P. Athanassiou

Vitamin D and rheumatoid arthritis

Objectives: Vitamin D deficiency has been implicated in the pathogenesis of autoimmune diseases, such as diabetes mellitus type 1 and multiple sclerosis. Reduced vitamin D intake has been linked to increased susceptibility to the development of rheumatoid arthritis (RA) and vitamin D deficiency has been found to be associated with disease activity in patients with RA. The objective was to evaluate vitamin D status in patients with RA and to assess the relationship between vitamin D levels and disease activity. Methods: In a cohort of 44 patients with RA, 25-hydroxyvitamin D3 [25(OH)D3] levels, parathyroid hormone levels, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were measured. Disease activity was evaluated by calculating the 28-joint Disease Activity Score (DAS28). A control group (n = 44), matched for age and sex, was evaluated as well. Results: In the cohort of 44 patients with RA 25(OH)D3 levels were found to be low compared with the control group, 25(OH)D3 being 15.26 ± 1.07 ng/ml [mean ± standard error of the mean (SEM)] and 25.8 ± 1.6 ng/ml in the patient and control group respectively (Student’s t test, p < 0.001). Parathyroid hormone levels were 71.08 ± 7.02 pg/ml (mean ± SEM) (normal values 10.0–65.0 pg/ml), CRP 7.6 ± 1.57 mg/litre (mean ± SEM) (normal values < 3 mg/litre) and ESR was 38.0 ± 4.6 mm/h (mean ± SEM) in the group of patients with RA. Levels of 25(OH)D3 were found to be negatively correlated to the DAS28, the correlation coefficient being −0.084. Levels of 25(OH)D3 were also found to be negatively correlated to CRP and ESR, the correlation coefficient being –0.115 and −0.18, respectively. Conclusion: It appears that vitamin D deficiency is highly prevalent in patients with RA, and that vitamin D deficiency may be linked to disease severity in RA. As vitamin D deficiency has been linked to diffuse musculoskeletal pain, these results have therapeutic implications. Vitamin D supplementation may be needed both for the prevention of osteoporosis as well as for pain relief in patients with RA.

Vitamin D and glycemic control in diabetes mellitus type 2.

Objectives: The extraskeletal effects of vitamin D have attracted considerable interest. Vitamin D deficiency appears to be related to the development of diabetes mellitus type 2 and the metabolic syndrome. Vitamin D may affect glucose homeostasis, vitamin D levels having been found to be inversely related to glycosylated hemoglobin levels in gestational diabetes mellitus. In addition, vitamin D appears to protect from the development of gestational diabetes mellitus. The aim was to study levels of 25-hydroxy vitamin D3 [25(OH)D3] and the relationship between 25(OH)D3 levels and glycemic control in patients with diabetes mellitus type 2. Methods: Glycosylated hemoglobin (HbA1c) and 25(OH)D3 levels were measured in a group of 120 diabetes mellitus type 2 patients. The same measurements were performed in a group of 120 control subjects of the same age and sex. 25(OH)D3 was measured by radioimmunoassay and glycosylated hemoglobin (HbA1c) was measured by high-performance liquid chromatography. Results: 25(OH)D3 levels were lower in the diabetes mellitus type 2 patients than in the control group, being 19.26 ± 0.95 ng/ml and 25.49 ± 1.02 ng/ml, in the patient and control groups, respectively (p < 0.001, Student’s t-test). 25(OH)D3 levels were found to be inversely associated with HbA1c levels in the diabetic patients (p = 0.008, r2 = 0.058, linear regression). 25(OH)D3 levels were found to be inversely associated with HbA1c when the patient and control groups were analysed together (p < 0.001, r2 = 0.086). Conclusions: Vitamin D levels appeared to be lower in diabetes mellitus type 2 patients than in the control group, vitamin D levels being related to glycemic control in diabetes mellitus type 2. These findings may have therapeutic implications as cautious vitamin D supplementation may improve glycemic control in diabetes mellitus type 2.

Vitamin D deficiency in a patient with HDR syndrome.

