin-dependent kinase inhibitors (p21 and p27) were analysed by Western blotting after treatment with these compounds. In the responsive cells (BxPC-3, Hs 700T and SUP-1), our observations were: (1) marked up-regulation of p21 and p27 after 24 h treatment with 10(-7) mol l(-1) 1,25-dihydroxyvitamin D3 and 22-oxa-1,25-dihydroxyvitamin D3; and (2) marked down-regulation of cyclins, cyclin-dependent kinases and cyclin-dependent kinase inhibitors after 7 days' treatment. In non-responsive cells (Hs 766T and Capan-1), no such changes were observed. In conclusion, vitamin D analogues up-regulate p21 and p27 as an early event, which in turn could block the G1/S transition and induce growth inhibition in responsive cells.

161. Gastroenterology. 1996 May;110(5):1605-13.

Inhibitory effect of 220-oxa-1,25-dihydroxyvitamin D3 on the proliferation of pancreatic cancer cell lines.

Kawa S, Yoshizawa K, Tokoo M, Imai H, Oguchi H, Kiyosawa K, Homma T, Nikaido T, Furihata K.

Second Department of Internal Medicine, Shinshu University, School of Medicine, Matsumoto, Japan.

BACKGROUND & AIMS: Effective chemotherapy for pancreatic cancer is urgently needed. The aim of this study was to compare the anti-proliferative activity of a new vitamin D3 analogue, 22-oxa-1,25-dihydroxyvitamin D3 (22-oxa-calcitriol), on pancreatic cancer cells lines with that of 1,25-dihydroxyvitamin D3 (calcitriol) with analysis of vitamin D receptor status. METHODS: Antiproliferative effects of both agents were compared using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide method and by measuring the tumor size of xenograft inoculated into athymic mice. Vitamin D receptor contents by Scatchard analysis and mutational analysis of receptor complementary DNA were performed. RESULTS: In vitro, 22-oxa-calcitriol and calcitriol markedly inhibited the proliferation (3 of 9 cell lines) and caused a G1 phase cell cycle arrest by appearance of numerous domes. In vivo, 22-oxa-calcitriol inhibited the growth of BxPC-3 xenografts more significantly than calcitriol without including hypercalcemia. Hs 766T, showing no response to either agent, had the second highest receptor contents with no abnormalities in its primary structure deduced by receptor complementary DNA. CONCLUSIONS: 22-oxa-calcitriol may provide a more useful tool for the chemotherapy of pancreatic cancer than calcitriol. Also, the susceptibility of the cell lines to both agents is not well determined by evaluating either the contents or the mutation of vitamin D receptor.

162. Br J Cancer. 1996 Jun;73(11):1341-6.

Growth-inhibitory effects of vitamin D analogues and retinoids on human pancreatic cancer cells.

Zugmaier G, Jager R, Grage B, Gottardis MM, Havemann K, Knabbe C.

Department of Medical Oncology, Marburg University Medical Center, Germany.

Retinoids and vitamin D are important factors that regulate cellular growth and differentiation. An additive growth-inhibitory effect of retinoids and vitamin D analogues has been demonstrated for human myeloma, leukaemic and breast cancer cells. We set out to study the effects of the vitamin D analogue EB1089 and the retinoids all-trans- and 9-cis-retinoic acid on the human pancreatic adenocarcinoma cell lines Capan 1 and Capan 2 and the undifferentiated pancreatic carcinoma cell line Hs766T. The cell lines investigated expressed vitamin D receptor, retinoic acid receptor (RAR)-alpha and gamma as determined by polymerase chain reaction after reverse transcription. RAR-beta was expressed only in Hs766T cells. Addition of all-trans-retinoic acid increased the amount of RAR-alpha mRNA in the three cell lines and induced RAR-beta mRNA in Capan 1 and Capan 2 cells. All-trans-retinoic acid at a concentration of 10 nM inhibited the growth of Capan 1 and Capan 2 cells by 40% relative to controls. 9-cis-Retinoic acid was less effective. Neither all-trans-retinoic acid nor 9-cis-retinoic acid affected the growth of Hs766T cells. EB1089, if added alone to the cells, did not significantly inhibit growth. However, the combination of 1 nM EB1089 with 10 nM all-trans-retinoic acid exerted a growth-inhibitory effect of 90% in Capan 1 cells and of 70% in Capan 2 cells. Our data suggest that vitamin D analogues together with retinoids inhibit the growth of human pancreatic cancer cells. However, in vivo studies are necessary to examine the potential use of retinoids and vitamin D analogues on pancreatic cancer.

Multiple Sclerosis

163. Proc Soc Exp Biol Med. 1997 Oct;216(1):21-7.

Vitamin D and multiple sclerosis.

Hayes CE, Cantorna MT, DeLuca HF.

Department of Biochemistry, University of Wisconsin-Madison 53706, USA.

Recently, it has been clearly demonstrated that exogenous 1,25-dihydroxyvitamin D3, the hormonal form of vitamin D3, can completely prevent experimental autoimmune encephalomyelitis (EAE), a widely accepted mouse model of human multiple sclerosis (MS). This finding has focused attention on the possible relationship of this disease to vitamin D. Although genetic traits certainly contribute to MS susceptibility, an environmental factor is also clearly involved. It is our hypothesis that one crucial environmental factor is the degree of sunlight exposure catalyzing the production of vitamin D3 in skin, and, further, that the hormonal form of vitamin D3 is a selective immune system regulator inhibiting this autoimmune disease. Thus, under low-sunlight conditions, insufficient vitamin D3 is produced, limiting production of 1,25-dihydroxyvitamin D3, providing a risk for MS. Although the evidence that vitamin D3 is a protective environmental factor against MS is circumstantial, it is compelling. This theory can explain the striking geographic distribution of MS, which is nearly zero in equatorial regions and increases dramatically with latitude in both hemispheres. It can also explain two peculiar geographic anomalies, one in Switzerland with high MS rates at low altitudes and low MS rates at high altitudes, and one in Norway with a high MS prevalence inland and a lower MS prevalence along the coast. Ultraviolet (UV) light intensity is higher at high altitudes, resulting in a greater vitamin D3 synthetic rate, thereby accounting for low MS rates at higher altitudes. On the Norwegian coast, fish is consumed at high rates and fish oils are rich in vitamin D3. Further, experimental work on EAE provides strong support for the importance of vitamin D3 in reducing the risk and susceptibility for MS. If this hypothesis is correct, then 1,25-dihydroxyvitamin D3 or its analogs may have great therapeutic potential in patients with MS. More importantly, current research together with data from migration studies opens the possibility that MS may be preventable in genetically susceptible individuals with early intervention strategies that provide adequate levels of hormonally active 1,25-dihydroxyvitamin D3 or its analogs.

164. Proc Natl Acad Sci U S A. 1996 Jul 23;93(15):7861-4.

1,25-Dihydroxyvitamin D3 reversibly blocks the progression of relapsing encephalomyelitis, a model of multiple sclerosis.

Cantorna MT, Hayes CE, DeLuca HF.

Department of Biochemistry, University of Wisconsin, Madison 53706, USA.

Experimental autoimmune encephalomyelitis (EAE) is an autoimmune disease believed to be a model for the human disease multiple sclerosis (MS). Induced by immunizing B10.PL mice with myelin basic protein (MBP), EAE was completely prevented by the administration of 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3]. 1,25-(OH)2D3 could also prevent the progression of EAE when administered at the appearance of the first disability symptoms. Withdrawal of 1,25-(OH)2D3 resulted in a resumption of the progression of EAE. Thus, the block by 1,25-(OH)2D3 is reversible. A deficiency of vitamin D resulted in an increased susceptibility to EAE. Thus, 1,25-(OH)2D3 or its analogs are potentially important for treatment of MS.

165. Med Hypotheses. 1986 Oct;21(2):193-200.

Multiple sclerosis: decreased relapse rate through dietary supplementation with calcium, magnesium and vitamin D.

Goldberg P, Fleming MC, Picard EH.

A group of young patients having multiple sclerosis was treated with dietary supplements containing calcium, magnesium and vitamin D for a period of one to two years. The experimental design employed self-pairing: the response of each patient was compared with his/her own case history as control. The number of exacerbations observed during the program was less than one half the number expected from case histories. No side effects were apparent. The dietary regimen may offer a new means of controlling the exacerbation rate in MS, at least for younger patients. The results tend to support a theory of MS which states that calcium and magnesium are important in the development, structure and stability of myelin.

Osteoporosis

166. J Cell Biochem. 2003 Feb 1;88(2):209-15.

Role of the vitamin D-endocrine system in the pathophysiology of postmenopausal osteoporosis.

Riggs BL.

Endocrine Research Unit, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.

Impaired calcium absorption and impaired adaptation to a low calcium diet are common features of aging in women and these processes are even more severely impaired in patients with osteoporotic fractures. The calcium absorption defects are associated with several abnormalities of the vitamin D-endocrine system including secondary hyperparathyroidism, intestinal resistance to 1,25-dihydroxyvitamin D (1,25(OH)(2)D) action, decreased 1,25(OH)(2)D production due to impaired 25(OH)D 1alpha-hydroxylase activity, and, in some elderly persons, nutritional deficiency of vitamin D. However, in postmenopausal women, most of these abnormalities are normalized by administration of physiologic replacement dosages of estrogen and, thus, appear to be secondary consequences of estrogen deficiency. Nonetheless, a minority of them, especially nutritional vitamin D deficiency and impaired 25(OH)D 1alpha-hydroxylase activity late in life, appear to be primary and are independent of estrogen deficiency. Copyright 2002 Wiley-Liss, Inc.

167. J Cell Biochem. 2003 Feb 1;88(2):381-6. (Animal Study)

Rationale for active vitamin D and analogs in the treatment of osteoporosis.

Nishii Y.

Medical Culture, Inc., Tokyo, Japan. nishiiysh-mc@chugai-phram.co.jp

In 1981, Chugai Pharmaceutical succeeded in marketing alfacalcidol, a prodrug of calcitriol, as a therapeutic agent for renal osteodystrophy. In 1983, Chugai succeeded in extending the application of alfacalcidol to the treatment of osteoporosis as well. Clinicians in Japan have accepted alfacalcidol as a remedy for osteoporosis. However, the use of calcitriol and its analogs for the treatment of osteoporosis is still controversial. Some misunderstandings exist internationally about the efficacy of the active form of vitamin D for the treatment of osteoporosis. It is important to emphasize that patients with osteoporosis have intestinal calcium malabsorption and dysfunction in renal activation of vitamin D. When massive doses of parent vitamin D were administered to OVX rats, bone mass increased, but surprisingly, many porotic area were observed in the cortical bone. On the other hand, administration of alfacalcidol increased physiological bone without porotic observation. It is necessary to give the active form of vitamin D, D-hormone, with an RDA-equivalent supply of calcium. Alfacalcidol forms physiological strong bones that are hardly fractured by regulating calcium and bone metabolism. We proposed a new vitamin D analog, 2beta (3-hydroxypropoxy)calcitriol [ED-71] as a therapeutic drug for osteoporosis, which is more potent than calcitriol. ED-71 is now being investigated in phase 2 clinical studies in Japan. ED-71 will appear as more improved drugs for osteoporosis until 2010. Copyright 2002 Wiley-Liss, Inc.

168. Clin Exp Rheumatol. 2003 Jan-Feb;21(1):19-26.

Calcium, vitamin D and etidronate for the prevention and treatment of corticosteroid-induced osteoporosis in patients with rheumatic diseases.

Loddenkemper K, Grauer A, Burmester GR, Buttgereit F.

Department of Rheumatology and Clinical Immunology, Charite University Hospital, Humboldt University of Berlin, Berlin, Germany. konstanze.loddenkemper@charite.de

INTRODUCTION: Long-term glucocorticoid therapy, a major risk factor for the development of osteoporosis, is often necessary in chronically ill patients. At present there are no generally accepted guidelines for the prevention or treatment of steroid-induced osteoporosis. METHODS: In an open prospective study we investigated 99 patients with chronic rheumatic diseases receiving > or = 5 mg/day of prednisolone or the equivalent for at least one year. The objective was to identify osteoporosis risk factors in addition to glucocorticoid therapy and to evaluate the efficacy of prevention with calcium/vitamin D (group 1--patients with osteopenia) and treatment with cyclical etidronate (group 2--patients with osteoporosis). Biochemical markers of bone turnover, clinical parameters and bone mineral density (BMD) were measured. RESULTS: Increasing age and postmenopausal status were associated with more advanced manifestations of steroid-induced osteoporosis (p < 0.05). One year after the start of therapy parameters of bone metabolism increased significantly in group 1, while BMD did not change. In group 2, lumbar spine BMD increased significantly (p < 0.05) whereas femoral neck BMD and bone metabolism parameters remained constant. The intensity of back pain decreased in both groups (p < 0.05). There were fewer new fractures in group 2 than in group 1. CONCLUSION: Treatment with etidronate is effective in patients with glucocorticoid-induced osteoporosis.

169. Endocr Rev. 2002 Aug;23(4):560-9.

Meta-analyses of therapies for postmenopausal osteoporosis. VIII: Meta-analysis of the efficacy of vitamin D treatment in preventing osteoporosis in postmenopausal women.

Papadimitropoulos E, Wells G, Shea B, Gillespie W, Weaver B, Zytaruk N, Cranney A, Adachi J, Tugwell P, Josse R, Greenwood C, Guyatt G; Osteoporosis Methodology Group and The Osteoporosis Research Advisory Group.

OBJECTIVE: To review the effect of vitamin D on bone density and fractures in postmenopausal women. DATA SOURCE: We searched MEDLINE and EMBASE from 1966 to 1999 and examined citations of relevant articles and proceedings of international meetings. We contacted osteoporosis investigators and primary authors to identify additional studies and to obtain unpublished data. STUDY SELECTION: We included 25 trials that randomized women to standard or hydroxylated vitamin D with or without calcium supplementation or a control and measured bone density or fracture incidence for at least 1 yr. DATA EXTRACTION: For each trial, three independent reviewers assessed the methodological quality and abstracted data. DATA SYNTHESIS: Vitamin D reduced the incidence of vertebral fractures [relative risk (RR) 0.63, 95% confidence interval (CI) 0.45-0.88, P < 0.01) and showed a trend toward reduced incidence of nonvertebral fractures (RR 0.77, 95% CI 0.57-1.04, P = 0.09). Most patients in the trials that evaluated vertebral fractures received hydroxylated vitamin D, and most patients in the trials that evaluated nonvertebral fractures received standard vitamin D. Hydroxylated vitamin D had a consistently larger impact on bone density than did standard vitamin D. For instance, total body differences in percentage change between hydroxylated vitamin D and control were 2.06 (0.72, 3.40) and 0.40 (-0.25, 1.06) for standard vitamin D. At the lumbar spine and forearm sites, hydroxylated vitamin D doses above 50 microg yield larger effects than lower doses. Vitamin D resulted in an increased risk of discontinuing medication in comparison to control as a result of either symptomatic adverse effects or abnormal laboratory results (RR 1.37, 95% CI 1.01-1.88), an effect that was similar in trials of standard and hydroxylated vitamin D. CONCLUSIONS: Vitamin D decreases vertebral fractures and may decrease nonvertebral fractures. The available data are uninformative regarding the relative effects of standard and hydroxylated vitamin D.

170. Bone. 2002 Jul;31(1):114-8.

Amelioration of osteoporosis by menatetrenone in elderly female Parkinson's disease patients with vitamin D deficiency.

Sato Y, Honda Y, Kaji M, Asoh T, Hosokawa K, Kondo I, Satoh K.

Department of Rehabilitation Medicine, Hirosaki University School of Medicine, Hirosaki, Japan. noukenrs@cc.hirosaki-u.ac.jp

Significant reduction in bone mineral density (BMD) occurs in patients with Parkinson's disease (PD), correlating with immobilization and with vitamin D deficiency, and increasing the risk of hip fracture, especially in elderly women. As a biological indicator of compromised vitamin K status, an increased serum concentration of undercarboxylated osteocalcin (Oc) has been associated with reduced BMD in the hip and an increased risk of fracture in otherwise healthy elderly women. We evaluated treatment with vitamin K(2) (menatetrenone; MK-4) in maintaining BMD and reducing the incidence of nonvertebral fractures in elderly female patients with PD. In a random and prospective study of PD patients, 60 received 45 mg of MK-4 daily for 12 months, and the remaining 60 (untreated group) did not. At baseline, patients of both groups showed vitamin D and K(1) deficiencies, high serum levels of ionized calcium, and glutaminic residue (Glu) Oc, and low levels of parathyroid hormone (PTH) and 1,25-dihydroxyvitamin D [1,25-(OH)(2)D], indicating that immobilization-induced hypercalcemia inhibits renal synthesis of 1,25-(OH)(2)D and compensatory PTH secretion. BMD in the second metacarpals increased by 0.9% in the treated group and decreased by 4.3% in the untreated group (p < 0.0001). Vitamin K(2) level increased by 259.8% in the treated group. Correspondingly, significant decreases in Glu Oc and calcium were observed in the treated group, in association with an increase in both PTH and 1,25-(OH)(2)D. Ten patients sustained fractures (eight at the hip and two at other sites) in the untreated group, and one hip fracture occurred among treated patients (p = 0.0082; odds ratio = 11.5). The treatment with MK-4 can increase the BMD of vitamin D- and K-deficient bone by increasing vitamin K concentration, and it can also decrease calcium levels through inhibition of bone resorption, resulting in an increase in 1,25-(OH)(2)D concentration.

171. Med Clin (Barc). 2002 Jun 22;119(3):85-9.

[Prevalence of vitamin D deficiency in populations at risk for osteoporosis: impact on bone integrity]

[Article in Spanish]

Mezquita Raya P, Munoz Torres M, Lopez Rodriguez F, Martinez Martin N, Conde Valero A, Ortego Centeno N, Gonzalez Calvin J, Raya Alvarez E, Luna Jd Jde D, Escobar Jimenez F.

Area de Metabolismo Oseo, Servicio de Endocrinologia. Facultad de Medicina, Hospital Universitario San Cecilio, Granada, Spain.

BACKGROUND: Nowadays, severe deficiency of vitamin D is not a common finding in most developed countries. However, the prevalence of vitamin D insufficiency is relatively high and it can contribute to the descent of bone mass in osteoporosis risk populations. The objective of our study was to evaluate the prevalence of vitamin D insufficiency in postmenopausal women (PMW), patients with inflammatory bowel disease (IBD) and corticosteroid-dependent asthmatic patients (CAP) and to analyze its relationship with bone mineral density (BMD) and calciotropic hormones. PATIENTS AND METHOD: We studied 299 patients (PMW: 161; IBD: 61; CAP: 77). In all cases, serum levels of PTH and 25OHD were determined and the BMD (DXA, Hologic QDR1000) in lumbar spine (LS) and femoral neck (FN) was measured. RESULTS: Vitamin D insufficiency (25OHD < 15 ng/ml) was observed in 39.1% patients with PMW, 70.7% patients with IBD and 44.2% patients with CAP. 25OHD concentrations were lower in EII patients (p = 0.003) and PTH concentrations were higher in MPM (p < 0.001). We found a negative correlation between PTH and 25OHD in the overall group and this correlation persisted after considering each group separately. After adjusting for remaining variables, 25OHD was found to be significantly associated with BMD at lumbar spine and/or femoral neck in the three groups. CONCLUSIONS: In populations at risk of osteoporosis, there is a high prevalence of vitamin D insufficiency. This insufficiency has a significant effect on bone integrity.

172. Biogerontology. 2002;3(1-2):73-7.

Vitamin D deficiency and aging: implications for general health and osteoporosis.

Eriksen EF, Glerup H.

University Department of Endocrinology, Aarhus Amtssygehus, Denmark. eriksen_erik_f@lilly.com

Vitamin D deficiency is extremely prevalent in the elderly. Most often the first symptoms are caused by myopathy with muscle pain, fatigue, muscular weakness and gait disturbances. More severe deficiency causes osteomalacia with deep bone pain, reduced mineralization of bone matrix and low energy fractures. Recent data also suggest that hypovitaminosis D increases the risk of cancer of the prostate, colon and breast. Thus, hypovitaminosis D is associated with many diseases associated with aging. In order to diagnose hypovitaminosis D, the assessment of serum levels of 25-hydroxy vitamin D is mandatory. Screening based on other markers like alkaline phosphatase and parathyroid hormone (PTH) will be incomplete. The treatment of hypovitaminosis D is simple with administration of combined calcium (I g) and vitamin D supplements (calciferol, at least 800 IU). Severe cases may demand initial parenteral administration of vitamin D (repeated injections of 300,000 IU 2-3 times with monthly intervals). More potent analogues are rarely needed. One should aim at achieving S-25(OH)D values in the range 50-100 nmol/l.

173. Aliment Pharmacol Ther. 2002 May;16(5):919-27.

Osteoporosis in inflammatory bowel disease: effect of calcium and vitamin D with or without fluoride.

Abitbol V, Mary JY, Roux C, Soule JC, Belaiche J, Dupas JL, Gendre JP, Lerebours E, Chaussade S; Groupe D'etudes Therapeutiques des Affections Inflammatoires Digestives (GETAID).

Service de Gastroenterologie, Hopital Cochin, Paris, France, INSERM U444, Universite de Paris, Paris, France. vered@club-internet.fr

BACKGROUND: Previous data have indicated low bone formation as a mechanism of osteoporosis in inflammatory bowel disease. Fluoride can stimulate bone formation. AIM: To assess the effect of fluoride supplementation on lumbar spine bone mineral density in osteoporotic patients with inflammatory bowel disease treated in parallel with calcium and vitamin D. METHODS: In this prospective, randomized, double-blind, parallel and placebo-controlled study, 94 patients with inflammatory bowel disease (lumbar spine T score below - 2 standard deviations, normal serum 25OH vitamin D), with a median age of 35 years, were included. Bone mineral density was measured by dual-energy X-ray absorptiometry. Patients were randomized to receive daily either sodium monofluorophosphate (150 mg, n=45) or placebo (n=49) for 1 year, and all received calcium (1 g) and vitamin D (800 IU). The relative change in bone mineral density from 0 to 12 months was tested in each group (fluoride or placebo) and compared between the groups. RESULTS: Lumbar spine bone mineral density increased significantly in both groups after 1 year: 4.8 +/- 5.6% (n=29) and 3.2 +/- 3.8% (n=31) in the calcium-vitamin D-fluoride and calcium-vitamin D-placebo groups, respectively (P < 0.001 for each group). There was no difference between the groups (P=0.403). Similar results were observed according to corticosteroid intake or disease activity. CONCLUSIONS: Calcium and vitamin D seem to increase lumbar spine density in osteoporotic patients with inflammatory bowel disease; fluoride does not provide further benefit.

