Calcium Supplements for Bone Health in Juvenile Rheumatoid Arthritis
Condition: Juvenile Rheumatoid Arthritis
MeSH terms: Arthritis; Arthritis, Rheumatoid; Arthritis, Juvenile
Study type: Interventional
Phase: Phase 2

Summary: 
      This study looks at the effects of taking calcium pills on bone health in young people with
      juvenile rheumatoid arthritis (JRA). In this 2-year study, children aged 6-18 who have JRA
      will take either a calcium supplement or a matching placebo (inactive or "dummy" pill)
      containing no calcium. During the study, researchers and patients will not know if a patient
      is taking calcium or placebo. We believe that patients who take calcium supplements will have
      at least a 10 percent greater increase in total body bone mineral density compared to
      patients who take the placebo.

      We will evaluate patients at Children's Hospital Medical Center every 6 months for 2 years.
      During this 2-year period, participants in the study will take one multivitamin containing
      400 IU (international units) of vitamin D and either 1,000 mg of calcium carbonate (Tums
      tablets) by mouth or a matching placebo once a day. We will check patients 6 and 18 months
      after the 2-year treatment period to find out if people in the Tums-treated group maintain
      any increases in bone formation that occurred during the 2-year treatment period.
    

Detailed description: 
      This is a randomized, double-blind, placebo-controlled trial of 24 months in which juvenile
      rheumatoid arthritis (JRA) patients will take either an oral calcium supplement of 1,000 mg
      elemental calcium per day or a matching placebo containing no calcium (Ca), plus one
      multivitamin per day. We hypothesize that patients receiving calcium supplementation will
      demonstrate at least a 10 percent greater increase in total body bone mineral density
      compared to those treated with placebo.

      We will evaluate patients at Children's Hospital Medical Center (CHMC) every 6 months for 2
      years. We will also evaluate patients 6 and 18 months after the end of the intervention
      period to determine the persistence of any demonstrated increased bone mineralization in the
      Tums-treated group. The study requires analysis of human blood and urine samples and low-dose
      radiation exposure.

      We have randomized 193 JRA patients equally into two treatment groups (active and placebo).
      The active treatment group is taking, in a single daily dose, two 500 mg tablets of elemental
      Ca as CaC03 (calcium carbonate) and one multivitamin tablet containing 400 IU vitamin D. The
      placebo treatment group is taking, in a single daily dose, two placebo tablets (matched on
      size, appearance, and taste) containing 0 mg elemental Ca and one multivitamin tablet
      containing 400 IU vitamin D. We do all patient evaluations in the Clinical Research Center at
      Children's Hospital Medical Center.

      Every 6 months during the 2-year intervention trial, we will perform interval history,
      general and joint physical exam, anthropometric measurements (height, weight, BMI), pill
      counts, MMEM monitor check, DXA scan of total body and lumbar spine for bone mineral density,
      and dispensing of study drugs. At yearly intervals during the intervention trial, we will do
      the Youth/Adolescent Questionnaire (YAQ) on diet (which is validated for 1-year recall),
      3-day diet diary for current intake, blood tests for mineral and calcitropic hormone
      concentrations, 24-hour urine for measurements of bone turnover markers and mineral
      excretion, physical function assessment (JAFAR), and physical activity questionnaire. We will
      obtain blood for determining vitamin D receptor (VDR) genotype at baseline only. We will
      perform fasting random urine tests to determine Ca/creatinine ratio to assess for
      treatment-induced hypercalciuria at months 0, 3, 6, 12, 18, and 24.

      Monthly during the intervention trial, the study coordinator will contact all participants by
      phone in a blinded fashion to increase compliance and encourage continued participation in
      the trial. We will evaluate participants 6 and 18 moths after the end of the intervention
      trial. At each of these visits, we will obtain the following: general and medication history,
      general and joint physical exam, Tanner Stage, anthropometric measurements, blood for
      minerals and calcitropic hormones, 24-hour urine collection for measurements of bone turnover
      markers and mineral excretion, JAFAR, physical activity questionnaire, and total body and
      lumbar spine DXA scans. The YAQ and 3-day diet diary will be completed at the 42-month visit.
      Prior to every DXA scan, we will do a urine pregnancy test in all menstruating females to
      ensure that they are not pregnant. Any patient who withdraws from the blinded portion of the
      study early will complete an evaluation as outlined for the 24 months visit. Patients who
      withdraw early during the open phase of the study will complete the 42 months evaluation.

      We will exclude from the study people who have recently taken systemic corticosteroids,
      people taking oral contraceptives, smokers, and pregnant women because these factors have
      been shown to significantly lower bone mineralization. We will withdraw subjects from the
      study if they demonstrate an elevated fasting random urinary calcium/creatinine ratio (>0.2),
      a chronic disease in addition to JRA that affects growth or bone mineralization, or they
      become pregnant. We will include these patients and all those withdrawing from the study
      voluntarily in an "intention-to-treat" analysis.
    

Intervention name(s): Calcium carbonate
Intervention type(s): Drug
Intervention MeSH terms: Calcium Carbonate; Calcium
Allocation: Randomized
Masking: Double
Primary purpose: Treatment
Keywords: JRA; Osteopenia; Dietary calcium; Diet therapy; Bone density; Ossification; Biomarker; Dietary supplement