High dose interval vitamin D supplementation in pediatric patients with inflammatory bowel disease receiving Remicade
Wells, Reeder M.
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BACKGROUND: Patients suffering from inflammatory bowel disease (IBD) are at increased risk of vitamin D deficiency. Daily or weekly vitamin D supplementation has not proven to be effective in improving vitamin D status, and it is thought that this failure has been primarily due to a lack of compliance. Circulating vitamin D is crucial to bone growth and development in children and adolescents. However, more recent data has demonstrated that vitamin D also plays a significant role in the maintenance and regulation of the immune system. OBJECTIVES: The primary aim of this study is to investigate the safety and efficacy of administering high dose oral vitamin D therapy in pediatric patients with IBD. We chose to study patients receiving Remicade, an immunosuppressive monoclonal antibody therapy administered intravenously, as the need for scheduled hospital-based infusions provides a unique opportunity to ensure compliance in our study population. METHODS: We identified consecutive pediatric patients with IBD with a recent 25-hydroxyvitamin D (25OHD) level < 30ng/mL, maintained on Remicade, and with no history of kidney or liver disease for inclusion in the study from November 2017 and November 2018. Enrolled patients received one-year of open-label therapy. Vitamin D treatment doses were assigned by Remicade interval and patients received either 50,000 international units (IU) (every 4-5 weeks) or 100,000 IU (every 6-8 weeks) vitamin D3 orally at the time of their Remicade infusions. In addition to vitamin D levels, spot urine calcium to creatinine ratios, serum calcium, phosphorus, and blood urea nitrogen (BUN) levels, quality of life metrics, and surveys pertaining to dietary vitamin D intake and ultraviolet B (UVB) radiation exposure were collected throughout the study period. RESULTS: Baseline vitamin D status in enrolled patients did not differ by gender, dosing group, diet, or diagnosis (Crohn disease or ulcerative colitis). Subjects reached steady-state serum 25OHD levels after three doses administered over a span of 4 to 8 months, our data demonstrated an increase in average 25OH vitamin D levels from 21.17 ng/mL to 28.19 ng/mL in the 50,000 IU and 23.00 ng/mL to 33.18 ng/mL in the 100,000 IU dose groups, respectively. The improvement in vitamin D status did not correlate with changes in quality of life or disease activity. The response to vitamin D therapy was independent of diet, sun exposure, race, gender, diagnosis, or season of enrollment. There were no adverse events, including changes in urine calcium to creatinine excretion or serum BUN and creatinine values. Several patients manifest a small decrease in serum phosphorus during the initial phase of the study. However, these changes were transient and no subjects exhibited clinical signs or symptoms of hypophosphatemia. CONCLUSION: High dose, interval vitamin D supplementation achieved steady-state 25OHD levels of 30 ng/mL or greater, with no signs of toxicity in patients enrolled in this pilot study. These data suggest that high-dose interval therapy may be a feasible treatment option that bypasses limitations related to difficulties with patient compliance. Further studies are necessary to determine optimal dosage regimens and to assess endpoints related to immune function and improvements to gastrointestinal health.
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