174. Bone. 2002 Apr;30(4):582-8. (Animal Study)

ED-71, a vitamin D analog, is a more potent inhibitor of bone resorption than alfacalcidol in an estrogen-deficient rat model of osteoporosis.

Uchiyama Y, HiguchI Y, Takeda S, Masaki T, Shira-Ishi A, Sato K, Kubodera N, Ikeda K, Ogata E.

Fuji Gotemba Research Laboratory, Chugai Pharmaceutical Co., Ltd., Shizuoka, Japan.

Although active vitamin D is used in certain countries for the treatment of osteoporosis, the risk of causing hypercalcemia/hypercalciuria means that there is only a narrow therapeutic window, and this has precluded worldwide approval. The results of our previous animal studies have suggested that the therapeutic effect of active vitamin D on bone loss after estrogen deficiency can be dissociated at least partly from its effect of enhancing intestinal calcium absorption and suppressing parathyroid hormone (PTH) secretion. To test this, we compared the effects of ED-71, a hydroxypropoxy derivative of 1alpha,25-dihydroxyvitamin D3, with orally administered alfacalcidol, on bone mineral density (BMD) and the bone remodeling process as a function of their effects on calcium metabolism and PTH, in a rat ovariectomy (ovx) model of osteoporosis. ED-71 increased bone mass at the lumbar vertebra to a greater extent than alfacalcidol, while enhancing calcium absorption (indicated by urinary calcium excretion) and decreasing serum PTH levels to the same degree as alfacalcidol. ED-71 lowered the biochemical and histological parameters of bone resorption more potently than alfacalcidol, while maintaining bone formation markers. These results suggest that active vitamin D exerts an antiosteoporotic effect by inhibiting osteoclastic bone resorption while maintaining osteoblastic function, and that these anticatabolic/anabolic effects of active vitamin D take place independently of its effects on calcium absorption and PTH. The demonstration that ED-71 is more potent in these properties than alfacalcidol makes it an attractive candidate as an antiosteoporotic drug.

175. Urol Nurs. 2002 Dec;22(6):405-9.

Osteoporosis--Part II: Dietary and/or supplemental calcium and vitamin D.

Moyad MA.

University of Michigan Medical Center, Department of Urology, Ann Arbor, MI, USA.

Osteoporosis is a significant problem in women and men. As osteoporosis has garnered more attention there seems to be more attention than ever placed on the potential benefits of calcium and vitamin D. Health professionals need to inform patients that there are numerous healthy dietary sources of calcium and vitamin D. Several forms of calcium supplements are commercially available today and health professionals need to understand the similarities and differences between them. Calcium and vitamin D in moderation also have an excellent safety profile and may actually have benefits far beyond osteoporosis therapy.

176. Pharmacol Ther. 2002 Jan;93(1):37-49.

Role of Ca(2+) and vitamin D in the prevention and treatment of osteoporosis.

Rodriguez-Martinez MA, Garcia-Cohen EC.

Unidad de Ensayos Clinicos y Area de Investigacion Farmacologica, Servicio de Farmacologia Clinica, Hospital Universitario Clinica Puerta de Hierro de Madrid, C/ San Martin de Porres 4, 28035 Madrid, Spain. mariangeles.rodriguez@uam.es

Osteoporosis is defined as a progressive systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. The clinical relevance of osteoporosis derives from the fractures that it produces. More than one-third of the adult women will suffer one or more osteoporotic fractures in their lifetime. The lifetime risk in men is approximately one-half that in women. The decrease of the bone mineral density is the most important cause of risk fracture. Among other factors, Ca(2+) and vitamin D deficiencies are important risk factors for a decrease in bone mineral density, consequently inducing osteoporosis. The high prevalence of vitamin D deficiency in healthy elderly people living mainly in southern European countries increase the risk of osteoporotic fractures in these populations above those anticipated for the general elderly population of the European community. In addition, the ageing of the European population will double the number of osteoporotic fractures over the next 50 years, unless adequate preventative measures are undertaken. The efficacy and safety of Ca(2+) and vitamin D supplements at preventing bone loss and reducing the risk of hip and other fractures have been assessed in different clinical trials, which are extensively discussed in this review.

177. Med J Aust. 2001 Oct 15;175(8):401-5.

Vitamin D status of women in the Geelong Osteoporosis Study: association with diet and casual exposure to sunlight.

Pasco JA, Henry MJ, Nicholson GC, Sanders KM, Kotowicz MA.

The University of Melbourne, Department of Clinical and Biomedical Sciences--Barwon Health, The Geelong Hospital, VIC.

OBJECTIVE: To assess vitamin D intake and casual exposure to sunshine in relation to serum 25-hydroxyvitamin D (25OHD) levels. DESIGN: Cross-sectional study of a population-based, random sample of women aged 20-92 years, assessed between 1994 and 1997. SETTING AND PARTICIPANTS: 861 women from the Barwon Statistical Division (population, 218000), which includes the city of Geelong (latitude 38 degrees south) in Victoria. MAIN OUTCOME MEASURES: Vitamin D intake; serum 25OHD level; season of assessment; exposure to sunshine. RESULTS: Median intake of vitamin D was 1.2 microg/day (range, 0.0-11.4 microg/day). Vitamin D supplements, taken by 7.9% of participants, increased intake by 8.1% to 1.3 microg/day (range, 0.0-101.2 microg/day) (P< 0.001). A dose-response relationship in serum 25OHD levels was observed for sunbathing frequency before and after adjusting for age (P< 0.05). During winter (May-October), serum 25OHD levels were dependent on vitamin D intake (partial r2= 0.01; P<0.05) and were lower than during summer (November-April) (age-adjusted mean, 59nmol/L [95% Cl, 57-62] v 81 nmol/L [95% CI, 78-84]; P<0.05). No association was detected between serum 25OHD and vitamin D intake during summer. The prevalences of low concentrations of serum 25OHD were, for <28nmol/L, 7.2% and 11.3% overall and in winter, respectively; and, for <50 nmol/L, 30.0% and 43.2% overall and in winter, respectively. CONCLUSIONS: At latitude 38 degrees south, the contribution of vitamin D from dietary sources appears to be insignificant during summer. However, during winter vitamin D status is influenced by dietary intake. Australia has no recommended dietary intake (RDI) for vitamin D, in the belief that adequate vitamin D can be obtained from solar irradiation alone. Our results suggest that an RDI may be needed.

178. Leukemia. 2001 Nov;15(11):1701-5.

Loss of bone mass and vitamin D deficiency after hematopoietic stem cell transplantation: standard prophylactic measures fail to prevent osteoporosis.

Massenkeil G, Fiene C, Rosen O, Michael R, Reisinger W, Arnold R.

Department of Internal Medicine, Clinic for Nuclear Medicine and Institute of Radiology, University Hospital Charite, Berlin, Germany.

Bone mineral density (BMD) and biochemical markers of bone metabolism were analyzed in 67 adults with ALL (n = 27), AML (n = 14), MDS (n = 6) and CML (n = 20) before and after allogeneic stem cell transplantation (SCT). Median age was 36 years (17-56). Twenty-six out of 53 patients (49%) had osteopenia and osteoporosis before SCT, 21/26 had acute leukemias and 5/26 had chronic myeloid leukemia (CML). T-score before SCTwas -1.23 in patients with acute leukemias and 0.62 in CML patients (P = 0.001). After SCT, a significant loss of BMD was observed in all patients. After 6 months, 24 of 36 evaluable patients (67%) had pathologic BMD, 11 of them (30%) had developed osteoporosis. After 12 months, 20 of 32 evaluable patients (62%) had BMD values below normal and nine of them (28%) had osteoporosis. Increased pyridinium excretion was observed in 12/20 patients (60%) with acute leukemias, but only in 3/13 (23%) with CML (P = 0.014). A prolonged vitamin D deficiency for more than 6 months developed early after SCT in all patients. Patients with acute leukemias frequently have osteopenia and osteoporosis before SCT. After SCT, a further loss of BMD occurs independent from the underlying disease. Standard prophylactic measures are not sufficient to prevent loss of bone mass. Studies on prophylactic interventions are needed to prevent severe osteoporosis in long-term survivors of SCT.

179. Nurs Clin North Am. 2001 Sep;36(3):417-31, viii.

Role of calcium, vitamin D, and other essential nutrients in the prevention and treatment of osteoporosis.

Dowd R.

Department of Medicine, Creighton University Osteoporosis Research Center, Omaha, Nebraska 68131, USA. racheld@creighton.edu

Calcium is an essential nutrient for the prevention and treatment of osteoporosis. Despite universal recognition of its importance, most people still do not obtain recommended amounts. Recent additions to the treatment of osteoporosis with potent bone active drugs produce an even greater need for calcium and total nutrition for restoration of lost bone. Practitioners and patients need to emphasize and appreciate the role that calcium, vitamin D, and other nutrients play in the promotion of health and in the prevention and treatment of disease.

180. Exp Clin Endocrinol Diabetes. 2001;109(2):87-92.

Vitamin D status, trunk muscle strength, body sway, falls, and fractures among 237 postmenopausal women with osteoporosis.

Pfeifer M, Begerow B, Minne HW, Schlotthauer T, Pospeschill M, Scholz M, Lazarescu AD, Pollahne W.

Institute of Clinical Osteology Gustav Pommer and Clinic Der Furstenhof, Bad Pyrmont, Germany. iko_pyrmont@t.online.de

The aim of this study was to identify factors associated with fractures in patients with postmenopausal osteoporosis. The overall hypothesis was that trunk muscle strength, body sway and hypovitaminosis D would influence daily activities and the likelihood of falls and fractures. - In 237 women (mean age 62.9+/-7.4 years) osteoporosis was defined by a T-score at the femoral neck below -2.5 SD. Trunk muscle strength was determined using isokinetic dynamometry and body sway was measured according to Lord et al. Limitations in everyday life were assessed and the history of falls was documented. A fracture was defined as a vertebral height reduction of more than 20% or at least 4 mm. The assessment was carried out using the Spine Deformity Index (SDI) and was confirmed by an experienced radiologist. Pearson coefficients of correlation were calculated. - After correction for age, significant associations were found for body sway and 25-hydroxyvitamin D (p<0.001), body sway and falls (p<0.001), body sway and rib fractures (p<0.01), trunk muscle strength and limitations in everyday life (p<0.001), trunk muscle strength and SDI (p<0.001), trunk muscle strength and bone density (p<0.001), and bone density and 25-hydroxyvitamin D (p<0.001). No significant correlation was found for trunk muscle strength and 25-hydroxyvitamin D (p=0.712). - Findings suggest that hypovitaminosis D is associated with increased body sway and an elevated risk for falls and falls-related fractures. Musculoskeletal rehabilitation should include strengthening exercises for the trunk muscles and training of neuromuscular co-ordination and balance.

181. Cochrane Database Syst Rev. 2001;(1):CD000227.

Update of: Cochrane Database Syst Rev. 2000;(2):CD000227.

Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis.

Gillespie WJ, Avenell A, Henry DA, O'Connell DL, Robertson J.

Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin, NEW ZEALAND. bill.gillespie@stonebow.otago.ac.nz

BACKGROUND: Due to their known effects on bone metabolism, vitamin D and related compounds have been proposed for the prevention of osteoporosis and fractures. OBJECTIVES: To determine the effects of supplementation with Vitamin D or a Vitamin D analogue in the prevention of fractures of the axial and appendicular skeleton in elderly men or women with involutional or post-menopausal osteoporosis. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CINAHL, LILACS, CABNAR, BIOSIS, HEALTHSTAR, Current Contents, The Cochrane Database of Systematic Reviews, the Cochrane Musculoskeletal Injuries Group trials register, and bibliographies of identified trials and reviews. Date of the most recent search: September 2000. SELECTION CRITERIA: Any randomised or quasi-randomised trial which compared vitamin D or a vitamin D analogue, either alone or in combination with calcium supplementation, with a placebo, no intervention, or the administration of calcium supplements, with eligible fracture outcomes, in elderly men or women with involutional or post-menopausal osteoporosis. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Additional information was sought from trialists. Where possible the data were pooled. Pooling of data, where it was admissible, used pooled relative risk and fixed effects model. MAIN RESULTS: Almost all estimates of treatment effects are based on single studies. Administration of vitamin D3 alone without calcium co-supplementation was not associated with any reduction in incidence of hip fracture (relative risk (RR) 1.20, 95% confidence interval (CI) 0.83, 1.75) or other non-vertebral fracture. Administration of vitamin D3 with calcium co-supplementation to frail elderly people in sheltered accommodation was associated with a reduction in incidence of hip fracture (RR 0.74, 95% CI 0.60, 0.91). In healthy younger, ambulant participants the effect on hip fracture is unknown (RR 0.36, 95% CI 0.01, 8.78), although there appears to be a significant overall effect on non-vertebral fracture incidence in this group ( RR 0.46, 95% CI 0.23,0.90). Calcitriol (1,25 dihdyroxy vitamin D) was effective in reducing the incidence of vertebral deformity (RR 0.49, 95% CI 0.25, 0.95). Calcitriol was more effective than calcium in reducing the frequency of new vertebral deformities during the third year of treatment (RR 0.28, 95% CI 0.15, 0.52). 1-alpha-hydroxy vitamin D was effective in reducing the incidence of non-vertebral fractures in a single small study of elderly people whose mobility was impaired by neurological disease (RR 0.12, 95% CI 0.02, 0.95). No statistically significant effects were found for other comparisons of vitamin D or its analogues against each other, with and without calcium supplementation. REVIEWER'S CONCLUSIONS: Uncertainty remains about the efficacy of regimens which include vitamin D or its analogues in fracture prevention. Particularly if co-supplementation of calcium is required, significant cost differences are likely to exist between regimens. Further large randomised trials are currently being conducted to clarify the effectiveness of community fracture prevention programmes employing vitamin D supplementation.

182. Rheum Dis Clin North Am. 2001 Feb;27(1):101-30.

Calcium and vitamin D in osteoporosis.

Morgan SL.

Division of Clinical Nutrition and Dietetics, Departments of Nutrition Sciences and Medicine, Schools of Medicine, Health Related Professions, and Dentistry, University of Alabama at Birmingham, Birmingham, Alabama, USA. slmorgan@uab.edu

Calcium and vitamin D are useful adjunctive therapies in the prevention and treatment of osteoporosis. Peak BMD is optimally achieved with sustained optimal calcium and vitamin D intakes. Calcium and vitamin D intakes continue to be important after the third decade and into senescence. Although calcium and vitamin D are not therapies to be used alone to prevent early postmenopausal bone loss, they assume more prominent roles in late menopause and in the elderly to preserve bone health with advancing age. Calcium and vitamin D supplementation is an important adjunctive therapy to use together with antiresorptive therapies.

183. J Clin Endocrinol Metab. 2001 Mar;86(3):1212-21.

Erratum in: J Clin Endocrinol Metab 2001 Jul;86(7):3008.

A global study of vitamin D status and parathyroid function in postmenopausal women with osteoporosis: baseline data from the multiple outcomes of raloxifene evaluation clinical trial.

Lips P, Duong T, Oleksik A, Black D, Cummings S, Cox D, Nickelsen T.

Department of Endocrinology, Academic Hospital Vrije Universiteit, 1007 M.B. Amsterdam, The Netherlands. p.lips@azvu.nl

Vitamin D deficiency leads to secondary hyperparathyroidism, increased bone turnover, and bone loss and, when severe, to osteomalacia. Vitamin D deficiency is common in elderly people, especially the institutionalized. The definition of vitamin D deficiency is hampered by the fact that large interlaboratory differences exist in assays for serum 25-hydroxyvitamin D (25OHD), the main circulating metabolite. The international Multiple Outcomes of Raloxifene Evaluation study, a large prospective intervention trial in postmenopausal women with osteoporosis, offered the opportunity to compare vitamin D status and parathyroid function throughout many countries over the world. For this study, baseline data were available from 7564 postmenopausal women from 25 countries on 5 continents. All women had osteoporosis, i.e. bone mineral density (BMD) at femoral neck or lumbar spine was lower than t-score -2.5, or they had 2 vertebral fractures. Serum 25OHD was measured by RIA, and serum PTH was measured by immunoradiometric assay. BMD was measured by dual x-ray absorptiometry. The mean (+/-SD) serum 25OHD was 70.8 +/- 30.9 nmol/L. A low serum 25OHD (<25 nmol/L) was observed in 4.1% of all women in the Multiple Outcomes of Raloxifene Evaluation study, ranging from 0% in south east Asia (very few patients) to 8.3% in southern Europe. Serum 25OHD was between 25-50 nmol/L in 24.3% of the women. Serum 25OHD showed a significant seasonal relationship, with lower values in all regions in winter. Serum PTH correlated negatively with serum 25OHD (r = -0.25; P < 0.001). This significant negative correlation was observed in all regions. When serum 25OHD was less than 25, 25-50, or more than 50 nmol/L, respectively, mean serum PTH levels were 4.8, 4.1, and 3.5 pmol/L, respectively (by ANOVA, P < 0.001). Similarly, mean alkaline phosphatase levels were 83.7, 79.1, and 75.7 U/L (P < 0.001), respectively, with increasing serum 25OHD. The effect of serum 25OHD on BMD was only significant for the BMD of the trochanter where a serum 25OHD level less than 25 nmol/L was associated with a 4% lower BMD. After 6 months of treatment with vitamin D(3) (400-600 IU/day) and calcium (500 mg/day), serum 25OHD increased from 70.8 +/- 29.8 to 92.3 +/- 28.6 nmol/L. Serum PTH decreased significantly after 6 months of treatment, and this decrease depended on baseline serum 25OHD. When baseline serum 25OHD was less than 25, 25-50, or more than 50 nmol/L, respectively, serum PTH decreased by 0.8, 0.5, or 0.2 pmol/L, respectively (P < 0.001). In conclusion, serum 25OHD was less than 25 nmol/L in 4% of the women, and this was associated with a 30% higher serum PTH. In 24% of the women serum 25OHD was between 25-50 nmol/L, associated with a 15% higher level of serum PTH compared with women with a serum 25OHD greater than 50 nmol/L. A low serum 25OHD level was also associated with higher serum alkaline phosphatase and lower BMD of the trochanter. Treatment with vitamin D(3) and calcium increased serum 25OHD and decreased serum PTH significantly; the effect was greater for lower baseline serum 25OHD.

184. J Bone Miner Res. 2000 Nov;15(11):2276-83.

A randomized controlled trial of vitamin D supplementation on preventing postmenopausal bone loss and modifying bone metabolism using identical twin pairs.

Hunter D, Major P, Arden N, Swaminathan R, Andrew T, MacGregor AJ, Keen R, Snieder H, Spector TD.

Twin Research and Genetic Epidemiology Unit, St. Thomas' Hospital, London, United Kingdom.

Vitamin D supplementation, when given with calcium, has been shown to increase bone mineral density (BMD) and reduce the incidence of hip fracture in elderly subjects. Despite its widespread use, the benefits of vitamin D supplementation in younger women and as a single agent are less clear. We performed a randomized co-twin, placebo-controlled, double-blind trial over 2 years to measure the effect of vitamin D3 supplementation on bone density and bone metabolism in young postmenopausal women. Seventy-nine monozygotic (MZ) twin pairs (mean age, 58.7 years; range, 47-70 years) were recruited. For each twin pair, one was randomized to 800 IU cholecalciferol/day for 2 years and the other was randomized to placebo. BMD was measured at the spine and hip and heel ultrasound at baseline, 12, 18, and 24 months. Samples were collected at 0, 3, and 6 months to measure serum calcium, 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), osteocalcin, and urinary deoxypyridinoline (DPD). In total, 64 pairs completed the study. No differences in baseline characteristics were seen between the groups. At 6 months, the treatment group had an increase in serum vitamin D [mean +/- SEM intrapair difference, 14.1+/-2.4 microg/liter (p < 0.001)]. There were no significant differences in other serum measurements or bone markers at 3 months or 6 months. At 24 months, no significant treatment effect was seen on BMD or calcaneal ultrasound change within pairs. Subanalysis of treatment response by vitamin D receptor (VDR) genotype revealed no significant difference in effect on BMD variables with treatment. On the basis of these results, vitamin D supplementation, on its own, cannot be recommended routinely as an osteoporosis prevention for healthy postmenopausal women with normal vitamin D levels under the age of 70 years.

185. Med Clin (Barc). 2000 Jun 10;115(2):46-51.

[Treatment of osteoporosis with calcium and vitamin D. Systematic review]

[Article in Spanish]

Vallecillo G, Diez A, Carbonell J, Gonzalez Macias J.

Servicio de Medicina Interna y Enfermedades Infecciosas, Hospital del Mar, Barcelona.

BACKGROUND: Systematic review of the efficacy of calcium and vitamin D for the treatment of osteoporosis. MATERIAL AND METHOD: Review of the database MEDLINE between 1996 and may 1998, by the key words: osteoporosis, calcium, vitamin D (and related terms) and randomized clinical trial. Review of the electronic versions of Best Evidence, The Cochrane Library, congress abstracts and references from two main textbooks. Ascending review of the literature. All the reviews were performed independently by two of the authors. Design parameters and main results of the primary publications of the identified trials were tabulated. Two independent observers carried out methodological scoring of the studies. Results were tabulated and a judgement made for the results. RESULTS: Eleven studies on calcium, 8 of vitamin D and 12 about calcitriol and other hormone derivatives were included. Studies with calcium were mainly performed on non-clinical populations and in three anti-fracture efficacy was analyzed. Results were positive in population with low baseline intake and substantial supplementation. Trials on vitamin D were done in non-clinical and on institutionalized populations. Trials with calcitriol were developed mainly in osteoporotic fracture populations and reached poorer methodological validity scores. Heterogeneity of the studies precluded a meta-analysis of the different treatments. Studies on calcium showed clinical efficacy in a more consistent way. Inter-observer score was good (kappa = 0.81) and there were no significant correlations between sample size and effect in the different studies. CONCLUSIONS: Calcium treatment is efficacious in populations with low intake receiving substantial supplementation. Vitamin D is efficacious associated with calcium mainly in deficient populations. Efficacy of calcitriol and other derivatives is more controversial.

186. Cochrane Database Syst Rev. 2000;(2):CD000952.

Calcium and vitamin D for corticosteroid-induced osteoporosis.

Homik J, Suarez-Almazor ME, Shea B, Cranney A, Wells G, Tugwell P.