The case of a patient with clinical symptoms, laboratory and imaging findings of hypoparathyroidism, sensorineural deafness, renal dysplasia HDR, or Barakat syndrome (hypoparathyroidism, deafness, renal dysplasia), and vitamin D deficiency, is presented. A Caucasian man aged 51 years with a history of chronic hypocalcaemia since childhood, was admitted with hypertonia of the body and extremities, and loss of consciousness. On admission, he was found to have severe hypocalcaemia, hyperphosphataemia, severe hypoparathyroidism, low serum magnesium and mild renal insufficiency. Calcium gluconate was administered intravenously supplemented with magnesium, and the patient recovered consciousness while clinical and laboratory findings improved. Evaluation revealed left renal aplasia and sensorineural deafness affecting both ears. Vitamin D deficiency was also present. He was given calcium and vitamin D supplements orally, and the hypocalcaemia was corrected. This case is described as it is an extremely rare case of HDR syndrome with concurrent vitamin D deficiency.

PS3:65 Vitamin d deficiency in patients with systemic lupus erythematosus and relationship with disease activity

Purpose Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder which mainly affects women in the reproductive age. Vitamin D appears to have an immunomodulatory action, low levels of vitamin D having been described in patients with autoimmune rheumatic diseases. The aim was to report vitamin D levels and their relationship with disease activity in a cohort of SLE patients. Methods A cohort of 20 patients, 18 female and 2 male is described. The patients were diagnosed with SLE and had arthralgias, cutaneous manifestations, fatigue and decreased complement levels. Blood levels of 25(OH)D3 were measured in all patients. 25(OH)D3 levels were measured by radioimmunoassay. The measurement of 25(OH)D3 by radioimmunoassay consisted of a two-step procedure. The first step involved a rapid extraction of 25(OH)D and other hydroxylated metabolites from serum or plasma with acetonitrile. Following extraction, the treated samples were then assayed by competitive RIA using an antibody with specificity to 25OHD. The sample, antibody and tracer were incubated for 90 min at 20–25 0C. Phase separation was accomplished after 20 min incubation at 20–25 0C with a second antibody precipitating complex. To reduce non-specific binding buffer was added after this incubation prior to centrifugation. The sensitivity of the assay was <1.6 ng/ml. The recovery was approximately 100% for 25(OH)D3. Within and between batch precision was <12% and<11%, respectively. Results In the cohort of SLE patients low blood levels of 25(OH)D3 were observed. A positive relationship between 25(OH)D3 blood levels and complement levels was observed, namely low 25(OH)D3 levels were positively correlated with low complement levels. An inverse relationship was observed between 25(OH)D3 levels and disease activity, namely low 25(OH)D3 levels were related with high disease activity. Conclusions Vitamin D is a hormone directly related to the regulation of the musculoskeletal system. Vitamin D also has extraskeletal actions. The immunomodulatory action of vitamin D appears to be a key action of the hormone. In the work presented herein low blood levels of vitamin D were observed in SLE patients which were positively related to complement levels and inversely related to disease activity.

PS10:189 Neuropsychiatric lupus. a severe manifestation of systemic lupus erythematosus

Purpose Nervous system involvement in systemic lupus erythematosus (SLE) is a grave manifestation of the disease affecting health, quality of life and disease outcome. It is one of the most complex manifestations of SLE and may affect the central, peripheral and autonomous nervous system. Complex interrelated pathogenetic mechanisms are involved in disease pathogenesis. The aim of the study was to describe a patient with neuropsychiatric lupus. Methods A patient, female aged 50 years presented with SLE with a duration of 20 years. The diagnosis of the disease was made when she presented with intense fatigue, hair loss, a light sensitive rash, arthralgias and positive antinuclear and anti-dsDNA antibodies. In the course of the disease the patient developed CNS involvement with epileptic convulsions, permanent dysarthria and delusions. A brain MRI scan was without specific alterations, however an EEG performed was abnormal and a brain single-photon emission CT (SPECT) revealed decreased perfusion of both frontal and parietal lobes. The patient developed musculoskeletal manifestations at many stages of the disease. At diagnosis the patient had arthralgias of both wrists and knees. The patient presented with a flare with fatigue, mouth ulcers, convulsions, decreased ability to concentrate, intense delusions and dysarthria. At disease flare, when neuropsychiatric symptoms evolved she had diffuse arthralgias. Results Pulse methylprednisolone i.v. followed by pulse cyclophosphamide i.v. were administered in order to achieve remission. Disease stabilisation was induced by pulse cyclophosphamide at bimonthly intervals and orally administered prednisolone. When remission of the disease was induced by pulse methylprednisolone and cyclophosphamide the patient developed muscle weakness. At disease stabilisation with pulse cyclophosphamide at bimonthly intervals the patient developed arthritis of the hand joints. The disease is now in remission, corticosteroid doses having been significantly reduced. Conclusions Neuropsychiatric lupus is a grave and complex manifestation of SLE. The disease may be accompanied by various manifestations and severely affects quality of life. Neuropsychiatric lupus should be aggressively treated in order to improve quality of life and disease outcome.

