Vitamin d status and cardiometabolic risk factors in long-term psychiatric inpatients.

OBJECTIVE: Low vitamin D levels are common in psychiatric patients, but a need for vitamin D supplementation in these individuals remains controversial. Low vitamin D levels are reportedly associated with high prevalence of cardiometabolic risk factors, and both are common in psychiatric patients, but the relationship between diagnosis and severity of illness and cardiometabolic risk status and the effect of vitamin D treatment on them is not known. We studied these relationships and effect of vitamin D(3) treatment on them in 290 long-term psychiatric inpatients. METHOD: All patients admitted to the hospital during April 2009-March 2010 who agreed to 25-hydroxyvitamin-D testing were included. Serum 25-hydroxyvitamin D level, Brief Psychiatric Rating Scale (BPRS) score, body mass index, blood pressure, and fasting levels of blood glucose, triglycerides, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were measured at baseline, and changes after vitamin D(3) treatment for up to 12 months were observed. For the purposes of this study, 25-hydroxyvitamin-D levels < 32 ng/mL were considered as "low"; < 20 ng/mL, as "insufficient"; and < 12 ng/mL, as "deficient." RESULTS: A serum 25-hydroxyvitamin-D level < 32 ng/mL was found in 90.0% of patients, and a level <20 ng/mL was found in 48.6% of patients. A BPRS score > 36 was present in 56.0% of patients; obesity, in 75.7%; hypertension, in 44.8%; low HDL-C, in 43.6%; high triglycerides, in 31.2%; high LDL-C, in 17.8%; and increased glucose, in 14.6%. Serum 25-hydroxyvitamin-D levels correlated poorly with BPRS score and the other variables listed above (R, -0.02 to -0.22). After vitamin D(3) treatment, 25-hydroxyvitamin-D level increased to ≥ 20 ng/mL in all patients and ≥ 32 ng/mL in 85% of patients, but despite > 124% increase in mean 25-hydroxyvitamin-D level, mean improvement in other variables was < 12%. CONCLUSIONS: Nearly half of our patients had vitamin D levels < 20 ng/mL, putting them at risk for poor bone health and requiring vitamin D supplementation. Cardiometabolic risk factors were also highly prevalent, but correlated poorly with vitamin D levels in their severity. Increasing vitamin D levels to ≥ 32 ng/mL was not associated with improvement in BPRS score or any cardiometabolic risk factor, emphasizing that intensification of therapeutic measures other than vitamin D supplementation is required.

Relative oral corticosteroid-sparing effect of 7 inhaled corticosteroids in chronic asthma: a meta-analysis.

BACKGROUND: The relative efficacy of various inhaled corticosteroids (ICSs) for oral corticosteroid (OCS)-sparing effect in asthma is not known. To our knowledge, no randomized controlled trial directly comparing 2 ICSs has been reported, but several randomized controlled trials have reported comparison of various ICSs with placebo. OBJECTIVE: To conduct an adjusted indirect comparison of 7 ICSs for their OCS-sparing effect. METHODS: PubMed and bibliographies of relevant articles. Eighteen placebo-controlled randomized trials of 7 ICSs were analyzed using a random-effect model. Pooled benefit ratios (BRs) (ICS/placebo) for elimination of OCS and weighted mean differences (ICS - placebo) for OCS dose change by each ICS vs placebo were determined. Pairwise adjusted indirect comparisons of various ICSs were then made. RESULTS: For OCS elimination, all ICSs were more effective than placebo (BR: mometasone, 17.2; budesonide, 8.2; beclomethasone and fluticasone, 5.4; triamcinolone, 4.6; ciclesonide, 2.8; and flunisolide, 2.2). On pairwise adjusted indirect comparison, the BR of mometasone was significantly higher than that of triamcinolone (P = .02), ciclesonide (P = .01), and flunisolide (P = .01) and that of budesonide was significantly higher than that of ciclesonide (P = .02) and flunisolide (P = .03). For OCS dose change, beclomethasone achieved a significantly lower final mean OCS dose than fluticasone or flunisolide (P < .001). In all other comparisons, the differences were not statistically significant. CONCLUSIONS: All ICSs studied were significantly more effective than placebo for OCS sparing, but mometasone seemed to be more effective than others. However, because of very few trials for some ICSs, more placebo-controlled trials for adjusted indirect comparison or randomized trials for direct comparison of these ICSs are needed for definitive conclusions.

Evidence-based selection of inhaled corticosteroid for treatment of chronic asthma.

Published literature relevant to comparison of various inhaled corticosteroids (ICSs) was reviewed. Marked heterogeneity was found in the reported results. The efficacy and side effects of ICSs depend on their formulation, dosing and device used, and the subjects' age, severity of asthma, and inhaler technique. All these factors have not been included uniformly in most study designs. Notwithstanding this limitation, it appears that fluticasone is generally very effective and safe in low-to-medium doses and may be used for most patients. Budesonide is the only Pregnancy Category B ICSs, all others being Category C, and it is available as nebulizer suspension suitable for use in children over 6 months of age. Budesonide, also available as dry powder inhaler, and beclomethasone, available as metered-dose inhaler, are equal in efficacy, and side effects and may be chosen according to the patient's ability to handle the device. Flunisolide causes fewer side effects but is also relatively less effective. Triamcinolone is generally less effective and causes more side effects than most of the other ICSs. Mometasone may be preferred if once-daily dosing is desired. Ciclesonide has been found highly effective in once-daily dose and without side effects even in high doses. Further studies comparing it with other ICSs over longer periods of use will determine its place in treatment of chronic asthma.