Medicine, 562 Heritage Medical Research Centre, University Of Alberta, Edmonton, Alberta, Canada, T6G 2S2. jhomik@gpu.srv.ualberta.ca

OBJECTIVES: To assess the effects of calcium and vitamin D compared to calcium alone or placebo in the prevention of bone loss in patients taking systemic corticosteroids. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal trials register, Cochrane Controlled Trials Register, EMBASE and Medline up to 1996. We also conducted a hand search of abstracts from various scientific meetings and reference lists of selected trials. SELECTION CRITERIA: All randomized trials comparing calcium and vitamin D to calcium alone or placebo in patients taking systemic corticosteroids. DATA COLLECTION AND ANALYSIS: Data was abstracted from trials by two investigators. Methodological quality was assessed in a similar manner. Analysis was performed using fixed effects models. MAIN RESULTS: Five trials were included, with 274 patients. The analysis was performed at two years after starting calcium and vitamin D. There was a significant weighted mean difference (WMD) between treatment and control groups in lumbar (WMD 2.6 (95% CI 0.7, 4.5), and radial bone mineral density (WMD 2.5 (95% CI 0.6, 4.4). The other outcome measures (femoral neck bone mass, fracture incidence, biochemical markers of bone resorption) were not significantly different. REVIEWER'S CONCLUSIONS: This meta-analysis demonstrated a clinically and statistically significant prevention of bone loss at the lumbar spine and forearm with vitamin D and calcium in corticosteroid treated patients. Because of low toxicity and cost all patients being started on corticosteroids should receive prophylactic therapy with calcium and vitamin D.

187. Arthritis Rheum. 1999 Aug;42(8):1740-51.

Comment in: Arthritis Rheum. 2000 May;43(5):1188-90.

The role of vitamin D in corticosteroid-induced osteoporosis: a meta-analytic approach.

Amin S, LaValley MP, Simms RW, Felson DT.

Boston University Arthritis Center, Massachusetts 02118, USA.

OBJECTIVE: To determine if vitamin D is more effective than no therapy or calcium alone in the management of corticosteroid-induced osteoporosis, and to determine how vitamin D compares with other osteoporosis therapies, e.g., bisphosphonates, calcitonin, or fluoride, for this condition. METHODS: We evaluated all formulations of vitamin D, including its active metabolites and analogs. A systematic search for published and unpublished studies was conducted using MEDLINE (1966-December 1997), bibliographic references, abstracts from proceedings of recent national meetings, and contact with pharmaceutical companies and content experts. We included all randomized controlled trials lasting at least 6 months (and reporting extractable results), of patients receiving oral corticosteroids, that compared vitamin D with either 1) no therapy or calcium alone, or 2) bisphosphonates, calcitonin, or fluoride. The primary outcome measure of interest was change in lumbar spine bone mineral density. RESULTS: We found a moderate beneficial effect of vitamin D plus calcium versus no therapy or calcium alone (9 trials) (effect size 0.60; 95% confidence interval [95% CI] 0.34, 0.85; P < 0.0001). In comparisons of vitamin D with other osteoporosis therapies, bisphosphonates were more effective than vitamin D (6 trials) (effect size 0.57; 95% CI 0.09, 1.05). Calcitonin was similar in efficacy to vitamin D (4 trials) (effect size 0.03; 95% CI -0.39, 0.45). Fluoride was more effective than vitamin D, but there were only 2 trials. CONCLUSION: Vitamin D plus calcium is superior to no therapy or calcium alone in the management of corticosteroid-induced osteoporosis. Vitamin D is less effective than some osteoporosis therapies. Therefore, treatment with vitamin D plus calcium, as a minimum, should be recommended to patients receiving long-term corticosteroids.

188. MMW Fortschr Med. 1999 Aug 12;141(31-32):32-6.

[Therapy of osteoporosis: native vitamin D or as hormone? Advantages of activated vitamin D in secondary osteoporosis]

[Article in German]

Scharla SH.

Abteilung Innere Medizin, Klinikum Berchtesgadener Land, Schonau am Konigssee.

Vitamin D and its active metabolite (D-Hormone) are major weapons in the therapeutic arsenal available for the treatment of osteoporosis. With regard to native vitamin D, controlled studies have confirmed the prophylactic effect of treatment with vitamin D (+ calcium) in the area of nonvertebral fractures, in particular in elderly women with vitamin D deficiency. The widespread prophylactic use of this form of treatment, which is both inexpensive and largely free of side effects, would presumably save costs by greatly reducing the incidence of fractures of the femur. Treatment with D-hormone (calcitriol) or the pro-hormone 1 alpha-hydroxy-vitamin D (alfacalcidol) is a specific form of treatment of osteoporosis that has been shown to prevent fractures, in particular of the vertebrae, in a number of controlled prospective studies. The D-hormone is of particular value in the treatment of secondary forms of osteoporosis (induced by glucocorticoids or chronic inflammatory disease). Although the incidence of severe side effects is low, monitoring of serum calcium ist nevertheless recommended.

189. Calcif Tissue Int. 1999 Oct;65(4):295-306.

Vitamin D therapy of osteoporosis: plain vitamin D therapy versus active vitamin D analog (D-hormone) therapy.

Lau KH, Baylink DJ.

Department of Medicine, Loma Linda University, and Musculoskeletal Disease Center (151), 11201 Benton Street, Loma Linda, California 92357 USA.

Normal intestinal calcium (Ca) absorption is an essential feature of bone homeostasis. As with many other organ systems, intestinal Ca absorption declines with aging, and this is one pathological factor that has been identified as a cause of senile osteoporosis in the elderly. This abnormality leads to secondary hyperparathyroidism, which is characterized by high serum parathyroid hormone (PTH) and an increase in bone resorption. Secondary hyperparathyroidism due to poor intestinal Ca absorption has been implicated not only in senile osteoporosis but also in age-related bone loss. Accordingly, in population-based studies, there is a gradual increase in serum PTH from about 20 years of age onward, which constitutes a maximum increase at 80 years of age of 50% of the basal value seen at 30 years of age. The cause of the increase in PTH is thought to be partly due to impaired intestinal Ca absorption that is associated with aging, a cause that is not entirely clear but at least in some instances is related to some form of vitamin D deficiency. There are three types of vitamin D deficiency: (1) primary vitamin D deficiency, which is due to a deficiency of vitamin D, the parent compound; (2) a deficiency of 1,25(OH)(2)D(3) resulting from decreased renal production of 1,25(OH)(2)D(3); and (3) resistance to 1,25(OH)(2)D(3) action owing to decreased responsiveness to 1, 25(OH)(2)D(3) of target tissues. The cause for the resistance to 1, 25(OH)(2)D(3) could be related to the finding that the vitamin D receptor level in the intestine tends to decrease with age. All three types of deficiencies can occur with aging, and each has been implicated as a potential cause of intestinal Ca malabsorption, secondary hyperparathyroidism, and senile osteoporosis. There are two forms of vitamin D replacement therapies: plain vitamin D therapy and active vitamin D analog (or D-hormone) therapy. Primary vitamin D deficiency can be corrected by vitamin supplements of 1000 U a day of plain vitamin D whereas 1,25(OH)(2)D(3) deficiency/resistance requires active vitamin D analog therapy [1, 25(OH)(2)D(3) or 1alpha(OH)D(3)] to correct the high serum PTH and the Ca malabsorption. In addition, in the elderly, there are patients with decreased intestinal Ca absorption but with apparently normal vitamin D metabolism. Although the cause of poor intestinal Ca absorption in these patients is unclear, these patients, as well as all other patients with secondary hyperparathyroidism (not due to decreased renal function), show a decrease in serum PTH and an increase in Ca absorption in response to therapy with 1, 25(OH)(2)D(3) or 1alpha(OH)D(3). In short, it is clear that some form of vitamin D therapy, either plain vitamin D or 1,25(OH)(2)D(3) or 1alpha(OH)D(3), can be used to correct all types of age-dependent impairments in intestinal Ca absorption and secondary hyperparathyroidism during aging. However, from a clinical standpoint, it is important to recognize the type of vitamin D deficiency in patients with senile osteoporosis so that primary vitamin D deficiency can be appropriately treated with plain vitamin D therapy, whereas 1,25(OH)(2)D(3) deficiency/resistance will be properly treated with 1,25(OH)(2)D(3) or 1alpha(OH)D(3) therapy. With respect to postmenopausal osteoporosis, there is strong evidence that active vitamin D analogs (but not plain vitamin D) may have bone-sparing actions. However, these effects appear to be results of their pharmacologic actions on bone formation and resorption rather than through replenishing a deficiency.

190. Clin Endocrinol (Oxf). 1999 Aug;51(2):217-21.

Vitamin D insufficiency increases bone turnover markers and enhances bone loss at the hip in patients with established vertebral osteoporosis.

Sahota O, Masud T, San P, Hosking DJ.

Ageing and Disability Research Unit, University Hospital, Nottingham, UK.

AIM: The aim of this study was to determine whether the presence of vitamin D insufficiency increases bone turnover and enhances bone loss by examining the relationship between bone turnover markers and Bone mineral density (BMD) in vitamin D insufficient and vitamin D sufficient patients, with established vertebral osteoporosis. SUBJECTS: 119 consecutive, active, community dwelling, elderly women were assessed over a 7-month period between the months of March to October. RESULTS: There was a significant correlation between parathyroid hormone (PTH) and 25 hydroxyvitamin D (25(OH)D), r = - 0. 42 (P < 0.01). The prevalence of vitamin D insufficiency was 26.9% (defined by a 25(OH)D >/= 6.1 microg/l and </= 12 microg/l). This resulted in a statistically significant increase in bone turnover markers compared to the vitamin D sufficient group: bone alkaline phosphatase (P < 0.05), osteocalcin (P < 0.01), hydroxyproline (P < 0.05), free deoxypyridinoline (P < 0.05) and lower bone mineral density at the total hip (P < 0.01). CONCLUSIONS: These results show that there is a high prevalence of vitamin D insufficiency in the active community dwelling elderly with established vertebral osteoporosis presenting to clinical attention, which leads to increased bone turnover, decreased BMD at the hip and thus enhanced risk of further osteoporotic fractures in comparison with vitamin D sufficient subjects.

191. Endocrinol Metab Clin North Am. 1998 Jun;27(2):389-98.

The roles of calcium and vitamin D in the prevention of osteoporosis.

Reid IR.

Department of Medicine, University of Auckland, New Zealand.

Calcium supplementation produces small beneficial effects on bone mass throughout postmenopausal life and may reduce fracture rates by more than this change would predict--possibly by as much as 50%. There is little reason to use vitamin D in young populations that are replete in this compound, but in the elderly at risk of vitamin D deficiency, there is now evidence of significant reductions in nonvertebral fracture rates from physiologic replacement regimens. Some of the most substantial reductions in fracture rates have been found with combined therapy with calcium and vitamin D, and in these protocols it is not clear which is the principal active agent or whether, in fact, the combination is necessary for optimal antifracture efficacy.

192. Nippon Rinsho. 1998 Jun;56(6):1505-10.

[Treatment of osteoporosis by active vitamin D]

[Article in Japanese]

Kawakami H, Morii H.

Osaka City University Medical School.

Supplementation of active vitamin D has been thought to be reasonable for those who convert insufficiently vitamin D to active form, especially for senile persons. Treatment of osteoporosis by vitamin D are accepted as not only supplementation of vitamin D but also direct activation of bone turnover. Several previous clinical trials suggest active vitamin D prevents fractures more effectively rather than the increase of the bone mass. The calcium intake of Japanese people is less than that of Western countries, and many of Japanese have the vitamin D receptor genotype which is more responsive to vitamin D. Therefore, it is probable that active vitamin D is more effective for Japanese than Western people.

193. J Bone Miner Res. 1998 Apr;13(4):544-8.

Seasonal deficiency of vitamin D in children: a potential target for osteoporosis-preventing strategies?

Docio S, Riancho JA, Perez A, Olmos JM, Amado JA, Gonzalez-Macias J.

Service of Pediatrics, Hospital Laredo, Santander, Spain.

Peak bone mass attained after skeletal growth is a major determinant of the risk of developing osteoporosis later in life, hence the importance of nutritional factors that contribute to bone mass gain during infancy and adolescence. An adequate supply of vitamin D is essential for normal bone homeostasis. This study was undertaken to determine what the levels are of 25-hydroxyvitamin D (25(OH)D) that may be considered desirable in children and to assess if normal children maintain these levels throughout the year. Vitamin D metabolites and parathyroid hormone (PTH) serum levels were measured in 21 children in March and October, prior to and after the administration of a daily supplement of 25(OH)D (40 microg for 7 consecutive days). There were inverse correlations between basal 25(OH)D levels and supplementation-induced changes in serum 1,25(OH)2D (r = 0.57, p < 0.05) and PTH (r = 0.41, p < 0.05). When basal levels of 25(OH)D were below 20 ng/ml, the supplement induced an increase in serum 1,25(OH)2D; with basal 25(OH)D under 10-12 ng/ml, the supplement also decreased serum PTH. The lowest serum level of 25(OH)D in 43 normal children studied in summer was 13 ng/ml. Those results suggested that the lowest limit for desirable levels of 25(OH)D in children was somewhere between 12 and 20 ng/ml. However, 31% of 51 normal children studied in winter had levels below 12 ng/ml, and 80% had levels lower than 20 ng/ml. Those children are likely to have suboptimal bioavailability of vitamin D, which might hamper their achievement of an adequate peak bone mass. Since cutaneous synthesis of vitamin D is rather limited in winter, oral vitamin D supplementation should be considered.

194. Am J Med Sci. 1996 Dec;312(6):278-86.

Therapy of osteoporosis: calcium, vitamin D, and exercise.

Reid IR.

Department of Medicine, University of Auckland, New Zealand.

Calcium supplementation has long been regarded as a fundamental part of the prevention and treatment of postmenopausal osteoporosis, but it is only in recent years that clear evidence has emerged demonstrating its impact on bone mass. Calcium supplementation does not completely arrest postmenopausal bone loss but slows the rate of decline by 30 to 50%. The effect of calcium supplementation on fracture incidence in postmenopausal women has not been established. Vitamin D deficiency is common in the frail elderly, particularly in countries where fortification or food with this vitamin is not practiced. Treatment of vitamin D deficiency has been associated with significant reductions in the number of hip fractures. The role of the potent vitamin D metabolites, calcitriol and alphacalcidol, in the management of postmenopausal osteoporosis is not clear. Although some studies show substantial benefits in bone density or fracture rate from the use of these compounds, the published data are inconsistent. In general, hormone replacement therapy and the potent bisphosphonates produce greater effects on bone density and there is a greater consistency among the results of the published studies of these other interventions. Controlled trials of exercise interventions in postmenopausal women show that exercise can positively influence bone density by a few percent. Exercise interventions in the elderly have been reported to decrease fall frequency by 10%. This latter effect may have a greater impact on fracture frequency than the modest benefits of exercise on bone-density.

195. CMAJ. 1996 Oct 1;155(7):955-61.

Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 8. Vitamin D metabolites and analogs in the treatment of osteoporosis.

Jones G, Hogan DB, Yendt E, Hanley DA.

Department of Biochemistry, Queen's University, Kingston, Ont.

OBJECTIVE: To review recent findings on the skeletal actions of vitamin D and to examine results of the latest clinical trials of vitamin D in the treatment of osteoporosis. OPTIONS: The vitamin D analog 1-alpha hydroxycholecalciferol (1 alpha-OH-D3); the vitamin D metabolite calcitriol. OUTCOMES: Fracture and loss of bone mineral density in osteoporosis; increased bone mass, prevention of fractures and improved quality of life associated with vitamin D therapies. EVIDENCE: Relevant laboratory and clinical studies and reports were examined. Greatest reliance was placed on recent large-scale, randomized, controlled trials; others were noted and their methods critiqued. Clinical practice in Japan was also considered. VALUES: Reducing fractures, increasing bone mineral density and minimizing side effects of treatment were given a high value. BENEFITS, HARMS AND COSTS: Vitamin D maintains the dynamic nature of bone and so presumably helps to keep it healthy. Calcitriol and 1 alpha-OH-D3 may be effective in increasing bone mass and preventing fractures in osteoporosis. Calcitriol may be an alternative treatment in the prevention and management of corticosteroid-induced osteoporosis. Possible side effects of vitamin D analogs and metabolites are hypercalcemia, hypercalciuria, renal calcification and renal stones. RECOMMENDATIONS: The use of 1 alpha-OH-D3 for the treatment of osteoporosis in Canada cannot be supported without larger and longer randomized, controlled clinical trials. Calcitriol appears to prevent vertebral fractures in patients with osteoporosis. More information is needed on its mechanism of action and efficacy in preventing hip fractures. Future studies should focus on comparisons with other effective therapies and on determining whether its effect on fractures is greater than that achieved through improved vitamin D nutrition. Patients taking calcitriol at dose levels required for antifracture effects should be monitored for serum and urine calcium response to the drug. Calcitriol should not be given to patients whose calcium intake is at current generally recommended levels. At present, prescription of calcitriol for the treatment of osteoporosis should be reserved for physicians with a special interest in the treatment of metabolic bone disease.

196. J Rheumatol. 1996 Jun;23(6):995-1000.

Comment in: J Rheumatol. 1997 Feb;24(2):407.

Vitamin D and calcium in the prevention of corticosteroid induced osteoporosis: a 3 year followup.

Adachi JD, Bensen WG, Bianchi F, Cividino A, Pillersdorf S, Sebaldt RJ, Tugwell P, Gordon M, Steele M, Webber C, Goldsmith CH.

Rheumatic Disease Unit, St. Joseph's Hospital, McMaster University, Hamilton, Canada.

OBJECTIVE: To determine the efficacy and safety of vitamin D 50,000 units/week and calcium 1,000 mg/day in the prevention of corticosteroid induced osteoporosis. METHODS: A minimized double blind, placebo controlled trial in corticosteroid treated subjects in a tertiary care university affiliated hospital. The sample was 62 subjects with polymyalgia rheumatica, temporal arteritis, asthma, vasculitis, or systemic lupus erythematosus. The primary outcome measure was the percentage change in bone mineral density (BMD) of the lumbar spine in the 2 treatment groups from baseline to 36 mo followup. RESULTS: BMD of the lumbar spine in the vitamin D and calcium treated group decreased by a mean (SD) of 2.6% (4.1%) at 12 mo, 3.7% (4.5%) at 24 mo, and 2.2% (5.8%) at 36 mo. In the placebo group there was a decrease of 4.1% (4.1%) at 12 mo, 3.8% (5.6%) at 24 mo, and 1.5% (8.8%) at 36 mo. The observed differences between groups were not statistically significant. The difference at 36 mo was-0.693% (95% CI -5.34, 3.95). CONCLUSION: Vitamin D and calcium may help prevent the early loss of bone seen in the lumbar spine as measured by densitometry of the lumbar spine. Longterm vitamin D and calcium in those undergoing extended therapy with corticosteroids does not appear to be beneficial.

197. Proc Soc Exp Biol Med. 1996 Jun;212(2):110-5.

Vitamin D in the treatment of osteoporosis revisited.

Fujita T.

Calcium Research Institute, Osaka, Japan.

Interest in vitamin D treatment for osteoporosis has recently been revived because of the focus in various parts of the world on the elderly population, which is predominantly vitamin D deficient, in addition to postmenopausal osteoporosis due to estrogen withdrawal, which has been the central theme of osteoporosis research for many years. Combined use of other agents along with vitamin D has fortified the therapeutic armory against osteoporosis. The recent suggestion of a role of vitamin D receptor polymorphism in the development and progress of osteoporosis, possibly by interfering with its expected action, provoked intense discussions on the role of vitamin D in the pathogenesis and treatment of osteoporosis. Vitamin D receptor polymorphism may explain some of the racial differences in the incidence of osteoporosis and its complications. Responses to vitamin D treatment may also be predicted by vitamin D receptor allelic analysis, though the currently proposed allelic patterns are yet far from being widely accepted. The outlook for vitamin D treatment for osteoporosis may require insight into vitamin D receptor, not only for vitamin D's given form, but also for a possible future form designed to intervene at the genomic level.

198. Clin Rheumatol. 1995 Sep;14 Suppl 3:9-13.

Role of calcium and vitamin D in the prevention and the treatment of postmenopausal osteoporosis: an overview.

Kaufman JM.

Department of Endocrinology and Rheumatology, University Hospital, Ghent, Belgium.

When discussing the use of calcium and vitamin D in the prevention and the treatment of osteoporosis one can make a distinction between the use as dietary supplementation to correct or prevent deficiencies, and the pharmacologic use of higher doses, whether or not in association with other drugs. However, in practical terms it is not always possible to clearly make this distinction. Available evidence suggests that increasing the calcium intake can favourably affect the build-up of bone mass in adolescence. In this population, the daily consumption of calcium in the diet should, optimally, be at least 1200 mg/day. In view of the lack of data pertaining to the effect on the final peak bone mass, there is at present time no basis for the systematic administration of calcium supplements to healthy children and adolescents. Calcium supplementation, aiming at a total calcium intake of at least 1500 mg/day, has a partial protective effect on postmenopausal bone loss, this effect being documented mainly in women more than 5 years after menopause. In the present state of our knowledge, there is no established role for vitamin D supplementation in the prevention of postmenopausal osteoporosis, except in elderly patients presenting with a higher risk for relative vitamin D deficiency and with low calcium intake. The results of a controlled trial suggest that in institutionalised elderly patients, systematic administration of calcium and vitamin D supplements can substantially reduce the risk of hip fracture. In the treatment of established postmenopausal osteoporosis, calcium supplementation has only a role as a general adjuvant therapeutic measure and as a specific complement to the treatment with other active compounds. There are indications that treatment alpha-calcidol or calcitriol has a positive effect on the evolution of bone mass, but awaiting further confirmation of a favourable effect on the incidence of osteoporotic fractures, treatment with these drugs remains experimental.

199. Nord Med. 1995;110(10):253-7.

[Vitamin D and osteoporosis]

[Article in Swedish]

Ljunghall S, Charles P, Falch J, Haug E, Melhus H, Mellstrom D, Mosekilde L, Pedersen JI, Sorensen OH, Toss G.

Medicinkliniken, Akademiska Sjukhuset, Uppsala.

Vitamin D constitutes a complex endocrine-regulated system, and is both a prohormone for the endogenous synthesis of the active hormone, calcitriol, and a vitamin which may be administered to supply the organism's requirements. No single test or investigation is available for the demonstration of vitamin D deficiency. Both vitamin D intake and ability to synthesise vitamin D decrease with increasing age, and particularly the elderly in institutionalised care are at risk of developing vitamin D deficiency. Iceland excepted, mean daily vitamin D consumption in the Nordic countries is less then 5 micrograms; and in approximately 10-25 per cent of the population, daily intake is less than 2.5 micrograms which is insufficient to maintain an adequate serum calcidiol concentration in individuals unexposed to sunlight. The recommended daily intake of 5 micrograms, currently adopted in the Nordic countries, may be too low-an intake of 10 micrograms is probably necessary to satisfy requirements in the elderly.