Vitamin D in acutely ill patients

Objective To investigate 25(OH)D3 levels and their relationship to survival in a cohort of acutely ill patients on admission to an intensive care unit. Methods This study enrolled acutely ill patients at admission to an intensive care unit and a group of sex- and age-matched healthy control subjects. The 25(OH)D3 levels were measured using an enzyme immunoassay. C-reactive protein and procalcitonin levels were also measured using immunoassays. Results A total of 50 acutely ill patients and 50 healthy control subjects were enrolled in the study. The mean ± SEM 25(OH)D3 levels were significantly lower in the acutely ill patients compared with the control group (11.74 ± 0.88 ng/ml versus 24.66 ± 1.60 ng/ml, respectively). The 25(OH)D3 levels were not related to survival. An inverse relationship was observed between 25(OH)D3 levels and C-reactive protein levels. A weak inverse relationship was also observed between 25(OH)D3 levels and procalcitonin levels. Conclusions The 25(OH)D3 levels were decreased in acutely ill patients admitted to an intensive care unit compared with healthy control subjects. 25(OH)D3 levels may be inversely related to C-reactive protein and procalcitonin levels.

AB0831 Management of Primary Hyperparathyroidism with Cinacalcet

Background Primary hyperparathyroidism is currently recognized with increasing frequency by routine calcium measurement in biochemical examinations. Primary hyperparathyroidism may be due to a parathyroid adenoma, parathyroid hyperplasia and, rarely, parathyroid carcinoma. Cinacalcet is used in the medical management of primary hyperparathyroidism. Objectives The aim was to assess the role of cinacalcet in the treatment of primary hyperparathyroidism. Methods Patients with primary hyperparathyroidism (n=20) (aged 56-85 years) were studied. Amongst them 4 patients had parathyroid hyperplasia and 16 had a parathyroid adenoma. Calcium and PTH levels were increased in all patients. All patients had ultrasonography and a 99mTc-Sestamibi scan. In 16 patients a parathyroid adenoma was observed either on ultrasound or on scanning or in both. In 4 of the patients a parathyroid adenoma was not localized by imaging. Results Cinacalcet was used in all 16 parathyroid adenoma patients to normalize serum calcium levels prior to surgery. In 10 of the parathyroid adenoma patients the adenoma was surgically excised, in a female aged 56, hyperparathyroidism recurring a year after surgery. Sequentially, cinacalcet was administered at a dose of 30 mg twice daily and serum calcium levels normalized. Within the group of patients with a parathyroid adenoma 6 were elderly, aged >75 years, with comorbidity and cinacalcet was administered at a dose of 30 mg twice daily in 3 and 60 mg twice daily in 1 to avoid surgery. In the group of patients with parathyroid hyperplasia cinacalcet was used for the treatment of hypercalcemia. Within the whole group, 2 patients experienced mild gastrointestinal symptoms, but discontinuation of the drug could be avoided. Conclusions Cinacalcet may be used for the treatment of primary hyperparathyroidism. It can be used for the normalization of serum calcium prior to surgery, if surgery is not an option, in the event of recurrence after surgery and in parathyroid hyperplasia. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4848