Investigating the Effects of Hydroxyvitamin D3 on Multiple Sclerosis

Study Overview
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Brief Summary
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Investigating the effects of hydroxyvitamin D3 on clinical, radiologic and immunomodulatory markers in MS patients: A randomized, clinical trial- a pilot study

Detailed Description
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Vitamin D deficiency/insufficiency is a risk factor for developing MS and is linked to increased disease activity in those with established disease. Several clinical trials have already been conducted to consider the effect of vitamin D supplementation on clinical outcomes of the disease but the findings were inconsistent. This paradox may be explained by supplementation dose, trial duration and also an insufficient rise in serum 25-hydroxyvitamin D to be effective on immunomodulatory pathways and consequent clinical outcomes. Of note, it was revealed that MS patients have a lower rise in serum 25-hydroxyvitamin D [25(OH)D] levels compared with healthy controls (HCs), when given the same amount of oral cholecalciferol supplementation. Cholecalciferol is the main vitamin D supplement that was used in these trials. When vitamin D3 is ingested, it is incorporated into chylomicrons and enters the lymphatic system. The chylomicrons then enter into the bloodstream via the superior cava. Most of the vitamin D is incorporated into the body fat. Vitamin D3 in the circulation and the vitamin D3 that is slowly released from the body fat into the circulation is converted in the liver to 25(OH)D3, taking approximately 6-8 weeks to achieve a steady state concentration of 25(OH)D3. The more rapid increase in serum concentrations of 25(OH)D3, by treatment with calcifediol instead of cholecalciferol, may provide an advantage through rapid entry into its target innate and adaptive immune cells, resulting in the paracrine/autocrine production of 1α,25(OH)2D which interacts with the vitamin D receptor (VDR) to modulate immune function.

Official Title
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Investigating the Effects of Hydroxyvitamin D3 Versus Vitamin D3 on Clinical, and Radiologic Progress and Th17/Tregs Balance in MS Patients: A Randomized, Clinical Trial- a Pilot Study

Conditions
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Multiple Sclerosis, Relapsing-Remitting, Adult ALL, Vitamin D3 Deficiency

Intervention / Treatment
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* Dietary Supplement: 25(OH)D3
* Dietary Supplement: vitamin D3


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: MS type: relapsing-remitting MS (RRMS) older than 18 year-old Vitamin D deficiency/insufficiency (25(OH)D<30 ng/ml Exclusion Criteria: medications or disorders that would affect vitamin D metabolism history of other chronic disorders history of conditions that could lead to high serum calcium levels pulse therapy in the last 3 months history of attack in the last 3 months using corticosteroid in the last 3 months be pregnant

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 55 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: This is a randomized clinical trial with a parallel group and allocation 1:1.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: 25(OH)D3 (Calcifediol)<br>50 micrograms per day 25(OH)D3 or vitamin D hydroxylated for 24 weeks | Dietary Supplement: 25(OH)D3<br>* calcifediol<br>* Other names: vitamin D analog;|
| Experimental: Cholecalciferol<br>50 micrograms (2000IU) per day Cholecalciferol for 24 Weeks | Dietary Supplement: vitamin D3<br>* Cholecalciferol<br>* Other names: activated 7-dehydrocholesterol;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of relapses | neurologic symptoms lasting more than 24 hours which occur at least 30 days after the onset of a preceding event | 6 months (baseline and end of 6th month) in each intervention arm | 
| disability | Change in expanded disability status scale (EDSS) according to Kurtzke 1983. The minimum is 0 (no disability) and maximum value is 10 (Death due to MS)- higher scores mean a worse outcome. | 6 months (baseline and end of 6th month) in each intervention arm | 
| Change in MRI parameters | new lesions on T2 weighted images, gadolinium enhancing lesions in T1-weighted images | 6 months (baseline and end of 6th month) in each intervention arm | 
| changing in brain parameters of Diffusion tensor imaging (DTI) | the integrity of white matter (WM) by analyzing WM microstructure through DTI | 6 months (baseline and end of 6th month) in each intervention arm | 
| changing in Cognition | Changing in cognitive functions by the Minimal Assessment of Cognitive Function in MS (MACFIMS) battery. The lower the score the more disfunction. MACFIMS is consisting of 7 subtests including: the California Verbal Learning Test second edition (CVLT-II), with the range score: 0-80 the Paced Auditory Serial Addition Test (PASAT), with the range score: 0-16 the Symbol Digit Modalities Test (SDMT), with the range score: 0-110 the Brief Visuospatial Memory Test-Revised (BVMT-R), with the range score: 0-36 the Controlled Oral Word Association Test (COWAT), with the range score: 0-12 the Delis-Kaplan Executive Function System (DKEFS) sorting Test, with the range score: 0- undetermined the Judgment of Line Orientation Test (JLO), with the range score: 0-30 The higher score in each subtest means the better cognitive function | 6 months (baseline and end of 6th month) in each intervention arm | 
| CD4+ T cell response | After six months, changing the balance of Th17 and Tregs subtypes of CD4+ T cells. Detecting interleukin (IL) 17 -expressing T cells and Tregs expressing T cells by flow cytometry. | 6 months (baseline and end of 6th month) in each intervention arm | 
| Differential gene expression | After six months of 25-hydroxy vitamin D supplementation, the differentially expressed genes (DEGs) in peripheral blood mononuclear cells at the transcriptome level will be considered by RNA-seq | 6 months (baseline and end of 6th month) in each intervention arm | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| needing hospitalization | needing hospitalization due to remissions and exacerbations of the disease | 6 months (baseline and end of 6th month) in each intervention arm | 
| changing in quality of life | changing in quality of life that determined by the Short Form Health Survey that contains 36-item (Sf36). The score is between 0-100. The lower the score the more disability. The higher the score the less disability. | 6 months (baseline and end of 6th month) in each intervention arm | 
| effective in rapidly raising circulating levels of 25(OH)D3 | Serum levels of 25-hydroxy vitamin D (25(OH)D will be measured by High-performance liquid chromatography (HPLC) | 6 months (baseline and end of 6th month) in each intervention arm | 
| changing in the circulating levels of interleukin 17 as a inflammatory marker | After six months of calcifediol/or cholecalciferol supplementation, measuring serum levels of IL-17 by enzyme-linked immunoassay (ELIZA) kit. | 6 months (baseline and end of 6th month) in each intervention arm | 
| changing in the levels of interleukin 10 as anti- inflammatory marker | After six months of calcifediol/or cholecalciferol supplementation, measuring serum levels of IL-10 by ELIZA kit. | 6 months (baseline and end of 6th month) in each intervention arm | 
| changing in the levels of Tumor Necrosis Factor alpha (TNF-a) as an inflammatory marker related the T-CD4 subsets | After six months of calcifediol/or cholecalciferol supplementation, measuring serum levels of TNF-a by ELIZA kit. | 6 months (baseline and end of 6th month) in each intervention arm |