200. Rheum Dis Clin North Am. 1994 Aug;20(3):759-75.

Role of vitamin D, its metabolites, and analogs in the management of osteoporosis.

Bikle DD.

University of California, San Francisco.

Vitamin D and its metabolites are well-established regulators of bone mineral homeostasis. Their clearest role is in the prevention and treatment of rickets and osteomalacia, bone diseases characterized by inadequate bone formation, and mineralization. Much of the effectiveness of vitamin D and its active metabolite 1,25(OH)2D in treating such disorders rests with their ability to increase serum levels of calcium and phosphate principally by stimulating intestinal calcium and phosphate absorption. Osteoporosis is not a disease resulting from obvious deficiencies in vitamin D, calcium, and phosphate. More subtle deficiencies, however, may be found, especially among the elderly with decreased intake of dairy products, reduced sunlight exposure, and less efficient intestinal absorption of bone minerals. Such subtle deficiencies may account for the ability of vitamin D and calcium supplementation to have a beneficial effect on bone mineral density in this population. Estrogen administration to postmenopausal females raises 1,25(OH)2D levels, presumably through increased renal production, and this increase is associated with increased intestinal calcium transport. Serum measurements of the vitamin D metabolites in general, however, and 1,25(OH)2D in particular do not consistently show evidence of a decrease at the time of menopause. Although most studies show a fall in intestinal calcium transport with age, which can be reversed with 1,25(OH)2D or estrogen, even these observations have not been found consistently. Thus, some investigators have addressed the issue of tissue resistance to 1,25(OH)2D and have noted decreased VDR in the intestine and reduced 1,25(OH)2D accumulation by bone with age. Despite no obvious deficiency of vitamin D in most patients with osteoporosis, clinical trials with vitamin D or 1,25(OH)2D show promise. Vitamin D treatment will probably prove most efficacious in populations with marginal vitamin D intake and/or limited sunlight exposure; high doses would not be required, and the treatment would be safe. This would be a physiologic and not a pharmacologic use of vitamin D. The use of 1,25(OH)2D for treatment of osteoporosis in individuals with adequate nutrition and sunlight exposure may require somewhat higher than physiologic doses to be effective. Perhaps such doses are necessary to stimulate osteoblast activity and/or differentiation; by raising the serum calcium level, such doses of 1,25(OH)2D might block its otherwise stimulatory effect on osteoclast number and activity. Such doses run the risk of hypercalcemia and hypercalciuria, leading to nephrolithiasis and/or nephrocalcinosis. These undesirable side effects appear to be less common with the use of 1 alpha OHD compared with 1,25(OH)2D, but this may be because of the lower levels of calcium consumption in Japan where 1 alpha OHD is widely prescribed.(ABSTRACT TRUNCATED AT 400 WORDS)

201. Eur J Gastroenterol Hepatol. 1995 Jul;7(7):609-14.

Prevention of bone mineral loss in patients with Crohn's disease by long-term oral vitamin D supplementation.

Vogelsang H, Ferenci P, Resch H, Kiss A, Gangl A.

Clinic of Internal Medicine IV (Department of Gastroenterology and Hepatology), University of Vienna, Austria.

OBJECTIVE: To determine whether long-term dietary supplementation with low doses of vitamin D helps to prevent bone loss and the development of osteoporosis or osteomalacia in out-patients with Crohn's disease. DESIGN: A randomized controlled study. SETTING: The out-patient clinic of a tertiary centre (university hospital). PATIENTS: Seventy-five out-patients (31 men and 44 women, aged 16-77 years) with Crohn's disease. INTERVENTIONS: All patients were randomly assigned to receive either an oral supplement of 1000 IU/day vitamin D for 1 year or no supplement. Bone mineral density, assessed in the distal part of the nondominant forearm using single photon absorptiometry, and serum levels of 25-hydroxyvitamin D, assessed using a competitive protein binding assay, were measured before and after the period of dietary supplementation. MAIN OUTCOME MEASURE: Relative change of bone mineral density. RESULTS: Serum levels of 25-hydroxyvitamin D increased in 57% of patients who received a supplement (compared with 37% of control patients). Bone mineral density decreased significantly in control patients [median -7%, interquartile range -12.6-(+0.4%)] but not in patients who received a supplement [median -0.2%, interquartile range -3.8-(+14%); P < 0.005]. Increases in bone mineral density were especially prevalent among patients who received the supplement and had normal serum levels of 25-hydroxyvitamin D (68%), whereas increases occurred in only 18% of patients with low serum levels of 25-hydroxyvitamin D (P = 0.008). Patients without an intestinal resection and receiving the vitamin D supplement had a marginally greater increase in bone mineral content than patients who had undergone a resection (P = 0.05). CONCLUSION: Long-term oral vitamin D supplementation seems to be an efficient means of preventing bone loss in patients with Crohn's disease and could be recommended, especially for patients at high risk of osteoporosis.

202. Osteoporos Int. 1993 Jul;3(4):209-14.

Metabolic effects of thiazide and 1,25-(OH)2 vitamin D in postmenopausal osteoporosis.

Sakhaee K, Zisman A, Poindexter JR, Zerwekh JE, Pak CY.

Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75235-8885.

It was previously shown that the stimulation of intestinal calcium absorption by exogenous 25-hydroxyvitamin D (25-OHD) in postmenopausal women with osteoporosis was attenuated when thiazide was added, probably due to the suppression of endogenous synthesis of 1,25-(OH)2 vitamin D (1,25-(OH)2D). To test whether the above attenuation could be averted if exogenous 1,25-(OH)2D replaced 25-OHD, 10 women with postmenopausal osteoporosis participated in a three-phase study comprising control (pretreatment), treatment with 1,25-(OH)2D 0.5 microgram/day for 4 weeks, and combined 1,25-(OH)2D and trichlormethiazide (TZ) 2 mg/day for 4 weeks. The 1,25-(OH)2D treatment significantly increased serum 1,25-(OH)2D from 60 +/- 7.2 (SD) to 154 +/- 48 pmol/l, fractional intestinal calcium absorption (alpha) from 0.386 +/- 0.055 to 0.613 +/- 0.081, and urinary calcium from 3.7 +/- 0.8 to 6.6 +/- 1.9 mmol/day. Addition of TZ significantly reduced urinary calcium from 6.6 +/- 1.9 to 4.8 +/- 1.3 mmol/day, without changing alpha (0.613 +/- 0.081 to 0.584 +/- 0.070), serum calcium or 1,25-(OH)2D (154 +/- 48 to 154 +/- 38 pmol/l). Thus, estimated calcium balance (absorbed minus urinary calcium, increased marginally to +5.6 mmol/day on 1,25-(OH)2D alone (p = 0.028) and significantly to +6.8 mmol/day on 1,25-(OH)2D+TZ, from the control value of +4.0 mmol/day. Seven patients who were treated long-term with combined 1,25-(OH)2D and TZ for 11-29 months maintained their alpha (0.593 +/- 0.099) and a marginally more positive estimated calcium balance (+6.4 mmol/day, p = 0.025 from the control phase). Moreover, there was a stability of bone density of radial shaft, femoral neck, and lumbar spine.(ABSTRACT TRUNCATED AT 250 WORDS)

203. J Cell Biochem. 1992 May;49(1):19-25.

Osteoporosis and vitamin D.

Nordin BE, Morris HA.

Division of Clinical Chemistry, Institute of Medical and Veterinary Science, Adelaide, South Australia.

Bone "density" (bone mass/bone volume) declines with age from the menopause in women and from about age 55 in men. This fall in bone density (osteoporosis) weakens the bones and leads to a progressive rise in fracture rates, particularly in women. Many risk factors contribute to the bone-losing process, but one which attracts increasing attention is calcium absorption. The main physiological regulator of calcium absorption is vitamin D. This is manufactured in the skin under the influence of UV-light and then converted to more potent metabolites in the liver and kidney. Although the serum levels of the most potent metabolite 1,25(OH)2D3 (calcitriol) are generally normal in osteoporotic women, treatment with small doses of calcitriol (about 0.25 micrograms daily) has a remarkable effect on absorptive performance and slows down the rate of bone loss. Improved synthetic metabolites are under development. There is likely also to be greatly increased scope for the use of vitamin D itself in osteoporosis. With advancing age, there is a tendency for men and women to be exposed to less and less sunlight, which is the main natural source of vitamin D. Vitamin D levels, therefore, decline with age, particularly in those who are housebound, and are found to be low in most reported series of hip fractures. It is likely that this form of vitamin D "insufficiency" has an adverse effect on calcium absorption in the elderly which accelerates bone loss and increases the risk of hip fracture and can be treated with small doses of vitamin D or its 25-hydroxy derivative.(ABSTRACT TRUNCATED AT 250 WORDS)

204. Calcif Tissue Int. 1991 Feb;48(2):78-81.

The relationship between serum vitamin D concentrations and in vivo tetracycline labeling of osteoid in crush fracture osteoporosis.

Mawer EB, Arlot ME, Reeve J, Green JR, Dattani J, Edouard C, Meunier PJ.

Department of Medicine, University of Manchester, UK.

Twenty of 22 consecutive British patients with crush fracture osteoporosis had transiliac bone biopsies following double in vivo tetracycline labeling synchronized with the collection of serum for the measurement of vitamin D metabolites. A significant but direct (rather than inverse) relationship was found between 25-hydroxyvitamin D (calcidiol) levels and the fraction of cancellous surfaces covered with osteoid not taking either tetracycline label (r = 0.53, P less than 0.02). There was no correlation with 1,25-dihydroxyvitamin D levels. No patient had frankly thickened osteoid seams although 3 had reduced but measurable calcidiol levels. These results make it unlikely that the majority of patients with osteoporosis who have osteoid of normal thickness but reduced uptake of tetracycline have a mineralization defect secondary to vitamin D deficiency. The pathophysiological significance of unlabeled osteoid in osteoporosis requires further investigation.

205. Calcif Tissue Int. 1991;49 Suppl:S46-9.

Is there a role for vitamin D in osteoporosis?

Lamberg-Allardt C.

Endocrine Research Laboratory, University of Helsinki, Minerva Foundation Institute for Medical Research, Finland.

Vitamin D has certain clearly defined effects on bone: vitamin D deficiency results in defective bone mineralization, whereas 1,25-dihydroxy-vitamin D3 (1,25-(OH)2D3) stimulates bone resorption. Studies of the use of 1,25-(OH)2D3 to prevent or treat osteoporosis have given conflicting results concerning bone remodeling. However, 1,25-(OH)2D3 or other vitamin D metabolites seem to play a role in the correction of calcium malabsorption, which is a common feature in osteoporosis.

206. Calcif Tissue Int. 1989 Sep;45(3):137-41.

Effect of calcitonin and vitamin D in osteoporosis.

Palmieri GM, Pitcock JA, Brown P, Karas JG, Roen LJ.

Department of Medicine, University of Tennessee, Memphis.

Vitamin D has complex effects in bone: it stimulates matrix formation and bone maturation but also enhances osteoclastic activity and may influence differentiation of bone cell precursors. Calcitonin inhibits the function of osteoclasts, reducing bone resorption, thus, the combination of vitamin D and calcitonin could result in a positive bone balance. We tested the hypothesis that chronic treatment with high doses of vitamin D (150,000 U/week), moderate doses of salmon calcitonin (120 MRC U/week), and adequate Ca supplementation (1 g/day) could be beneficial in osteoporosis. Thirteen women with postmenopausal osteoporosis received this treatment for 2-6 years (mean 3.5 years). No side effects, hypercalcemia, or hypercalciuria occurred. There was marked reduction in bone pain. The fracture rate in 11 patients with vertebral compression fracture was 240/1,000 patient years, threefold lower than the reported 834 fractures for untreated patients of similar age. Single photon bone densitometry of the radius did not change. Iliac crest bone biopsies obtained at the initiation and conclusion of the study showed a 43% increment in trabecular bone volume (P = 0.0003), without changes of the normal osteoid thickness, surface, and volume. Because single photon densitometry reflects mostly cortical bone, the data suggest that the combination of vitamin D and calcitonin increases trabecular bone mass and prevents the fall of cortical bone mass in osteoporosis. Previous reports suggest that calcitonin alone or with small doses of vitamin D increased bone mass for about 2 years. The present study suggests a prolonged beneficial effect of the combination of high doses of vitamin D with rather moderate (less than 150 MRC U/week) doses of calcitonin in postmenopausal osteoporosis.

207. Am J Med. 1987 Sep;83(3):593-5.

Premenopausal osteoporosis associated with vitamin D-responsive calcium malabsorption. A case report.

Glauber HS, Catherwood BD.

Department of Medicine, Veterans Administration Medical Center, San Diego, California 92161.

A premenopausal woman with severe osteoporosis was found to have impaired calcium absorption, without other evidence of intestinal malabsorption. Although circulating levels of 25-OH-vitamin D and 1,25-(OH)2-vitamin D were normal, calcium absorption improved markedly following two weeks of treatment with synthetic 1,25-(OH)2-vitamin D. This suggests that a partial intestinal resistance to the actions of 1,25-(OH)2-vitamin D contributed to the development of her osteoporosis. This case report demonstrates the feasibility of using the calciuric response to a standard oral calcium load to screen for impaired calcium absorption in osteoporotic patients.

208. Am J Med. 1987 Feb;82(2):224-30.

Vitamin D toxicity complicating the treatment of senile, postmenopausal, and glucocorticoid-induced osteoporosis. Four case reports and a critical commentary on the use of vitamin D in these disorders.

Schwartzman MS, Franck WA.

Hypervitaminosis D developed in four patients with osteoporosis or osteomalacia. All patients were given pharmacologic doses of vitamin D, had reduced baseline levels of renal function, and became hypercalcemic with acute renal failure. Measured 25-hydroxyvitamin D (25-OH D) levels were elevated in three patients; levels were not determined in a fourth patient who became normocalcemic when vitamin D therapy was discontinued. Published data on the use of vitamin D for prophylaxis or treatment of any form of osteoporosis fail to document benefits superior to those of calcium alone or calcium with estrogens and fluoride. Data on the use of 25-OH D show no greater benefit than for vitamin D. The use of 1,25-dihydroxyvitamin D (1,25-OH2 D) plus calcium may be superior to the use of calcium alone in some forms of osteoporosis. Vitamin D toxicity is associated with enhanced resorption of bone in some patients. Morbidity included extended hospitalization, dialysis, and chronic renal failure. Pharmacologic doses of vitamin D cannot be recommended for any form of osteoporosis.

209. Miner Electrolyte Metab. 1987;13(2):96-103.

Safety of osteoporosis treatment with sodium fluoride, calcium phosphate and vitamin D.

Hasling C, Nielsen HE, Melsen F, Mosekilde L.

Department of Medical Endocrinology, Aarhus Amtssygehus, Denmark.

During an 8-year period, 163 consecutive patients with spinal crush fracture osteoporosis started a 5-year treatment with a combination of sodium fluoride (60 mg/day), calcium phosphate (45 mmol/day) and vitamin D2 (18,000 IU/day), and were followed in the outpatient clinic every 3 months. Fourty-three patients completed the 5-year treatment. Mean observation time was 2.8 years, totalling 460 patient-years. Fifty-one percent of the patients experienced joint-related (37%) or gastrointestinal (25%) side effects at one time or another. All side effects subsided after a median 6-week withdrawal of fluoride. Six percent of the patients withdrew from treatment due to side effects. Mean serum calcium values slightly decreased during treatment and no hypercalcemic episodes were seen. Urinary excretion of calcium did not change during treatment. No changes in renal, bone marrow or thyroid functions could be detected. The liver function might be slightly affected as indicated by minute increases in serum bilirubin and decreases in serum coagulation factors and albumin, but no other changes in liver function were observed.

210. Eur J Nucl Med. 1987;13(9):462-6.

99mTc-MDP retention in osteoporosis: relationship to other indices of bone cell activity and response to calcium and vitamin D therapy.

Davie MW, Britton JM, Haddaway M, McCall IW.

Department of Metabolic Medicine, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire, UK.

Serum calcium, albumin, phosphorus, and alkaline phosphatase, urinary creatinine and retention of 99mTc-methylene bisphosphonate (99mTc-MDP) were measured in 61 subjects with osteoporosis and the values compared with those obtained in normal subjects. 99mTc-MDP retention was inversely related with urinary creatinine output in normal subjects. In osteoporotic subjects urinary creatinine output was lower and 99mTc-MDP retention higher even when urinary creatinine output was taken into account. Other measurements were similar. In 21 subjects these measurements together with urinary hydroxyproline were performed before and after treatment with calcium and vitamin D. 99mTc-MDP and alkaline phosphatase fell; urinary hydroxyproline was unchanged. A single 24 h urine measurement after 99mTc-MDP injection is a valuable method of predicting whether calcium and vitamin D therapy will be useful in a particular case of osteoporosis.

211. J Nutr Sci Vitaminol (Tokyo). 1985 Dec;31 Suppl:S61-5. (Animal Study)

Effect of vitamin D metabolites on bone metabolism in a rat model of postmenopausal osteoporosis.

Matsumoto T, Ezawa I, Morita K, Kawanobe Y, Ogata E.

A rat model of postmenopausal osteoporosis was introduced, using ovariectomized rats on a low Ca diet. CT treatment of these animals for one month prevented the decrease in both mineral contents and physical properties of the femoral bone. Treatment of the animals with 1,25(OH)2D3 was effective in increasing bone mineral contents and maintaining positive mineral balance, but did not increase the physical tolerance of bones. In contrast, 24,25(OH)2D3 increased the breaking force of the femoral bone, with minimal effect on bone mineral contents and mineral balance. These results suggest that 1,25(OH)2D3 and 24,25(OH)2D3 act differently on the matrix phase and mineral phase of bones, but that they act together to maintain mineral balance and structural integrity of bones. The mechanism of how these vitamin D metabolites affect bone metabolism remain to be clarified.

212. Schweiz Med Wochenschr. 1985 Jul 9;115(27-28):922-31.

[Multidisciplinary study of the prolonged treatment of involution osteoporosis using sodium fluoride with calcium, phosphate and vitamin D]

[Article in French]

Courvoisier B, Baud CA, Very JM, Assimacopoulos A, Tochon-Danguy HJ, Boivin G, Donath A, Garcia J, Gasser A, Fischer J, et al.

A multidisciplinary study on the prolonged treatment of involution osteoporosis with fluoride was performed on a homogeneous population of 31 women aged 51 to 75 years (mean 64 years). The selection criteria were the following: significant backache, vertebral compression fractures on X-rays, bone biopsy evidence of osteoporosis, and absence of other risk factors after a complete workup. The patients were treated for a period of 3 to 6 years (mean 4 years) with daily doses of 30 mg (10 mg 3 times) fluorides ion associated during the last 3 years with 500 mg calcium twice daily, 750 mg phosphate and 1000 units vitamin D daily. The study demonstrated a favourable effect of the treatment on the backache and that it was well tolerated in the majority of cases, the side effects being intermittent osteo-articular pains of the lower extremities due to the fluoride in 9 patients, and gastric intolerance to the phosphate in 7. X-ray follow-up showed slowing of the vertebral compressions after the first year of treatment, but no effect on fractures of the extremities. There was no evidence of alterations in parameters of mineral and bone metabolism, and in endocrine, hepatic, renal or hematological assays. Histomorphometric and biophysical examination of biopsies indicated that, although there was no significant increase in the quantity of mineralized bone under the treatment, there was a very significant improvement in the crystallinity of the mineral substance, thus enhancing the quality of the bone tissue and its resistance to pressure. This study is the first in which a catamnesis of the patients was undertaken, 28 of them having received a clinical and radiological examination 2 years after the end of therapy: a favourable evolution was observed in most of the cases, both in those patients treated for a period of 3 years and in those whose treatment had lasted for a longer period.

213. J Endocrinol Invest. 1984 Aug;7(4):373-8.

The hormonal form of vitamin D in the pathophysiology and therapy of postmenopausal osteoporosis.

Caniggia A, Nuti R, Lore F, Vattimo A.

Sixty-two women with symptomatic postmenopausal osteoporosis underwent long-term treatment with 1,25-dihydroxyvitamin D3. The following results were obtained: i) a dramatic improvement of the intestinal transport of radioactive calcium, which was impaired prior to the treatment; ii) non significant increases in fasting serum calcium; iii) significant increases in the 24 h urinary excretion of calcium and phosphate, resulting from the improvement of intestinal calcium absorption, and a decrease in the urinary cAMP/Cr ratio; iv) non significant changes in serum phosphate, serum alkaline phosphatase, urinary hydroxyproline; v) non significant increases in bone mineral content; vi) relief from pain and improvement of motility in all the patients; vii) no side effect was noticed. In conclusion the treatment with 1,25-dihydroxyvitamin D3 was shown to be useful in postmenopausal osteoporosis.

214. J Clin Invest. 1984 Jun;73(6):1668-72.

Impaired vitamin D metabolism with aging in women. Possible role in pathogenesis of senile osteoporosis.

Tsai KS, Heath H 3rd, Kumar R, Riggs BL.

Calcium absorption decreases with aging, particularly after age 70 yr. We investigated the possibility that this was due to abnormal vitamin D metabolism by studying 10 normal premenopausal women (group A), 8 normal postmenopausal women within 20 yr of menopause (group B), 10 normal elderly women (group C), and 8 elderly women with hip fracture (group D) whose ages (mean +/- SD) were 37 +/- 4, 61 +/- 6, 78 +/- 4, and 78 +/- 4 yr, respectively. For all subjects, serum 25-hydroxyvitamin D [25(OH)D] did not decrease with age, but serum 1,25-dihydroxyvitamin D [1,25(OH)2D], the physiologically active vitamin D metabolite, was lower (P = 0.01) in the elderly (groups C and D; 20 +/- 3 pg/ml) than in the nonelderly (groups A and B; 35 +/- 4 pg/ml). The increase of serum 1,25(OH)D after a 24-h infusion of bovine parathyroid hormone fragment 1-34, a tropic agent for the enzyme 25(OH)D 1 alpha-hydroxylase, correlated inversely with age (r = -0.58; P less than 0.001) and directly with glomerular filtration rate (r = 0.64; P less than 0.001). The response was more blunted (P = 0.01) in elderly patients with hip fracture (13 +/- 3 pg/ml) than in elderly controls (25 +/- 3 pg/ml). We conclude that an impaired ability of the aging kidney to synthesize 1,25(OH)2D could contribute to the pathogenesis of senile osteoporosis.

215. Spec Top Endocrinol Metab. 1983;5:83-148.

The vitamin D endocrine system, calcium metabolism, and osteoporosis.

Slovik DM.

Although the nutritional aspects related to bone development and subsequent bone loss have been appreciated for many years, they are now being reemphasized in view of current information concerning the vitamin D endocrine system, the development of new assay procedures and more sensitive radiologic techniques to assess changes in bone mass, and the realization that clinical problems related to bone loss will increase as individuals live longer. The vitamin D endocrine system is complex, involving the skin, liver, and kidney for synthesis of the vitamin D metabolites and, primarily, the intestine and bone for biologic expression. Numerous factors and disorders affecting the skin, gastrointestinal tract, and kidney will adversely affect vitamin D metabolism. Vitamin D deficiency is common in elderly individuals, especially those who are chronically ill, house-bound, and poorly nourished. Subclinical vitamin D deficiency and osteomalacia may also be complicating problems in elderly patients with osteoporosis and hip fractures. At present the role of the vitamin D endocrine system in the pathogenesis and treatment of osteoporosis is unclear. There is little evidence that vitamin D or its metabolites are helpful in osteoporosis, except perhaps to heal osteomalacia which may be present. It is hoped that encouraging results will follow the use of more potent vitamin D metabolites, either alone or in combination with other agents. Calcium homeostasis is affected by numerous dietary factors (including protein, phosphorus, fiber, and lactose) and drugs (including alcohol, diuretics, and antacids), and calcium absorption in the intestine and the ability to adapt to low-calcium diets will decrease with advancing age. There are conflicting reports concerning the relation between low-calcium intake and osteoporosis, and about the role of calcium intake in the development and then maintenance of bone mass. There is little doubt that many older individuals ingest less calcium than is recommended, especially at a time when even more may be required to maintain bone mass. Several studies show that calcium supplementation producing a total calcium intake of 1,200-1,500 mg/day can slow the rate of bone loss. When the high doses of calcium are given along with vitamin D, periodic monitoring of blood and urine calcium is necessary to avoid hypercalcemia and hypercalciuria.

216. Arch Fr Pediatr. 1981 Mar;38(3):165-70.

[Serum concentrations of vitamin D metabolites in idiopathic juvenile osteoporosis (author's transl)]

[Article in French]

Leroy D, Garabedian M, Guillozo H, Bourdeau A, Sauvegrain J, Balsan S.

This report concerns a 13 year old girl with the clinical and radiological features of mild idiopathic juvenile osteoporosis. In this patient, no alteration was detected in serum calcium (total + ionized) and phosphorus concentration, serum alkaline phosphatase activity, nor in urinary calcium and phosphorus excretions. Plasma concentrations of cortisol were normal during daytime and sleep. Circulating immunoreactive parathyroid hormone was normal or low. The serum 25-(OH)D and 24,25-(OH)2D concentrations were below the normal range, and the 1,25-(OH)2D concentrations were above the normal range (720 pmol/l) at the beginning of the investigation. All vitamin D metabolites concentrations returned to normal values at the time of radiological recovery and after calcium and 25-(OH)D3 supplementation. A possible relationship between alterations of bone and of circulating vitamin D metabolites is discussed.

217. Curr Med Res Opin. 1981;7(5):337-48.

The vitamin D metabolites in the pathogenesis and management of osteoporosis.

Crilly RG, Horseman A, Peacock M, Nordin BE.

Studies on post-menopausal osteoporotic patients indicate that 1,25-(OH)2 D3 concentrations are no different from those in age-matched normal subjects and the data suggest that the malabsorption of calcium found in many osteoporotic patients cannot generally be attributed to low plasma 1,25-(OH)2 D3 levels. The effects are discussed of three different therapies - sex hormones alone, vitamin D metabolites alone and a combination of both - on calcium balance and peripheral bone loss in treated compared with untreated osteoporotic patients. The results indicate that combined therapy with a vitamin D metabolite and an oestrogen is more effective in inhibiting the rate of bone resorption in post-menopausal osteoporosis than treatment with either agent used alone, and should be regarded as the treatment of choice at the present time. It is suggested that, using this regimen which is suitable for patients up to about 65 years of age, calcium supplementation is not required, provided daily calcium intake is reasonably adequate, and may even be undesirable by increasing the risk of hypercalcaemia.

218. Rev Rhum Mal Osteoartic. 1980 Dec;47(12):693-8.

[Histological effects of the treatment of osteoporosis with the combination of sodium fluoride, vitamin D and calcium]

[Article in French]

Briancon D, Charhon S, Edouard C, Meunier PJ.

A histomorphometric and dynamic study of non-decalcified transiliac biopsies was carried out in 51 cases of osteoporosis who had received double marking with tetracycline before and after two years treatment with association of sodium fluoride (50 mg/day) vitamin, D2 (8,000 IU/day) and calcium (1 g/day). The main effect of fluoride is an increase in the osteoblastic population, which is shown by an increase in the osteoid parameters. The osteoid volume is multiplied by 3,6, the osteoid surfaces by 2,4, and the index of osteoid thickness by 1,2. There exists a lesser increase in the reabsorption surfaces (X 1,2). There results a very significant increase in bony trabecular volume, the average value of which increase from 9,8 +/- 3,1% to 16,6 +/- 9.3% (X 1,8; p < 0.001). These results were found again both in apparently primary osteoporosis and in secondary osteoporosis. No significant depression was noted in the rate of calcification, but six patients developed a state of histological osteomalacia associated in 5 cases with an increased calcified volume. All these results are in good agreement with those of the world literature and indicate that fluoride is able in most cases (60%) to restore normal bones in osteoporosis with reduced risk of fracture.

219. J Clin Endocrinol Metab. 1980 Dec;51(6):1359-64.

Effect of estrogen on calcium absorption and serum vitamin D metabolites in postmenopausal osteoporosis.

Gallagher JC, Riggs BL, DeLuca HF.

Osteoporotic women have decreased calcium absorption and decreased serum 1,25-dihydroxyvitamin D [1,25-(OH)2D] and are usually in negative calcium balance. Estrogen therapy improves calcium balance in patients with postmenopausal osteoporosis. In birds, estrogen administration increases the conversion of 25-hydroxyvitamin D (25OHD) to 1,25-(OH)2D. To determine if estrogen therapy affects vitamin D metabolism in human subjects, we studied 21 osteoporotic women before and after 6 months of treatment. We compared groups treated with either placebo (9 patients) or conjugated equine estrogen (1.2-2.5 mg/day; 12 patients). Fractional calcium absorption (mean +/- SE) was unchanged after treatment with placebo (0.51 +/- 0.03 to 0.52 +/- 0.01) but increased after treatment with estrogen (0.53 +/- 0.02 to 0.65 +/- 0.04; P < 0.005). The increase after estrogen was similar to the increase observed in 10 additional osteoporotic women treated for 6 months with a small dose of 0.5 microgram/day 1,25-(OH)2D (0.54 +/- 0.03 to 0.68 +/- 0.04; P < 0.005). Serum 1,25-(OH)2D was unchanged after treatment with placebo (27.5 +/- 1.3 to 27.6 +/- 1.7 pg/ml) but increased after treatment with estrogen (23.6 +/- 2.7 to 33.2 +/- 3.7 pg/ml; P < 0.005). Serum immunoreactive parathyroid hormone (PTH) increased (23.0 +/- 4.2 to 32.7 +/- 4.6 microliter eq/ml; P < 0.05) after estrogen but not after placebo treatment. After treatment with estrogen, the increases in serum immunoreactive PTH and serum 1,25-(OH)2D were correlated (r = 0.68; P < 0.05), and the increases in serum 1,25-(OH)2D and calcium absorption were highly correlated (r = 0.89; P < 0.001). We conclude that estrogen treatment increases calcium absorption in postmenopausal osteoporosis by increasing serum 1,25(OH)2D. This effect appears to be mediated indirectly through stimulation of renal 1 alpha-hydroxylase by increased serum PTH.

220. Endocrinol Jpn. 1979 Jun;26(Suppl):7-13.

Vitamin D and osteoporosis.

Ohato M, Fujita T.

In elderly people with marginal exposure to the sunlight, males showed higher serum 25-hydroxycalciferol than females, whereas in those with ample or poor sunlight exposure, serum 25-hydroxycalciferol was higher or very low, respectively, exhibiting no sex difference in the vitamin D metabolite levels. The male predominance in serum 25-hydroxycalciferol levels seen among some aged population would be explained, at least in part, by the result of animal experiment suggesting the stimulatory effect of testosterone on vitamin D biosynthesis induced by ultaviolet irradiation. Testosterone was, furthermore, shown to have hypocalcemic action, probably through suppression of bone resortopton in vitamin D depleted but not in replete rats. Clinical implication of these two-fold effects of testosterone observed in rats was discussed in relevance to male predominance in serum 25-hydroxycalciferol level and bone mineral content in the aged population.

221. J Clin Endocrinol Metab. 1977 Aug;45(2):199-208.

Vitamin D metabolism and the response to 1,25-dihydroxycholecalciferol in Osteoporosis.

Davies M, Mawer EB, Adams PH.

The metabolism of isotopically-labelled cholecalciferol and the response to small doses of 1,25-dihydroxycholecalciferol (1,25-(OH)2D3) was studied in a group of women with osteoporosis presenting with crush vertebral fracture. No abnormality of vitamin D metabolism was detected. The administration of 1 microgram 1,25-(OH)2D3 for between 8 and 20 days was associated with an increased intestinal absorption and urinary excretion of calcium but caused no improvement in calcium balance. There was a small but significant rise in serum calcium and phosphorus and significant reduction in immunoassayable parathyroid hormone levels during treatment. It is concluded that 1,25-(OH)2D3 is unlikely to be of value in the management of osteoporosis.

222. J Clin Endocrinol Metab. 1976 Jun;42(6):1139-44.

Effects of oral therapy with calcium and vitamin D in primary osteoporosis.

Riggs BL, Jowsey J, Kelly PJ, Hoffman DL, Arnaud CD.

Eighteen patients (17 women and 1 man) with primary osteoporosis were divided into two groups of 9 patients each. Group A received 2.0 to 2.5 g of calcium and 400 units of vitamin D per day orally and was studied before and after short-term (3 to 4 months) treatment; group B received 1.5 to 2.0 g of calcium per day and 50,000 units of vitamin D twice weekly and was studied before, after short-term, and after long-term (1 year) treatment. In group A there was a decrease (P is less than 0.01) in bone-resorbing surfaces (microradiography of bone biopsy samples) after short-term treatment. In group B there was a decrease (P is less than 0.01) in bone-forming and bone-resorbing surfaces after both short-tern and long-term treatment. Fasting-state (morning) serum immunoreactive parathyroid hormone (iPTH) concentrations decreased after short-term treatment (combined data of groups A and B) and after long-term treatment (group B). We conclude that the principal effect of the oral calcium and vitamin D therapy in primary osteoporosis is to decrease bone turnover. The most probable mechanism for this effect on bone is a partial inhibition of PTH secretion.

Older persons

223. J Am Geriatr Soc. 2003 Sep;51(9):1219-26.

Effects of vitamin d supplementation on strength, physical performance, and falls in older persons: a systematic review.

Latham NK, Anderson CS, Reid IR.

Clinical Trials Research Unit Department of Medicine, University of Auckland, Auckland, New Zealand Center for Rehabilitation Effectiveness, Sargent College, Boston University, Boston, Massachusetts.

OBJECTIVES: : To identify, appraise, and synthesize data from randomized, controlled trials of vitamin D supplementation in older people. DESIGN: : A systematic review of trials identified from searches of databases, reference lists, review articles, and recent conference proceedings. SETTING: : Most studies performed in ambulatory setting. PARTICIPANTS: : Older people (mean age=60). INTERVENTIONS: : Vitamin D or vitamin D metabolites. MEASUREMENTS: : Strength, physical performance, or falls. RESULTS: : Thirteen trials involving 2,496 patients met this study's inclusion criteria. Most of the trials were small and had methodological problems. In 10 trials, there was no evidence that vitamin D or vitamin D metabolites had an effect on falls or physical function, but three trials showed a positive effect of vitamin D in combination with calcium. When available data from the four highest quality trials were pooled (n=1,317), there continued to be no evidence that vitamin D reduced the risk of falling (relative risk= 0.99, 95% confidence interval=0.89-1.11), although a single trial of vitamin D and calcium showed a positive effect. CONCLUSION: : Although there is insufficient evidence that vitamin D supplementation alone improves physical performance in older people, some data suggest a benefit from vitamin D combined with calcium supplementation, but this requires confirmation in large, well-designed trials.

224. Joint Bone Spine. 2003 Jun;70(3):203-8.

Effects on bone mineral density of calcium and vitamin D supplementation in elderly women with vitamin D deficiency.

Grados F, Brazier M, Kamel S, Duver S, Heurtebize N, Maamer M, Mathieu M, Garabedian M, Sebert JL, Fardellone P.

Rheumatology Department, North Hospital Group, 80054 cedex 1, Amiens, France.

OBJECTIVE: Calcium and vitamin D deficiency is common in older individuals, particularly those who live in nursing homes, and increases the risk of osteoporosis and fractures. METHODS: We conducted a randomized double-blind placebo-controlled study of combined supplementation with 500 mg of elemental calcium, as carbonate, and 400 IU of vitamin D bid for 12 months in women older than 65 years of age with vitamin D deficiency, defined as serum 25(OH)D concentrations </=12 ng/ml. RESULTS: Mean patient age was 75 +/- 7 years, and median daily dietary intakes of calcium and vitamin D were 697 mg and 66.8 IU in the supplemented group (n = 95) and 671 mg and 61.8 IU in the placebo group (n = 97). The median serum 25(OH)D level was 7.0 ng/ml in both groups, and the medial intact parathyroid hormone (PTHi) levels were 49 and 48 pg/ml in the supplemented and placebo groups, respectively. The median increase in serum 25(OH)D was 22.0 ng/ml in the supplemented group and 4 ng/ml in the placebo group (P < 0.0001), and the median PTHi decrease was 17 and 5 pg/ml, respectively (P < 0.0001). The median bone mineral density increase was significantly greater in the supplemented group than in the placebo group: +2.98% vs. -0.21% at L2-L4 (P = 0.0009), +1.19% and -0.83% at the femoral neck (P = 0.015), +0.86% and -0.56% at the trochanter (P = 0.015), and +0.99% and +0.11% for the whole body (P = 0.01). Similarly, the median decrease in the main bone markers was significantly greater in the treated group than in the placebo group: -1.35 microg/l vs. +0.50 microg/l for bone alkaline phosphatase (P = 0.008), -16.6 nmol/mmol creatinine vs. -2.3 nmol/mmol creatinine for urinary type I amino-terminal telopeptide (P = 0.001), and -896 pmol/l vs. -201 pmol/l for serum type I carboxy-terminal telopeptide (P = 0.003). We found no significant differences between the two groups for serum calcium, although urinary calcium excretion changed more in the supplemented group than in the placebo group. In conclusion, bone mass in older women with vitamin D deficiency increases significantly at the lumbar spine, femur, trochanter, and whole body after calcium and vitamin D supplementation for 1 year, and concomitantly bone markers improved as vitamin D levels returned to normal.

225. Am J Clin Nutr. 2003 May;77(5):1324-9.

Vitamin D supplementation and bone mineral density in early postmenopausal women.

Cooper L, Clifton-Bligh PB, Nery ML, Figtree G, Twigg S, Hibbert E, Robinson BG.

Department of Diabetes, Endocrinology and Metabolic Medicine, Northern Metabolic Bone Centre, Royal North Shore Hospital, St Leonards, Australia.

BACKGROUND: Increased vitamin D intake may preserve or increase bone mineral density (BMD) in older persons. OBJECTIVE: A 2-y double-blind study was undertaken to determine whether weekly administration of 10 000 units of vitamin D(2) maintained or increased BMD in younger postmenopausal women more efficiently than did calcium supplements alone. DESIGN: One hundred eighty-seven women who were >or= 1 y postmenopausal were randomly assigned to take either 1000 mg Ca/d after the evening meal or 1000 mg Ca/d plus 10 000 U vitamin D(2)/wk in a double-blind, placebo-controlled format. The BMD of the proximal forearm, lumbar spine, femoral neck, Ward's triangle, and femoral trochanter was measured at 6-mo intervals by osteodensitometry. RESULTS: During the 2-y period, there was no significant difference in the change in BMD at any site between the subjects taking calcium supplements and those taking calcium plus vitamin D(2). Both groups significantly (P < 0.005) gained BMD in Ward's triangle and the femoral trochanter but significantly (P < 0.005) lost bone in the proximal radius. There was no significant change in the lumbar spine or femoral neck BMD. CONCLUSION: In younger postmenopausal women ( age: 56 y) whose average baseline serum 25-hydroxyvitamin D concentration was well within the normal range, the addition of 10 000 U vitamin D(2)/wk to calcium supplementation at 1000 mg/d did not confer benefits on BMD beyond those achieved with calcium supplementation alone.

226. Maturitas. 2003 Apr 25;44(4):299-305.

Calcium-vitamin D3 supplementation is cost-effective in hip fractures prevention.

Lilliu H, Pamphile R, Chapuy MC, Schulten J, Arlot M, Meunier PJ.

CLP-Sante, 9-11 rue du Mont Aigoual, F-75015 Paris, France. herve.lilliu@clp-sante.fr

OBJECTIVE: To assess the cost implications for a preventive treatment strategy for institutionalised elderly women with a combined 1200 mg/day calcium and 800 IU/day vitamin D(3) supplementation in seven European countries. DESIGN: Retrospective cost effectiveness analysis based on a prospective placebo-controlled randomised clinical trial. DATA SOURCES: Recently published cost studies in seven European countries. Clinical results from Decalyos, a 3-year placebo-controlled study in elderly institutionalised women. TRIALS: Decalyos study, with 36 months follow-up of 3270 mobile elderly women living in 180 nursing homes, allocated to two groups. One group received 1200 mg/day elemental calcium in the form of tricalcium phosphate together with 800 IU/day (20 microg) of cholecalciferol (vitamin D(3)), the other placebo. RESULTS: In the 36 months analysis of the Decalyos study, 138 hip fractures occurred in the group of 1176 women, receiving supplementation and 184 hip fractures in the placebo group of 1127 women. The mean duration of treatment was 625.4 days. Adjusted to 1000 women, 46 hip fractures were avoided by the calcium and vitamin D(3) supplementation. For all countries, the total costs in the placebo group were higher than in the group receiving supplementation, resulting in a net benefit of 79000-711000 per 1000 women. CONCLUSION: This analysis suggests that the supplementation strategy is cost saving. The results may underestimate the net benefits, as this treatment has also shown to be effective in decreasing the incidence of other non-vertebral fractures in elderly institutionalised women.

227. J Bone Miner Res. 2003 Feb;18(2):343-51.

Comment in: J Bone Miner Res. 2003 Jul;18(7):1342; author reply 1343.

Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial.

Bischoff HA, Stahelin HB, Dick W, Akos R, Knecht M, Salis C, Nebiker M, Theiler R, Pfeifer M, Begerow B, Lew RA, Conzelmann M.

Department of Orthopaedics, University of Basel, Basel, Switzerland. hbischof@hsph.harvard.edu

Specific receptors for vitamin D have been identified in human muscle tissue. Cross-sectional studies show that elderly persons with higher vitamin D serum levels have increased muscle strength and a lower number of falls. We hypothesized that vitamin D and calcium supplementation would improve musculoskeletal function and decrease falls. In a double-blind randomized controlled trial, we studied 122 elderly women (mean age, 85.3 years; range, 63-99 years) in long-stay geriatric care. Participants received 1200 mg calcium plus 800 IU cholecalciferol (Cal+D-group; n = 62) or 1200 mg calcium (Cal-group; n = 60) per day over a 12-week treatment period. The number of falls per person (0, 1, 2-5, 6-7, >7 falls) was compared between the treatment groups. In an intention to treat analysis, a Poisson regression model was used to compare falls after controlling for age, number of falls in a 6-week pretreatment period, and baseline 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D serum concentrations. Among fallers in the treatment period, crude excessive fall rate (treatment - pretreatment falls) was compared between treatment groups. Change in musculoskeletal function (summed score of knee flexor and extensor strength, grip strength, and the timed up&go test) was measured as a secondary outcome. Among subjects in the Cal+D-group, there were significant increases in median serum 25-hydroxyvitamin D (+71%) and 1,25-dihydroxyvitamin D (+8%). Before treatment, mean observed number of falls per person per week was 0.059 in the Cal+D-group and 0.056 in the Cal-group. In the 12-week treatment period, mean number of falls per person per week was 0.034 in the Cal+D-group and 0.076 in the Cal-group. After adjustment, Cal+D-treatment accounted for a 49% reduction of falls (95% CI, 14-71%; p < 0.01) based on the fall categories stated above. Among fallers of the treatment period, the crude average number of excessive falls was significantly higher in the Cal-group (p = 0.045). Musculoskeletal function improved significantly in the Cal+D-group (p = 0.0094). A single intervention with vitamin D plus calcium over a 3-month period reduced the risk of falling by 49% compared with calcium alone. Over this short-term intervention, recurrent fallers seem to benefit most by the treatment. The impact of vitamin D on falls might be explained by the observed improvement in musculoskeletal function.

228. J Rheumatol. 2003 Jan;30(1):132-8.

Comment in: J Rheumatol. 2003 Jan;30(1):1-3.

A cost effectiveness analysis of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women treated with glucocorticoids.

Buckley LM, Hillner BE.

Virginia Commonwealth University, Richmond 23298, USA. lbuckley@hsc.vcu.edu

OBJECTIVE: To assess the relative costs and benefits of calcium and vitamin D supplements, cyclic etidronate, or alendronate in the prevention of vertebral fractures for women and with normal bone density and osteopenia who are about to initiate moderate dose glucocorticoid treatment. METHODS: Using a decision analysis model, we evaluated the following patients: 4 hypothetical cohorts: 30-yr-old women with normal lumbar spine (LS) bone mineral density (BMD) (t score = 0), 50-yr-old women with borderline osteopenia (t score = -1), 60-yr-old women with moderate osteopenia (t score = -1.5), and 70-yr-old women with severe osteopenia (t score = -2) treated with a mean prednisone dose of 10 mg/day for one year. The main outcomes included the development of vertebral fractures 10 years after glucocorticoid treatment and at age 80 (life-time risk) and direct and indirect costs. RESULTS: At 10 years, calcium and vitamin D supplements decreased fracture rates by 30-50% at a minimal cost (US$800 or less per vertebral fracture avoided) or at a cost saving compared to no treatment for women with osteopenia (t score -1 to -2). Etidronate and alendronate are most cost effective in women with borderline osteoporosis (t scores of -1.5 and -2) in the 10 year analysis. In the life-time analysis, calcium and vitamin D treatment yielded a cost savings compared to no treatment for all groups with osteopenia. Etidronate decreased fracture rates further in all groups at a cost of less than $2,000 per fracture prevented. Alendronate reduced the fracture risk further at cost of $3,000-7,000 per fracture avoided. CONCLUSION: Calcium and vitamin D supplements and low cost bisphosphonate regimens such as cyclic etidronate decrease the life-time vertebral fracture risk at acceptable costs and should be considered when initiating glucocorticoid treatment for women who do not have osteoporosis.

229. Stroke. 2001 Jul;32(7):1673-7.

Vitamin D deficiency and risk of hip fractures among disabled elderly stroke patients.

Sato Y, Asoh T, Kondo I, Satoh K.

Department of Neurology, Kurume University Medical Center, Japan. noukenrs@cc.hirosaki-u.ac.jp

BACKGROUND AND PURPOSE: Risk of hip fracture after stroke is 2 to 4 times that in a reference population. Osteomalacia is present in some patients with hip fractures in the absence of stroke, while disabled elderly stroke patients occasionally have severe deficiency in serum concentrations of 25-hydroxyvitamin D (25-OHD) (</=5 ng/mL). To determine the effects of vitamin D status on hip fracture risk, we prospectively studied a cohort of patients with hemiplegia after stroke who were aged at least 65 years. METHODS: We compared baseline serum indices of bone metabolism, bone mineral density, and hip fracture occurrence in stroke patients with serum 25-OHD </=25 nmol/L (</=10 ng/mL; deficient group, n=88) with findings in patients from the same cohort who had 25-OHD levels 26 to 50 nmol/L (10 to 20 ng/mL; insufficient group, n=76) or >/=51 nmol/L (>/=21 ng/mL; sufficient group, n=72). RESULTS: Over a 2-year follow-up interval, hip fractures on the paretic side occurred in 7 patients in the deficient group and 1 patient in the insufficient group (P<0.05; hazard ratio=6.5), while no hip fractures occurred in the sufficient group. The 7 hip fracture patients in the deficient group had an osteomalacic 25-OHD level of <5 ng/mL. Higher age and severe immobilization were noted in the deficient group. Serum 25-OHD levels correlated positively with age, Barthel Index, and serum parathyroid hormone. CONCLUSIONS: Elderly disabled stroke patients with serum 25-OHD concentrations </=12 nmol/L (</=5 ng/mL) have an increased risk of hip fracture. Immobilization and advanced age cause severe 25-OHD deficiency and consequent reduction of BMD.

230. Eur J Clin Nutr. 2000 Aug;54(8):626-31.

Comment in: Eur J Clin Nutr. 2001 Apr;55(4):221-2; discussion 306-7. Eur J Clin Nutr. 2001 Apr;55(4):305-7.

Vitamin D(3) and vitamin K(1) supplementation of Dutch postmenopausal women with normal and low bone mineral densities: effects on serum 25-hydroxyvitamin D and carboxylated osteocalcin.

Schaafsma A, Muskiet FA, Storm H, Hofstede GJ, Pakan I, Van der Veer E.

Department of Research & Development Leeuwarden, Friesland Coberco Dairy Foods, Leeuwarden, The Netherlands. SchaafsA@FDF.NL

OBJECTIVE: Improvement of vitamin D and K status of about 60 -y-old postmenopausal Dutch women. DESIGN: In a randomized study postmenopausal women with normal (T-score >-1; n=96) and low (T-score< or =-1; n=45) bone mineral density (BMD) of the lumbar spine, were supplemented with 350-400 IU vitamin D(3), 80 microg vitamins K(1) vitamins K(1)+D(3), or placebo for 1 y. Serum 25-hydroxyvitamin D [25(OH)D] and percentage carboxylated osteocalcin (%carbOC) were measured at baseline and after 3, 6 and 12 months. RESULTS: Baseline %carbOC of the entire study population was positively correlated with BMD of the lumbar spine and femoral neck. Correspondingly, women with low BMD had lower %carbOC at baseline than women with normal BMD but this difference disappeared after 1 y of supplementation with vitamin K(1) ((mean+/-s.d.) 68+/-11% (95% CI, 64. 5-71.2%) vs 72+/-6% (95% CI, 70.1-72.9%), respectively). One year of supplementation with vitamin D(3) showed maximum increases in 25(OH)D of 33+/-29% (95% CI, 24.8-41.8%) and 68+/-58% (95% CI, 50.1-84.6%) in women with normal and low BMD, respectively. During winter, however, a 29% decline in maximum 25(OH)D levels was not prevented in women with low BMD. CONCLUSION: Daily supplementation of Dutch postmenopausal women with >400 IU vitamin D(3) is indicated to prevent a winter decline in 25(OH)D and to control serum parathyroid hormone levels. Daily supplementation with 80 microg vitamin K(1) seems to be necessary to reach premenopausal %carbOC levels. A stimulatory effect of calcium and/or vitamin D on %carbOC cannot be excluded. European Journal of Clinical Nutrition (2000) 54, 626-631.

231. J Clin Endocrinol Metab. 1999 Nov;84(11):3988-90.

Vitamin D supplementation in postmenopausal black women.

Kyriakidou-Himonas M, Aloia JF, Yeh JK.

Department of Medicine, Winthrop-University Hospital, Mineola, New York 11530, USA.

Black women have lower levels of serum 25-hydroxyvitamin D (25OHD) with higher serum PTH levels than white women. Correction of these alterations in the vitamin D-endocrine system could lead to less bone loss in postmenopausal women and, consequently, preservation of bone mass. Ten healthy postmenopausal black women were given 20 microg vitamin D3 daily for 3 months. At the end of the study, mean serum 25OHD levels had increased from 24 to 63 nmol/L. Serum intact PTH and nephrogenous cAMP declined significantly, and there was a 21% drop in the fasting urinary N-telopeptide of type I collagen. Vitamin D3 supplementation raises serum 25OHD levels in postmenopausal black women, decreases secondary hyperparathyroidism, and reduces bone turnover. These findings should spur further investigation of the use of vitamin D supplementation in the prevention of osteoporosis in this population.

232. Bone. 1998 Dec;23(6):555-7.

High prevalence of vitamin D deficiency and reduced bone mass in elderly women with Alzheimer's disease.

Sato Y, Asoh T, Oizumi K.

Department of Neurology, Futase Social Insurance Hospital, Iizuka, Japan. y-sato@ktarn.or.jp

Patients with Alzheimer's disease (AD) are at increased risk for falls and hip fractures. To better understand causes and prevention, we measured bone mineral density (BMD) in the second metacarpals of 46 ambulatory elderly women with AD and analyzed its relation to serum biochemical indices, sunlight exposure, and vitamin D intake. BMD was significantly less than in age-matched controls. In 26% of AD patients, the serum 25-hydroxyvitamin D (25-OHD) concentration was at a deficient level (5-10 ng/mL), and in 54% it was at an osteomalacic level (<5 ng/mL). Concentrations of ionized calcium were significantly lower in patients. Conversely, concentrations of serum bone Gla-protein and urinary hydroxyproline in patients were significantly higher than in controls. BMD correlated positively with 25-OHD concentration (p = 0.0041) and negatively with parathyroid hormone (PTH) concentration (p = 0.0022). PTH was higher in patients than in controls, and correlated negatively with 25-OHD (p < 0.0001). Many AD patients were sunlight-deprived and consumed less than 100 IU of vitamin D per day. We concluded that vitamin D deficiency due to sunlight deprivation and malnutrition, together with compensatory hyperparathyroidism, contributes significantly to reduced BMD in AD patients. Low BMD increases risk of hip fractures in patients with AD, but may be improved by vitamin D supplementation.

233. Med J Aust. 1998 Aug 3;169(3):138-41.

Hip fracture in elderly men: the importance of subclinical vitamin D deficiency and hypogonadism.

Diamond T, Smerdely P, Kormas N, Sekel R, Vu T, Day P.

St George Hospital, Sydney, NSW.

OBJECTIVE: To determine the major risk factors for hip fracture in elderly men. DESIGN: Prospective recruitment, followed by analysis of clinical and biochemical variables. PATIENTS AND SETTING: Men aged 60 years and older who presented to St George Hospital (a 650-bed tertiary-care centre) in 1995, comprising all 41 men with hip fractures, as well as 41 hospital inpatient and 41 outpatient control subjects without hip fractures. MAIN OUTCOME MEASURES: Osteoporotic risk factors (including age, body weight, comorbid illnesses, alcohol intake, cigarettes smoked, and corticosteroid use) and serum concentrations of creatinine, urea, calcium, albumin, alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D and free testosterone. RESULTS: There were no significant differences between the hip fracture and two control groups on any of the osteoporotic risk factors. Men with hip fracture had significantly lower mean serum 25-hydroxyvitamin D concentration (45.6 nmol/L; 95% confidence interval [CI], 36.9-52.3 nmol/L) than both inpatient (61.1 nmol/L; 95% CI, 50.0-72.2 nmol/L) and outpatient (65.9 nmol/L; 95% CI, 59.0-72.8 nmol/L) controls (P=0.007). Subclinical vitamin D deficiency (defined as <50 nmol/L serum 25-hydroxyvitamin D) was 63% in the fracture group, compared with 25% in the control groups combined (odds ratio, 3.9; 95% CI, 1.74-8.78; P=0.0007). Inpatients with and without hip fractures had significantly lower mean serum albumin, calcium and free testosterone concentrations than outpatients (P< 0.05). In a multiple regression analysis, subclinical vitamin D deficiency was the strongest predictor of hip fracture (beta [regression coefficient], 0.34+/-0.19; P=0.013). CONCLUSIONS: Subclinical vitamin D deficiency in Australian men may contribute significantly to the development of hip fracture through the effects of secondary hyperparathyroidism, resulting in increased bone loss.

234. Nutr Rev. 1998 May;56(5 Pt 1):148-50.

Combined calcium and vitamin D supplementation reduces bone loss and fracture incidence in older men and women.

O'Brien KO.

Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD 21205-2179, USA.

A recent supplementation study of 389 men and women, over the age of 65 years was conducted to address the impact of combined calcium and vitamin D supplementation on nonvertebral fracture incidence and maintenance of bone mass. Daily supplementation with 500 mg calcium and 700 IU vitamin D for 3 years moderately reduced bone loss at several sites and significantly decreased the rate of nonvertebral fractures, compared with a placebo group. Optimal intake of both calcium and vitamin D may be an easily implemented strategy to maintain existing bone mass and reduce the risk of fracture in older men and women.

235. Osteoporos Int. 1998;8(3):255-60.

Calcium and vitamin D supplementation increases spinal BMD in healthy, postmenopausal women.

Baeksgaard L, Andersen KP, Hyldstrup L.

Department of Endocrinology (157), Hvidovre Hospital, Denmark.

We undertook a double-masked, randomized, placebo-controlled trial to evaluate the effect of a calcium and vitamin D supplement and a calcium supplement plus multivitamins on bone loss at the hip, spine and forearm. The study was performed in 240 healthy women, 58-67 years of age. Duration of treatment was 2 years. Bone mineral density (BMD) was measured at the lumbar spine, hip and forearm. A dietary questionnaire was administered twice during the study and revealed a fairly good calcium and vitamin D intake (919 mg calcium/day; 3.8 micrograms vitamin D/day). An increase in lumbar spine BMD of 1.6% was observed in the treatment group after 2 years (p < 0.002). In the placebo group no significant changes were observed during the 2 years. Lumbar spine BMD was significantly higher in the treatment group at both 1 (p < 0.01) and 2 years (p < 0.05) compared with the placebo group. Though not significant, the same trend was seen at the hip. No significant changes from baseline values were observed at the distal forearm in either the treatment or the placebo group. In conclusion, we found a significant increase in urinary calcium excretion in the treatment group compared with the placebo group. Together with significant changes in serum calcium and serum parathyroid hormone, this indicates that a long-term calcium and vitamin supplement of 1 g elementary calcium (calcium carbonate) and 14 micrograms vitamin D3 increases intestinal calcium absorption. A positive effect on BMD was demonstrated, even in a group of early postmenopausal age, with a fairly good initial calcium and vitamin D status.

236. N Engl J Med. 1997 Sep 4;337(10):670-6.

Comment in: ACP J Club. 1998 Mar-Apr;128(2):47. N Engl J Med. 1997 Sep 4;337(10):701-2.

Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older.

Dawson-Hughes B, Harris SS, Krall EA, Dallal GE.

Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University, Boston, MA 02111, USA.

BACKGROUND: Inadequate dietary intake of calcium and vitamin D may contribute to the high prevalence of osteoporosis among older persons. METHODS: We studied the effects of three years of dietary supplementation with calcium and vitamin D on bone mineral density, biochemical measures of bone metabolism, and the incidence of nonvertebral fractures in 176 men and 213 women 65 years of age or older who were living at home. They received either 500 mg of calcium plus 700 IU of vitamin D3 (cholecalciferol) per day or placebo. Bone mineral density was measured by dual-energy x-ray absorptiometry, blood and urine were analyzed every six months, and cases of nonvertebral fracture were ascertained by means of interviews and verified with use of hospital records. RESULTS: The mean (+/-SD) changes in bone mineral density in the calcium-vitamin D and placebo groups were as follows: femoral neck, +0.50+/-4.80 and -0.70+/-5.03 percent, respectively (P=0.02); spine,+2.12+/-4.06 and +1.22+/-4.25 percent (P=0.04); and total body, +0.06+/-1.83 and -1.09+/-1.71 percent (P<0.001). The difference between the calcium-vitamin D and placebo groups was significant at all skeletal sites after one year, but it was significant only for total-body bone mineral density in the second and third years. Of 37 subjects who had nonvertebral fractures, 26 were in the placebo group and 11 were in the calcium-vitamin D group (P=0.02). CONCLUSIONS: In men and women 65 years of age or older who are living in the community, dietary supplementation with calcium and vitamin D moderately reduced bone loss measured in the femoral neck, spine, and total body over the three-year study period and reduced the incidence of nonvertebral fractures.

237. Osteoporos Int. 1997;7(5):439-43.

Prevalence of vitamin D insufficiency in an adult normal population.

Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S, Meunier PJ.

INSERM U. 403, Hopital Edouard Herriot, Lyon, France.

The vitamin D status of a general adult urban population was estimated between November and April in 1569 subjects selected from 20 French cities grouped in nine geographical regions (between latitude 43 degrees and 51 degrees N). Major differences in 25-hydroxyvitamin D (25(OH)D) concentration were found between regions, the lowest values being seen in the North and the greatest in the South, with a significant 'sun' effect (r = 0.72; p = 0.03) and latitude effect (r = -0.79; p = 0.01). In this healthy adult population, 14% of subjects exhibited 25(OH)D values < or = 30 nmol/l (12 ng/ml), which represents the lower limit (< 2 SD) for a normal adult population measured in winter with the same method (RIA Incstar). A significant negative correlation was found between serum intact parathyroid hormone (iPTH) and serum 25(OH)D values (p < 0.01). Serum iPTH held a stable plateau level at 36 pg/ml as long as serum 25(OH)D values were higher than 78 nmol/l (31 ng/ml), but increased when the serum 25(OH)D value fell below this. When the 25(OH)D concentration became equal to or lower than 11.3 nmol/l (4.6 ng/ml), the PTH values reached the upper limit of normal values (55 pg/ml) found in vitamin D replete subjects. These results showed that in French normal adults living in an urban environment with a lack of direct exposure to sunshine, diet failed to provide an adequate amount of vitamin D. It is important to pay attention to this rather high prevalence of vitamin D insufficiency in the general adult population and to discuss the clinical utility of winter supplementation with low doses of vitamin D.

238. Rev Rhum Engl Ed. 1996 Feb;63(2):135-40.

Biochemical effects of calcium and vitamin D supplementation in elderly, institutionalized, vitamin D-deficient patients.

Chapuy MC, Chapuy P, Thomas JL, Hazard MC, Meunier PJ.

National Institute for Health and Medical Research (INSERM) unit 403, Edouard Herriot Hospital, Lyon, France.

Forty-five subjects (41 women and 4 men) in long-stay and medium-stay facilities, aged 74 to 95 years (mean 86.4 years), with 25-hydroxy-vitamin D levels less than 12 ng/ml, were treated for six consecutive months with two tablets per day of a preparation containing vitamin D3 (800 IU/day) and calcium carbonate (1 g elemental calcium/day). Serum levels of 25-hydroxy-vitamin D were very low at baseline (5.6 +/- 0.4 ng/ml) and rose significantly under treatment, to normal values, 33.2 +/- 1.2 and 40.9 +/- 2.1 ng/ml after three and six months, respectively (p < 0.001 for both comparisons). Serum calcium increased significantly, by 4.5% (p < 0.001) during the first three months, and remained at a plateau thereafter. Corrected serum calcium rose by 8.9% (p < 0.001) during the trial. No patient developed hypercalcemia. Serum parathyroid hormone levels, which were elevated at baseline (71.6 +/- 5.8 pg/ml; normal, 12 to 54 pg/ml), decreased gradually and significantly throughout the treatment period, by 43.0% and 67.1% after three and six months, respectively (p < 0.001 for both comparisons). Serum alkaline phosphatase activity fell concomitantly, by 9.9% after three months (p < 0.01) and 36.5% after six months (p < 0.001). In conclusion, the preparation used in our study is effective in correcting both the vitamin D deficiency that is prevalent in elderly institutionalized patients and the resultant increase in bone turnover.

239. JAMA. 1995 Dec 6;274(21):1683-6.

Comment in: JAMA. 1996 Mar 20;275(11):838-9.

Vitamin D deficiency in homebound elderly persons.

Gloth FM 3rd, Gundberg CM, Hollis BW, Haddad JG Jr, Tobin JD.

Department of Medicine, Union Memorial Hospital, Baltimore, MD 21218, USA.

OBJECTIVE--To assess the vitamin D status in homebound, community-dwelling elderly persons; sunlight-deprived elderly nursing home residents; and healthy, ambulatory elderly persons. DESIGN--A cohort analytic study. PARTICIPANTS--Of 244 subjects at least 65 years old, 116 subjects (85 women and 31 men) had been confined indoors for at least 6 months, either in private dwellings in the community (the Hopkins Elder Housecall Program) or in a teaching nursing home (The Johns Hopkins Geriatrics Center). The 128 control subjects, a healthy ambulatory group, came from the Baltimore Longitudinal Study on Aging. All subjects were free of diseases or medications that might interfere with their vitamin D status. MAIN OUTCOME MEASURES--Serum levels of 25-hydroxyvitamin D (25-OHD) and 1,25-dihydroxyvitamin D (1,25-[OH]2D) were measured in all subjects. In a subgroup of 80 subjects, serum levels of intact parathyroid hormone (PTH), ionized calcium, and osteocalcin and intake of vitamin D (through 3-day food records) were assessed. A randomly selected cohort of sunlight-deprived subjects also had serum levels of vitamin D binding protein measured. RESULTS--In sunlight-deprived subjects overall, the mean 25-OHD level was 30 nmol/L (12 ng/mL) (range, < 10 to 77 nmol/L [< 4 to 31 ng/mL]) and the mean 1,25-(OH)2D level was 52 pmol/L (20 pg/mL) (range, 18 to 122 pmol/L [7 to 47 pg/mL]). In the sunlight-deprived subjects, 54% of community dwellers and 38% of nursing home residents had serum levels of 25-OHD below 25 nmol/L (10 ng/mL) (normal range, 25 to 137 nmol/L [10 to 55 ng/mL]). A significant inverse relationship existed between 25-OHD (ie, Log [25-OHD]) and PTH when they were analyzed together (r = -0.42; R2 = 0.18; P < .001) and for each cohort separately. All other parameters measured, except ionized calcium, differed significantly from the Baltimore Longitudinal Study Group means. The mean (SD) daily intakes of vitamin D (121 [132] IU) and calcium (583 [322] mg) were below the recommended dietary allowance only in the community-dwelling homebound population. The mean vitamin D binding protein level in the sunlight-deprived subgroup was in the normal range. CONCLUSIONS--Despite a relatively high degree of vitamin supplementation in the United States, homebound elderly persons are likely to suffer from vitamin D deficiency.

240. Rev Rhum Engl Ed. 1995 Oct;62(9):576-81.

Prevalence and biological consequences of vitamin D deficiency in elderly institutionalized subjects.

Fardellone P, Sebert JL, Garabedian M, Bellony R, Maamer M, Agbomson F, Brazier M.

Department of Rheumatology, North Hospital, Amiens, France.

The prevalence of vitamin D deficiency was evaluated in a population of elderly institutionalized subjects in seven long-term geriatric care facilities in France (Amiens, Francheville, Ivry, Lille, Montpellier, Oissel and Villejuif). Residents whose functional capability was relatively good were entered into the study. There were 126 patients (99 females and 27 males) with a mean age +/- SD of 84 +/- 6.6 years. All subjects had been institutionalized for over six months and were capable of walking at least as far as the dining room. None had received vitamin D or other compounds known to affect the metabolism of phosphorus and calcium within six months before the study. Vitamin D status was evaluated by determining serum 25 hydroxyvitamin D (25 OH D) levels using a radiocompetition assay after extraction and chromatographic separation. Mean serum 25 OH D was 3.17 +/- 2.52 ng/ml (median 2.5). Eighty-five per cent of subjects had serum 25 OH D values of less than 5 ng/ml and 98% had values under 10 ng/ml, which is the cutoff usually taken to define vitamin D deficiency. Mean serum levels of intact parathyroid hormone were increased approximately two-fold as compared with values in healthy adults (70 +/- 39 pg/ml versus 33 +/- 12 pg/ml). Biochemical markers for bone formation (alkaline phosphatase, osteocalcin) and bone resorption (TRAP, hydroxyproline, pyridinoline) were all increased, with mean values 1.4-fold to 3.4-fold those seen in healthy adults. Serum 25 OH D levels were negatively correlated with serum intact parathyroid hormone levels (r = 0.41; p < 0.0001). Serum intact parathyroid hormone levels were positively correlated with alkaline phosphatase activity (r = 0.30; p < 0.001) and serum osteocalcin levels (r = 0.36; p < 0.0001) and negatively correlated with corrected serum calcium levels (r = -0.20; p < 0.02). Conclusion. Our data demonstrate that severe vitamin D deficiency is present in virtually all elderly institutionalized subjects and is accompanied with secondary hyperparathyroidism responsible for increases in markers of bone remodeling. Routine vitamin D supplementation is warranted in elderly institutionalized subjects.

241. J Clin Endocrinol Metab. 1995 Apr;80(4):1052-8.

Prevention of bone loss by vitamin D supplementation in elderly women: a randomized double-blind trial.

Ooms ME, Roos JC, Bezemer PD, van der Vijgh WJ, Bouter LM, Lips P.

Institute for Research in Extramural Medicine (EMGO-Institute), Vrije Universiteit, Amsterdam, The Netherlands.

The purpose of the study was to determine the effect of vitamin D supplementation on bone turnover and bone loss in elderly women. Three hundred forty-eight women, ages 70 yr and older, were randomized to receive 400 IU vitamin D3 per day (n = 177) or placebo (n = 171), double-blind, for a period of 2 yr. Main outcome measures were bone mineral density of both hips (femoral neck and trochanter) and the distal radius, as well as biochemical markers of bone turnover. The effect of vitamin D supplementation was expressed as the difference in mean (percentage) change between the placebo group and the vitamin D group. The measurements were repeated in 283 women after 1 yr and in 248 women after 2 yr. Vitamin D supplementation significantly increased serum 25-hydroxyvitamin D (250HD) (+35 nmol/L) and 1,25-dehydroxyvitamin D [1,25-(OH)2D] (+7.0 pmol/L) levels and urinary calcium/creatinine ratios (+0.5%) and significantly decreased PTH(1-84) secretion (-0.74 pmol/L) after 1 yr. No effect was found for the parameters of bone turnover. The effect on the bone mineral density of the left femoral neck was +1.8% in the first yr, +0.2% in the second yr, and +1.9% during the whole period (95% confidence interval 0.4, 3.4%). At the right femoral neck the effects were +1.5%, +1.1%, and +2.6% (confidence interval 1.1, 4.0%), respectively. No effect was found at the femoral trochanter and the distal radius. Supplementation with 400 IU vitamin D3 daily in elderly women slightly decreases PTH secretion and increases bone mineral density at the femoral neck.

242. Am J Clin Nutr. 1993 Aug;58(2):187-91.

Secondary hyperparathyroidism in elderly people: combined effect of renal insufficiency and vitamin D deficiency.

Freaney R, McBrinn Y, McKenna MJ.

Metabolic Unit, St. Vincent's Hospital, Dublin, Ireland.

The relative effects of renal insufficiency and vitamin D deficiency on parathyroid gland function were assessed in 29 free-living elderly subjects by using a sensitive assay for intact parathyroid hormone (PTH). Serum calcium, phosphate, alkaline phosphatase, creatinine, 25-hydroxyvitamin D [25(OH)D], and PTH were measured after an overnight fast during wintertime, after oral vitamin D therapy (20 micrograms cholecalciferol/d for 4 wk), and at the end of the subsequent summer. Hypovitaminosis D [serum 25(OH)D < 25 nmol/L] was evident in 86% of the subjects during wintertime and 52% had elevated PTH concentrations. Multiple-regression analysis identified serum creatinine as the strongest predictor variable for serum PTH (multiple r = 0.73, P < 0.001). Mean (+/- SD) serum PTH declined from 6.3 +/- 2.8 to 5.0 +/- 2.0 pmol/L (P < 0.001) by the end of the summer season, coincident with an increase in serum 25(OH)D). Secondary hyperparathyroidism is common in elderly people, and in Ireland is the result of both renal insufficiency and hypovitaminosis D.

243. J S C Med Assoc. 1993 Jun;89(6):273-8.

Vitamin D deficiency found in the diet of the elderly in South Carolina.

Ryan C, Lui JH.

Department of Family and Preventive Medicine, University of South Carolina School of Medicine.

Dietary intake of vitamin D was assessed from a 24-hour food recall collected from 293 independent living adults 55 years of age or older who participated in the South Carolina Nutrition Survey. Mean vitamin D intake was only 46 percent of the RDA. The data in this study indicated that insufficient dietary intake of vitamin D is prevalent among older South Carolinians. Possible methods to correct this include: increased exposure to the sun, increased intake of food sources containing this nutrient or prescribing a vitamin D supplement.

244. N Engl J Med. 1992 Dec 3;327(23):1637-42.

Vitamin D3 and calcium to prevent hip fractures in the elderly women.

Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, Delmas PD, Meunier PJ.

Institut National de la Sante et de la Recherche Medicale (INSERM), Unite 234, Hopital Edouard Herriot, Lyon, France.

BACKGROUND. Hypovitaminosis D and a low calcium intake contribute to increased parathyroid function in elderly persons. Calcium and vitamin D supplements reduce this secondary hyperparathyroidism, but whether such supplements reduce the risk of hip fractures among elderly people is not known. METHODS. We studied the effects of supplementation with vitamin D3 (cholecalciferol) and calcium on the frequency of hip fractures and other nonvertebral fractures, identified radiologically, in 3270 healthy ambulatory women (mean [+/- SD] age, 84 +/- 6 years). Each day for 18 months, 1634 women received tricalcium phosphate (containing 1.2 g of elemental calcium) and 20 micrograms (800 IU) of vitamin D3, and 1636 women received a double placebo. We measured serial serum parathyroid hormone and 25-hydroxyvitamin D (25(OH)D) concentrations in 142 women and determined the femoral bone mineral density at base line and after 18 months in 56 women. RESULTS. Among the women who completed the 18-month study, the number of hip fractures was 43 percent lower (P = 0.043) and the total number of nonvertebral fractures was 32 percent lower (P = 0.015) among the women treated with vitamin D3 and calcium than among those who received placebo. The results of analyses according to active treatment and according to intention to treat were similar. In the vitamin D3-calcium group, the mean serum parathyroid hormone concentration had decreased by 44 percent from the base-line value at 18 months (P < 0.001) and the serum 25(OH)D concentration had increased by 162 percent over the base-line value (P < 0.001). The bone density of the proximal femur increased 2.7 percent in the vitamin D3-calcium group and decreased 4.6 percent in the placebo group (P < 0.001). CONCLUSIONS. Supplementation with vitamin D3 and calcium reduces the risk of hip fractures and other nonvertebral fractures among elderly women.

245. Rev Rhum Mal Osteoartic. 1990 Nov;57(11):809-13.

[Vitamin D supplementation in institutionalized elderly. Effects of vitamin D3 (100,000 IU) orally administered every 3 months on serum levels of 25-hydroxyvitamin D]

[Article in French]

Zeghoud F, Jardel A, Garabedian M, Salvatore R, Moulias R.

C.N.R.S. URA 583, Universite Paris V, Hopital Necker, Paris.

A clinical trial carried out during the autumn/winter season in 46 institutionalized elderly subjects (35 women, 11 men) (group mean age = 83 +/- 2 years) revealed a severe deficiency in vitamin D in these subjects (25-hydroxyvitamin D level less than or equal to 3 ng/ml). After oral administration of 100,000 IU of vitamin D3, an increase in 25-hydroxyvitamin D levels above the 10 ng/ml threshold was observed and maintained for three months. A second dose, administered after 3 months, made it possible to sustain this level. No sign of toxicity was detected, notably no trace of hypercalcemia. In contrast, no change in the deficit (25-hydroxyvitamin D level less than or equal to 3 ng/ml) was seen in the placebo population. Three-monthly administration of the moderate dosage of 100,000 IU of vitamin D3 all year round would offer a simple, effective and risk-free system to counteract vitamin D deficiency in the elderly and of preventing the risk of osteomalacia, thus reducing the incidence of fractures.

246. Exp Clin Endocrinol. 1990 Apr;95(2):275-8.

Increased serum osteocalcin levels in elderly females with vitamin D deficiency.

Pietschmann P, Woloszczuk W, Pietschmann H.

Department of Medicine II, University of Vienna, Austria.

Serum levels of osteocalcin (OC), a 49 amino acid bone matrix protein, have been found to be a biochemical parameter of bone formation. In order to study bone metabolism in aging subjects we measured serum levels of OC, parathyroid hormone (PTH) and 25 hydroxy-vitamin D (25 OH Vit D) in 36 institutionalized elderly females (age range: 80-93 years) and in 21 premenopausal control subjects. Serum levels of 25 OH Vit D were significantly decreased in the elderly subjects (p less than 0.0001), whereas serum levels of OC and PTH were significantly higher in the elderly subjects than in the controls (p less than 0.0025 and p less than 0.0001, respectively). Serum OC levels correlated significantly with the serum PTH levels (p less than 0.009). Our data demonstrate that in elderly females with vitamin-D deficiency secondary hyperparathyroidism is associated with increased serum OC levels indicating an increased bone formation; these conditions might contribute to the bone disease of geriatric patients.

247. J Am Geriatr Soc. 1989 Jul;37(7):589-92.

Vitamin D deficiency in elderly patients in a general hospital.

Goldray D, Mizrahi-Sasson E, Merdler C, Edelstein-Singer M, Algoetti A, Eisenberg Z, Jaccard N, Weisman Y.

Department of Geriatric Medicine, Ichilov Hospital, Tel-Aviv Medical Center, Israel.

Serum 25-hydroxyvitamin D (25-OHD) levels were measured in 338 elderly patients admitted to the Geriatric Medicine Departments of a general hospital in Israel in the course of one year. The mean (+/- SD) serum 25-OHD levels were significantly lower (P less than .01) in the elderly patients (13.5 +/- 8.9 ng/mL) than in healthy young controls (24.7 +/- 6.1 ng/mL). One hundred ten patients (35.5%) were either vitamin D deficient (25-OHD less than 5 ng/mL) or had borderline serum levels of 25-OHD (5-9 ng/mL). The mean (+/- SD) serum 25-OHD concentration of patients who were completely mobile before hospitalization was 15.5 +/- 8.8 ng/mL (n = 239). In patients mainly immobilized but able to leave the house occasionally, it was 10.2 +/- 6.3 ng/mL (n = 84) and of bed-ridden patients, it was 5.2 +/- 3.2 ng/mL (n = 15). No correlation was found between serum 25-OHD levels and the patients' age or serum calcium, phosphorus, alkaline phosphatase, and albumin values. Thus, in order to detect vitamin D deficiency in the elderly, it is necessary to measure serum 25-OHD concentration. The results demonstrate that vitamin D deficiency is common among elderly patients even in sunny climates and indicate the need for development of effective programs of prevention and treatment.

248. Isr J Med Sci. 1988 Mar;24(3):160-3.

Vitamin D-deficiency in the elderly: treatment with ergocalciferol and hydroxylated analogues of vitamin D3.

Shany S, Chaimovitz C, Yagev R, Bercovich M, Lowenthal MN.

Department of Clinical Biochemistry, Soroka Medical Center, Beer Sheva, Israel.

The purpose of the present work was to study the effect of vitamin D and its metabolites in correcting hypovitaminosis D in the elderly. Thirty elderly people (mean age 78.4 years) participated in this study. They all had low serum levels of 25-hydroxyvitamin D (25-OH-D), of 24,25-dihydroxyvitamin D [24,25(OH)2D] and of 1,25-dihydroxyvitamin D [1,25(OH)2D]. These low levels did not increase in nine subjects after oral administration of vitamin D2 (3,000 IU/day for 12 weeks). However, administration of 1 alpha-hydroxyvitamin D3 (1 alpha-OH-D3) to 12 other subjects (0.5 micrograms/day for 8 weeks) led to a significant increase in the serum levels of 1,25(OH)2D. The other vitamin D metabolite levels remained unchanged. A significant increase in the levels of all three main vitamin D metabolites was obtained following administration of 25-hydroxyvitamin D3 (25-OH-D3) to a third group of nine subjects (25 micrograms/day for 1 week). These results suggest that vitamin D nutrition in elderly people insufficently exposed to the sun could be maintained by regular administration of 25-OH-D, whereas the administration of native vitamin D (ergocalciferol) in the doses used was inadequate for vitamin D nutrition.

249. Scott Med J. 1986 Jul;31(3):144-9.

The prevention of vitamin D deficiency in the elderly.

Dunnigan MG, Fraser SA, McIntosh WB, Moseley H, Sumner DJ.

Vitamin D deficiency is common in the house-bound and institutionalised elderly population of Britain. A study of patients over 65 years discharged with a diagnosis of osteomalacia from Greater Glasgow Health Board hospitals between 1970 and 1981 inclusive showed a low incidence in the 65 to 74 years age group but a steeply rising incidence in older age groups. The majority (83%) of patients were female. The fortification of margarine, butter and milk with concentrations of vitamin D acceptable to the general population does not produce significant elevations in serum 25-hydroxyvitamin D (25-OHD) levels in vitamin D-deficient elderly patients. Low intensity background ultraviolet radiation (UVR) and intermittent high intensity UVR produce significant elevations in serum 25-OHD levels in elderly patients but both methods have disadvantages which limit their widespread use. Vitamin D supplements equivalent to 10 micrograms daily produce significant elevations in serum 25-OHD levels in vitamin D-deficient elderly patients. A vitamin D supplement policy for the housebound and institutionalised elderly population of Britain is required.

250. Age Ageing. 1986 Mar;15(2):77-83.

Seasonal changes in the biochemical indices of vitamin D deficiency in the elderly: a comparison of people in residential homes, long-stay wards and attending a day hospital.

Davies M, Mawer EB, Hann JT, Taylor JL.

The seasonal changes in the biochemical indices of vitamin D nutrition have been measured in elderly people with differing requirements for institutionalized care. Residents of local authority homes (LAH) showed an increase in serum 25-hydroxyvitamin D3 [25(OH)D3] between spring and autumn (means 14-17 nmol/l, P less than 0.002). No significant seasonal changes were seen in patients on long-stay wards [(GW) serum 25(OH)D3 9.5 and 9.5 nmol/l] and in day-hospital attenders [(GDH) 25 and 26.8 nmol/l]. Significant differences (P less than 0.02 to P less than 0.0001) were found between the mean serum 25(OH)D3 amongst the three groups. A significant linear relationship (r = 0.84, P = 0.036) was found between mean serum 25-hydroxyvitamin D2[25(OH)D2] and dietary vitamin D2. The intake of vitamin D was suboptimal in all groups. The incidence of 25-hydroxyvitamin D deficiency [25(OH)D less than 12.5 nmol/l] varied from 11.7% of residents in LAH in autumn to 47% of GW patients in spring; but hypocalcaemia occurred less often (LAH 1.3% in autumn, GW 4.7% in spring). The diet assumes a greater role in protecting against vitamin D deficiency when the total 25(OH)D is low. Because most diets contain insufficient amounts of vitamin D, elderly institutionalized people will remain at high risk of developing vitamin D deficiency unless specific preventative measures are adopted.

251. Am J Clin Nutr. 1985 Sep;42(3):470-4.

A prospective trial of the effect of vitamin D supplementation on metacarpal bone loss in elderly women.

Nordin BE, Baker MR, Horsman A, Peacock M.

The effect on cortical bone loss of treating elderly women with 15,000 IU vitamin D2 weekly was evaluated by sequential radiographic morphometry of the metacarpals. One hundred nine randomly selected women aged 65-74 yr were studied for 2 yr. The women were randomly allocated to control or treated groups taking placebo or vitamin D2 capsules. Hand radiographs and blood samples were obtained at the beginning and end of the trial. Plasma 25-hydroxyvitamin D was measured by radio-competitive protein binding assay. Comparing the treated and control groups, vitamin D treatment significantly raised the plasma 25-hydroxyvitamin D levels (p less than 0.001) and reduced the rate of cortical bone loss (p less than 0.01). The placebo had no measurable effect on the plasma levels.

252. Acta Med Scand. 1982;212(3):157-61.

Oral vitamin D and ultraviolet radiation for the prevention of vitamin D deficiency in the elderly.

Toss G, Andersson R, Diffey BL, Fall PA, Larko O, Larsson L.

Different methods for the prevention and treatment of vitamin D deficiency were studied in 42 institutionalized elderly people. One group received ultraviolet radiation (UVR) on a large area of the body surface once a week for three months. The results were compared with those in groups receiving either 450 IU vitamin D2 together with 420 mg calcium daily, 420 mg calcium alone, or no treatment. A significant increase in serum 25-hydroxyvitamin D was obtained with UVR. A similar increase was obtained with oral vitamin D2. A small but significant decrease in serum alkaline phosphatase was observed in subjects receiving vitamin D and calcium or calcium alone. No effects on serum phosphate, urinary cyclic adenosine monophosphate and urinary calcium were seen. Though brief UVR at one-week intervals is an efficient and safe method for prevention of vitamin D deficiency in the elderly, it is in our experience time-consuming for the ward staff and thus less convenient than oral vitamin D supplementation.

Hyperparathyroidism

253. Calcif Tissue Int. 2003 Sep 10 [Epub ahead of print].

Role of Vitamin D and Parathyroid Hormone in the Regulation of Bone Turnover and Bone Mass in Men: The MINOS Study.

Szulc P, Munoz F, Marchand F, Chapuy MC, Delmas PD.

INSERM 403 Research Unit, 69437 Lyon, France.

We investigated the role of vitamin D and of parathyroid hormone (PTH) in the regulation of bone mineral density (BMD), tone dimensions and seasonal variation of bone turnover in 881 men aged 19-85 years. Bone mineral content (BMC) and BMD of the lumbar spine, hip and whole body were measured with HOLOGIC 1000W and those of distal forearm with an OSTEOMETER DTX 100 device. Bone formation was evaluated using osteocalcin, bone alkaline phosphatase and N-terminal extension propeptide of type I collagen (PINP). Bone resorption was evaluated by 24-hour excretion of deoxypyridinoline and of C-terminal telopeptide of collagen type I. In young men (<55 yrs) PTH level decreased with age (r = -0.18, P < 0.005) whereas 25-hydroxyvitamin D (25OHD) concentration was stable. In older men (>55 years) 25OHD decreased whereas PTH increased with age (r = -0.27 and r = 0.21, P = 0.0001). In young men, 25OHD level varied with season but not PTH, biochemical markers of bone turnover nor BMD. In young men, 25OHD, but not PTH, was a significant determinant of BMC, cortical thickness and of biomechanical properties of the femoral neck. Biochemical bone markers and BMD were not correlated with PTH nor with 25OHD. In elderly men, winter levels of 25OHD were lowest whereas those of PTH, bone resorption markers and PINP were highest. After adjustment for age, body weight and season, biochemical markers of bone turnover were correlated with PTH. In elderly men, 25OHD and PTH were significant determinants of BMC, cortical thickness and of biomechanical parameters of the femoral neck. Men with vertebral deformities had lower concentrations of 25OHD, higher PTH levels and slightly elevated urinary excretion of biochemical markers of bone resorption compared with men without vertebral deformities. In conclusion, in young men, 25OHD discloses a seasonal variability in contrast to PTH and biochemical bone markers. In this group, 25OHD is a significant determinant of BMC and BMD but not of bone size. In elderly men, seasonal variation of 25OHD and PTH concentrations result in seasonal variation of bone resorption. In this group, both 25OHD and PTH are determinants of BMC and cortical thickness of the femoral neck and, consequently, of its mechanical parameters.

254. J Clin Endocrinol Metab. 2003 Jan;88(1):185-91.

Age-related changes in the 25-hydroxyvitamin D versus parathyroid hormone relationship suggest a different reason why older adults require more vitamin D.

Vieth R, Ladak Y, Walfish PG.

Department of Laboratory Medicine and Pathology, University of Toronto and Mount Sinai Hospital, Toronto, Ontario M5G 1X5, Canada. rvieth@mtsinai.on.ca

Vitamin D requirements are thought to vary with age, but there is little comparative evidence for this. One goal in establishing a vitamin D requirement is to avoid secondary hyperparathyroidism. We studied 1741 euthyroid, thyroid clinic outpatients without evidence of calcium abnormalities, ranging in age from 19 to 97 yr, whose serum and urine had been analyzed for calcium, vitamin D, and parathyroid status. We found no effect of age on the 25-hydroxyvitamin D [25(OH)D] concentration associated with specific vitamin D intakes, and there was no relationship between 25(OH)D and 1,25hydroxyvitamin D [1,25(OH)2D]. In every age group, serum 1,25(OH)2D declined with increasing creatinine (P < 0.001). What changed with age included creatinine, which correlated with 25(OH)D (r = 0.146, P < 0.001) only in the youngest age group (19-50 yr) but not in the older age groups (P > 0.1). Creatinine did not correlate with PTH in the youngest age group, but the relationship became significant as age increased (e.g. for the elderly, r = 0.365, P < 0.001). Linear regression of log PTH vs. log 25(OH)D agreed with the natural shape of the relationship observed with scatterplot smoothing, and this showed no plateau in PTH as 25(OH)D increased. We compared PTH concentrations among age groups, based on 20 nmol/liter increments in 25(OH)D. Mean PTH in adults older than 70 yr was consistently higher than in adults younger than 50 yr (P < 0.05 by ANOVA and Dunnett's t test). PTH levels of the elderly who had 25(OH)D concentrations greater than 100 nmol/liter matched PTH of younger adults having 25(OH)D concentrations near 70 nmol/liter. This study shows that all age groups exhibit a high prevalence of 25(OH)D insufficiency and secondary hyperparathyroidism. Older adults are just as efficient in maintaining 25(OH)D, but they need more vitamin D to produce the higher 25(OH)D concentrations required to overcome the hyperparathyroidism associated with their diminishing renal function.

255. Osteoporos Int. 2002 Mar;13(3):257-64.

Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study.

Chapuy MC, Pamphile R, Paris E, Kempf C, Schlichting M, Arnaud S, Garnero P, Meunier PJ.

Hopital Edouard Herriot, Lyon, France. chapuy@lyon151.inserm.fr

Vitamin D insufficiency and low calcium intake contribute to increase parathyroid function and bone fragility in elderly people. Calcium and vitamin D supplements can reverse secondary hyperparathyroidism thus preventing hip fractures, as proved by Decalyos I. Decalyos II is a 2-year, multicenter, randomized, double-masked, placebo-controlled confirmatory study. The intention-to-treat population consisted of 583 ambulatory institutionalized women (mean age 85.2 years, SD = 7.1) randomized to the calcium-vitamin D3 fixed combination group (n = 199); the calcium plus vitamin D3 separate combination group (n = 190) and the placebo group (n = 194). Fixed and separate combination groups received the same daily amount of calcium (1200 mg) and vitamin D3 (800 IU), which had similar pharmacodynamic effects. Both types of calcium-vitamin D3 regimens increased serum 25-hydroxyvitamin D and decreased serum intact parathyroid hormone to a similar extent, with levels returning within the normal range after 6 months. In a subgroup of 114 patients, femoral neck bone mineral density (BMD) decreased in the placebo group (mean = -2.36% per year, SD = 4.92), while remaining unchanged in women treated with calcium-vitamin D3 (mean = 0.29% per year, SD = 8.63). The difference between the two groups was 2.65% (95% CI = -0.44, 5.75%) with a trend in favor of the active treatment group. No significant difference between groups was found for changes in distal radius BMD and quantitative ultrasonic parameters at the os calcis. The relative risk (RR) of HF in the placebo group compared with the active treatment group was 1.69 (95% CI = 0.96, 3.0), which is similar to that found in Decalyos I (RR = 1.7; 95% CI = 1.0, 2.8). Thus, these data are in agreement with those of Decalyos I and indicate that calcium and vitamin D3 in combination reverse senile secondary hyperparathyroidism and reduce both hip bone loss and the risk of hip fracture in elderly institutionalized women.

256. Calcif Tissue Int. 2002 Feb;70(2):78-82. Epub 2002 Jan 28.

Influence of daily regimen calcium and vitamin D supplementation on parathyroid hormone secretion.

Reginster JY, Zegels B, Lejeune E, Micheletti MC, Kvsaz A, Seidel L, Sarlet N.

Bone and Cartilage Research Unit, University of Liege, Liege, Belgium. jyreginster@ulg.ac.be

Calcium and vitamin D supplementation has been shown to reduce secondary hyperparathyroidism and play a role in the management of senile osteoporosis. In order to define the optimal regimen of calcium and vitamin D supplementation to produce the maximal inhibition of parathyroid hormone secretion, we have compared the administration of a similar amount of Ca and vitamin D, either as a single morning dose or split in two doses, taken 6 hours apart. Twelve healthy volunteers were assigned to three investigational procedures, at weekly intervals. After a blank control procedure, when they were not exposed to any drug intake, they received two calcium-vitamin D supplement regimens including either two doses of Orocal D3 (500 mg Ca and 400 IU vitamin D) 6 hours apart or one water-soluble effervescent powder pack of Cacit D3 in a single morning dose (1000 mg Ca and 880 IU vitamin D). During the three procedures (control and the two calcium-vitamin D supplementations), venous blood was drawn every 60 minutes for up to 9 hours, for serum Ca and serum PTH measurements. The order of administration of the two Ca and vitamin D supplementation sequences was allocated by randomization. No significant changes in serum Ca were observed during the study. During the 6 hours following Ca and vitamin D supplementation, a statistically significant decrease in serum PTH was observed with both regimens, compared with baseline and with the control procedure. Over this period of time, no differences were observed between the two treatment regimens. However, between the sixth and the ninth hour, serum PTH levels were still significantly decreased compared with baseline with split dose Orocal D3 administration, while they returned to baseline value with the Cacit D3 preparation. During this period, the percentage decrease in serum PTH compared with baseline was significantly more pronounced with Orocal D3 than with Cacit D3 (P = 0.0021). We therefore conclude that the administration of two doses of 500 mg of calcium and 400 IU of vitamin D3 6 hours apart provides a more prolonged decrease in serum PTH levels than the administration of the same total amount of Ca and vitamin D as a single morning dose in young healthy volunteers. This might have implications in terms of protection of the skeleton against secondary hyperparathyroidism and increased bone resorption and turnover in elderly subjects.

257. J Clin Endocrinol Metab. 2001 Apr;86(4):1633-7.

Effects of a short-term vitamin D(3) and calcium supplementation on blood pressure and parathyroid hormone levels in elderly women.

Pfeifer M, Begerow B, Minne HW, Nachtigall D, Hansen C.

Institute of Clinical Osteology Gustav Pommer, Clinic der Furstenhof, 31812 Bad Pyrmont, Germany. iko-pyrmont@t-online.de

Calcium supplementation is effective in reducing blood pressure in various states of hypertension, including pregnancy-induced hypertension and preeclampsia. In addition, calcitropic hormones are associated with blood pressure. The hypothesis is that short-term therapy with calcium and vitamin D(3) may improve blood pressure as well as secondary hyperparathyroidism more effectively than calcium monotherapy. The effects of 8 weeks of supplementation with vitamin D(3) (cholecalciferol) and calcium on blood pressure and biochemical measures of bone metabolism were studied. The sample consisted of 148 women (mean +/- SD age, 74 +/- 1 yr) with a 25-hydroxycholecalciferol (25OHD(3)) level below 50 nmol/L. They received either 1200 mg calcium plus 800 IU vitamin D(3) or 1200 mg calcium/day. We measured intact PTH, 25OHD(3), 1,25-dihydroxyvitamin D(3), blood pressure, and heart rate before and after treatment. Compared with calcium, supplementation with vitamin D(3) and calcium resulted in an increase in serum 25OHD(3) of 72% (P < 0.01), a decrease in serum PTH of 17% (P = 0.04), a decrease in systolic blood pressure (SBP) of 9.3% (P = 0.02), and a decrease in heart rate of 5.4% (P = 0.02). Sixty subjects (81%) in the vitamin D(3) and calcium group compared with 35 (47%) subjects in the calcium group showed a decrease in SBP of 5 mm Hg or more (P = 0.04). No statistically significant difference was observed in the diastolic blood pressures of the calcium-treated and calcium- plus vitamin D(3)-treated groups (P = 0.10). Pearson coefficients of correlation between the change in PTH and the change in SBP were 0.49 (P < 0.01) for the vitamin D(3) plus calcium group and 0.23 (P < 0.01) for the calcium group. A short-term supplementation with vitamin D(3) and calcium is more effective in reducing SBP than calcium alone. Inadequate vitamin D(3) and calcium intake could play a contributory role in the pathogenesis and progression of hypertension and cardiovascular disease in elderly women.

258. J Bone Miner Res. 2000 Jun;15(6):1113-8.

Erratum in: J Bone Miner Res 2001 Oct;16(10):1935. J Bone Miner Res 2001 Sep;16(9):1735.

Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women.

Pfeifer M, Begerow B, Minne HW, Abrams C, Nachtigall D, Hansen C.

Institute of Clinical Osteology Gustav Pommer and Clinic DER FURSTENHOF, Bad Pyrmont, Germany.

Long-term vitamin D and calcium supplementation is effective in reducing nonvertebral fractures in elderly people. Increased bone fragility caused by secondary hyperparathyroidism (sHPT) and impaired balance are known risk factors for hip fractures. The hypothesis is that short-term therapy with calcium and vitamin D may improve body sway as well as sHPT more effectively than calcium monotherapy. The effects of 8 weeks of supplementation with vitamin D (cholecalciferol) and calcium on body sway and biochemical measures of bone metabolism were measured. The sample consisted of 148 women (mean [+/-SD] age, 74 +/- 1 years) with a 25-hydroxycholecalciferol level below 50 nmol/liter. They received either 1200 mg of calcium plus 800 IU of vitamin D or 1200 mg of calcium per day. We measured intact parathyroid hormone (PTH), markers of bone turnover, and body sway before and after treatment. Falls and fractures among the participants were followed over a 1-year period. Compared with calcium mono, supplementation with vitamin D and calcium resulted in an increase in serum 25-hydroxyvitamin D of 72% (p < 0.0001), a decrease in the serum PTH of 18% ( p = 0.0432), and a decrease in body sway of 9% (p = 0.0435). The mean number of falls per subject during a 1-year follow-up period was 0.45 for the calcium mono group and 0.24 for the calcium and vitamin D group (p = 0.0346). Short-term supplementation with vitamin D and calcium improves sHPT and body sway and therefore may prevent falls and subsequent nonvertebral fractures in elderly women.

259. Rev Rhum Engl Ed. 1996 Feb;63(2):135-40.

Biochemical effects of calcium and vitamin D supplementation in elderly, institutionalized, vitamin D-deficient patients.

Chapuy MC, Chapuy P, Thomas JL, Hazard MC, Meunier PJ.

National Institute for Health and Medical Research (INSERM) unit 403, Edouard Herriot Hospital, Lyon, France.

Forty-five subjects (41 women and 4 men) in long-stay and medium-stay facilities, aged 74 to 95 years (mean 86.4 years), with 25-hydroxy-vitamin D levels less than 12 ng/ml, were treated for six consecutive months with two tablets per day of a preparation containing vitamin D3 (800 IU/day) and calcium carbonate (1 g elemental calcium/day). Serum levels of 25-hydroxy-vitamin D were very low at baseline (5.6 +/- 0.4 ng/ml) and rose significantly under treatment, to normal values, 33.2 +/- 1.2 and 40.9 +/- 2.1 ng/ml after three and six months, respectively (p < 0.001 for both comparisons). Serum calcium increased significantly, by 4.5% (p < 0.001) during the first three months, and remained at a plateau thereafter. Corrected serum calcium rose by 8.9% (p < 0.001) during the trial. No patient developed hypercalcemia. Serum parathyroid hormone levels, which were elevated at baseline (71.6 +/- 5.8 pg/ml; normal, 12 to 54 pg/ml), decreased gradually and significantly throughout the treatment period, by 43.0% and 67.1% after three and six months, respectively (p < 0.001 for both comparisons). Serum alkaline phosphatase activity fell concomitantly, by 9.9% after three months (p < 0.01) and 36.5% after six months (p < 0.001). In conclusion, the preparation used in our study is effective in correcting both the vitamin D deficiency that is prevalent in elderly institutionalized patients and the resultant increase in bone turnover.

260. J Clin Endocrinol Metab. 1988 Oct;67(4):644-50.

The effect of vitamin D supplementation on vitamin D status and parathyroid function in elderly subjects.

Lips P, Wiersinga A, van Ginkel FC, Jongen MJ, Netelenbos JC, Hackeng WH, Delmas PD, van der Vijgh WJ.

Department of Endocrinology, Academisch Ziekenhuis Vrije Universiteit, Amsterdam, The Netherlands.

Vitamin D deficiency is common in the elderly and may lead to secondary hyperparathyroidism, cortical bone loss, and hip fractures. The effect of vitamin D supplementation for 1 yr was studied in 72 people living in a nursing home and 70 people living in an aged people's home. The subjects were randomized into 3 groups: control, and 400 or 800 IU vitamin D3/day. The initial vitamin D status of each subject was classified as deficient or borderline [serum 25-hydroxyvitamin D (25OHD) less than 30 nmol/L] in 79% and adequate (serum 25OHD greater than or equal to 30 nmol/L) in 21%. Serum 25OHD concentrations increased about 3-fold in both groups receiving vitamin D supplementation. Serum 1,25-dihydroxyvitamin D [1,25-(OH)2D] concentrations increased slightly but significantly, and the increase was inversely related to the initial serum 25OHD concentration. Serum intact PTH-(1-84) concentrations decreased about 15% during supplementation in both nursing home and aged people's home residents, whereas serum osteocalcin significantly decreased in the nursing home residents only. We conclude that a vitamin D3 supplement of 400 IU/day adequately improves vitamin D status in elderly people and increases 1,25-(OH)2D concentrations in those with vitamin D deficiency. Supplementation decreases parathyroid function and may depress bone turnover to some degree.

Serum Levels

261. Osteoporos Int. 1998;8(3):222-30.

Vitamin D and its major metabolites: serum levels after graded oral dosing in healthy men.

Barger-Lux MJ, Heaney RP, Dowell S, Chen TC, Holick MF.

Osteoporosis Research Center, Creighton University, Omaha, Nebraska 68131, USA.

We determined the quantitative relationships between graded oral dosing with vitamin D3, 25(OH)D3, and 1,25(OH)2D3 for short treatment periods and changes in circulating levels of these substances. The subjects were 116 healthy men (mean age, 28 +/- 4 years, with usual milk consumption of < or = 0.47 l/day and mean serum 25(OH)D of 67 +/- 25 nmol/l). They were distributed among nine open-label treatment groups: vitamin D3 (25, 250 or 1250 micrograms/day for 8 weeks), 25(OH)D3 (10, 20 or 50 micrograms/day for 4 weeks) and 1,25(OH)2D3 (0.5, 1.0 or 1.0 microgram/day for 2 weeks). All treatment occurred between January 3 and April 3. We measured fasting serum, calcium, parathyroid hormone, vitamin D3, 25(OH)D and 1,25(OH)2D immediately before and after treatment. In the three groups treated with vitamin D3, mean values for circulating vitamin D3 increased by 13, 137 and 883 nmol/l and serum 25(OH)D increased by 29, 146 and 643 nmol/l for the three dosage groups, respectively. Treatment with 25(OH)D3 increased circulating 25(OH)D by 40, 76 and 206 nmol/l, respectively. Neither compound changed serum 1,25(OH)2D levels. However, treatment with 1,25(OH)2D3 increased circulating 1,25(OH)2D by 10, 46 and 60 pmol/l, respectively. Slopes calculated from these data allow the following estimates of mean treatment effects for typical dosage units in healthy 70-kg adults: an 8-week course of vitamin D3 at 10 micrograms/day (400 IU/day) would raise serum vitamin D by 9 nmol/l and serum 25(OH)D by 11 nmol/l; a 4-week course of 25(OH)D3 at 20 micrograms/day would raise serum 25(OH)D by 94 nmol/l; and a 2-week course of 1,25(OH)2D3 at 0.5 microgram/day would raise serum 1,25(OH)2D by 17 pmol/l.

Osteomalacia

262. Am J Med. 2000 Mar;108(4):296-300.

Osteomalacia due to vitamin D depletion: a neglected consequence of intestinal malabsorption.

Basha B, Rao DS, Han ZH, Parfitt AM.

Bone and Mineral Metabolism Research Laboratory, Bone and Joint Center, Henry Ford Health System, Detroit, Michigan, USA.

PURPOSE: Osteomalacia due to vitamin D depletion is believed to be rare in the United States because of the routine fortification of milk and other dairy products with vitamin D. We present a series of patients with histologically verified osteomalacia due to vitamin D depletion to emphasize the need for more careful and systematic surveillance of patients at risk of this metabolic bone disease. METHODS: Between 1989 and 1994, 17 patients with osteomalacia due to vitamin D depletion were seen in the Bone and Mineral Division of Henry Ford Health System, Detroit. All patients had a transiliac bone biopsy after in vivo double tetracycline labeling. Biochemical indexes of vitamin D nutritional status, parathyroid function, markers of bone turnover, and bone mineral density were assessed at the time of bone biopsy. The duration of symptoms, the lag between the cause of vitamin D depletion and the development of symptoms, and the radiologic findings were recorded. RESULTS: Osteomalacia was suspected by the referring physician in only 4 of the 17 patients, although a gastrointestinal disorder that can lead to vitamin D depletion was present in every patient. Thirteen of the patients had sustained at least one osteoporotic fracture (wrist, spine, or hip), and most had low appendicular and axial bone mineral density. All patients had one or more biochemical abnormalities consistent with vitamin D depletion. In 4 patients, a progressive rise in the serum alkaline phosphatase level was recorded but was not investigated until the patient presented with bone pain, muscle weakness, or fracture. CONCLUSIONS: Osteomalacia due to vitamin D depletion appears not to be suspected or diagnosed promptly in susceptible patients, perhaps because their physicians were not sufficiently aware of this condition.

Immune

263. J Clin Endocrinol Metab. 1989 Jul;69(1):127-33.

Inhibition of interleukin-1 production by 1,25-dihydroxyvitamin D3.

Tsoukas CD, Watry D, Escobar SS, Provvedini DM, Dinarello CA, Hustmyer FG, Manolagas SC.

Department of Biology, San Diego State University, California 92182.

The hormonal form of vitamin D, 1,25-dihydroxyvitamin D3 [1,25-(OH)2D3], inhibits the proliferation of T lymphocytes and production of growth-promoting factors (including interleukin-2) (IL2) in CTLL2 murine cells. In this study, we investigated the role of monocytes in this hormone-mediated inhibitory effect, by testing the effects of 1,25-(OH)2D3 on the ability of the mitogenic lectin phytohemagglutinin (PHA) to induce T cell activation in either a monocyte-dependent or phorbol myristate acetate (PMA)-driven (monocyte-independent) system. The results indicate that proliferation of T cells and production of growth-promoting factors are inhibited by 1,25-(OH)2D3 only in the monocyte-dependent system. Preincubation of monocytes with 1,25-(OH)2D3 for various periods of time and subsequent removal of the hormone resulted in inhibition of the PHA-driven proliferation of T cells. Preincubation for 2 h resulted in 20% inhibition, while preincubation for 36 h reduced proliferation to 50% of the control value [no 1,25-(OH)2D3 exposure]. These data suggested that monocytes are important participants in 1,25-(OH)2D3-mediated events. Therefore, we tested the effects of the hormone on the production of IL1, a monocyte-derived product thought to be involved in the induction of IL2 release and the subsequent development of the T cell proliferative response. 1,25-(OH)2D3 inhibited the production of both extracellular and cell-associated immunoreactive IL1 alpha and IL1 beta. Indomethacin, a prostaglandin synthetase inhibitor, did not alter the inhibitory properties of 1,25-(OH)2D3, suggesting that prostaglandins are not responsible for the inhibitory phenomenon. We conclude that part of the ability of 1,25-(OH)2D3 to inhibit T cell proliferation may be due to direct effects on monocytes by down-regulating IL-1 production. However, it is unlikely that the immunoregulatory properties of 1,25-(OH)2D3 on T cells are mediated solely through monocytes, and it is possible that the hormone also exerts its influence directly on T cells.

264. Mol Cell Endocrinol. 1985 Dec;43(2-3):113-22.

Interactions of 1,25-dihydroxyvitamin D3 and the immune system.

Manolagas SC, Provvedini DM, Tsoukas CD.

A series of recent discoveries indicate that the hormonal form of vitamin D3, namely, 1,25(OH)2D3 plays a role in the regulation of the immune system. Cells of the monocyte/macrophage lineage possess receptors for 1,25(OH)2D3 regardless of their activation stage; cells of the lymphoid lineage also express these receptors but only at certain stages of their differentiation pathway and upon activation. Further, 1,25(OH)2D3 promotes the differentiation of monocyte precursors towards monocyte/macrophages and enhances monocyte function in antigen presentation. In addition 1,25(OH)2D3 is a potent inhibitor of interleukin-2 (IL-2) and suppresses effector functions of both T and B lymphocytes via IL-2-dependent as well as via IL-2-independent mechanisms. The theoretical and clinical implications of these discoveries are discussed.

Osteoarthritis

265. Arthritis Rheum. 1999 May;42(5):854-60.

Serum vitamin D levels and incident changes of radiographic hip osteoarthritis: a longitudinal study. Study of Osteoporotic Fractures Research Group.

Lane NE, Gore LR, Cummings SR, Hochberg MC, Scott JC, Williams EN, Nevitt MC.

Division of Rheumatology, University of California, San Francisco 94143, USA.

OBJECTIVE: The purpose of this study was to determine the relationship of serum levels of 25-vitamin D and 1,25-vitamin D to incident changes of radiographic hip osteoarthritis (OA) among elderly white women. METHODS: Baseline and followup hip radiographs of 237 subjects were obtained an average of 8 years apart. Hips were scored for individual radiographic features (IRF) and assigned a summary grade based on the number and type of IRF present. Serum 25- and 1,25-vitamin D levels from baseline samples were analyzed by radioimmunoassay. Logistic and linear regression were used to examine the association of 25- and 1,25-vitamin D levels with radiographic changes, adjusting for age, health status, physical activity, weight, vitamin D supplement use, and calcaneal bone mineral density. RESULTS: The risk of incident hip OA defined as the development of definite joint space narrowing was increased for subjects who were in the middle (odds ratio [OR] 3.21, 95% confidence interval [95% CI] 1.06, 9.68) and lowest (OR 3.34, 95% CI 1.13, 9.86) tertiles for 25-vitamin D compared with subjects in the highest tertile. Vitamin D levels were not associated with incident hip OA defined as the development of definite osteophytes or new disease according to the summary grade. No association between serum 1,25-vitamin D and changes in radiographic hip OA was found. CONCLUSION: Low serum levels of 25-vitamin D may be associated with incident changes of radiographic hip OA characterized by joint space narrowing.

266. Ann Intern Med. 1996 Sep 1;125(5):353-9.

Relation of dietary intake and serum levels of vitamin D to progression of osteoarthritis of the knee among participants in the Framingham Study.

McAlindon TE, Felson DT, Zhang Y, Hannan MT, Aliabadi P, Weissman B, Rush D, Wilson PW, Jacques P.

Boston University Medical Center, Tufts University, Massachusetts, USA.

BACKGROUND: Evidence suggests that pathophysiologic processes in bone are important determinants of outcome in osteoarthritis of the knee. Low intake and low serum levels of vitamin D may compromise favorable responses of bone to osteoarthritis, predisposing patients to progression. OBJECTIVE: To determine whether dietary intake and serum levels of vitamin D would predict the incidence and progression of osteoarthritis of the knee in participants of the Framingham Study. DESIGN: Prospective observational study. SETTING: The Framingham Study. PARTICIPANTS: Participants in the Framingham Heart Study who had knee radiography at examinations 18 (done between 1983 and 1985) and 22 (done between 1992 and 1993) and received interim assessments of vitamin D intake and serum levels. MEASUREMENTS: Intake of vitamin D and serum levels of 25-hydroxyvitamin D, calculated on the basis of dietary habits and supplement use as reported on a questionnaire, were evaluated at examination 20 (1988 to 1989). Knee radiographs were given scores for global severity of osteoarthritis, using a modification of the scale of Kellgren and Lawrence (range, 0 to 4), and for the presence of osteophytes and joint-space narrowing (range, 0 to 3). Covariates measured at examinations 18 and 20 were age, sex, body mass index, weight change, injury, physical activity, health status, bone mineral density, and energy intake. RESULTS: 556 participants (mean age at baseline +/- SD, 70.3 +/- 4.5 years) had complete assessments. Incident osteoarthritis occurred in 75 knees; progressive osteoarthritis occurred in 62 knees. Serum levels of vitamin D were modestly correlated with vitamin D intake (r = 0.24). Risk for progression increased threefold in participants in the middle and lower tertiles for both vitamin D intake (odds ratio for the lower compared with the upper tertile, 4.0 [95% Cl, 1.4 to 11.6]) and serum levels of vitamin D (odds ratio for the lower compared with the upper tertile, 2.9[Cl, 1.0 to 8.2]). Low serum levels of vitamin D also predicted loss of cartilage, as assessed by loss of joint space (odds ratio, 2.3 [Cl, 0.9 to 5.5]) and osteophyte growth (odds ratio, 3.1 [Cl, 1.3 to 7.5]). Incident osteoarthritis of the knee occurring after baseline was not consistently related to either intake or serum levels of vitamin D. CONCLUSIONS: Low intake and low serum levels of vitamin D each appear to be associated with an increased risk for progression of osteoarthritis of the knee.