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Author Manuscript
Lancet. Author manuscript; available in PMC 2014 September 26.
Published in final edited form as:
Lancet. 2011 January 15; 377(9761): 242–250. doi:10.1016/S0140-6736(10)61889-2.
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High-dose vitamin D3 during intensive phase treatment of
pulmonary tuberculosis: a double-blind randomised controlled
trial
Adrian R. Martineau, M.R.C.P.1,2,†, Peter M. Timms, F.R.C.Path3, Graham H. Bothamley,
F.R.C.P., Ph.D.3, Yasmeen Hanifa, M.R.C.G.P.1, Kamrul Islam, B.Sc.1, Alleyna P. Claxton,
M.R.C.P. F.R.C.Path3, Geoffrey E. Packe, F.R.C.P., M.D.4, John C. Moore-Gillon, F.R.C.P.,
M.D.5, Mathina Darmalingam, F.C.P.S.A.6, Robert N Davidson, F.R.C.P., M.D.7, Heather J.
Milburn, F.R.C.P., M.D.8, Lucy V. Baker, F.R.C.P.9, Richard D. Barker, M.R.C.P., M.D.10,
Nicholas J Woodward, M.R.C.P., F.R.C.R.11, Timothy R. Venton, FIBMS3, Korina E. Barnes,
M.Sc. FIBMS3, Christopher J. Mullett, B.Sc. MIBMS3, Anna K. Coussens, PhD2, Clare M.
Rutterford, M.Sc.1, Charles A. Mein, D.Phil12, Geraint R. Davies, M.R.C.P., Ph.D.13, Robert J.
Wilkinson, F.R.C.P., Ph.D.2, Vladyslav Nikolayevskyy, Ph.D.14, Francis A. Drobniewski,
F.R.C.Path, Ph.D.14, Sandra M. Eldridge, M.Sc., Ph.D.1, and Christopher J Griffiths,
F.R.C.G.P., F.R.C.P., D.Phil.1
1Centre
for Health Sciences, Queen Mary’s School of Medicine and Dentistry, Barts and The
London, London E1 2AT, UK
2Division
of Mycobacterial Research, National Institute of Medical Research, Mill Hill, NW7 1AA,
UK
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3Homerton
4Newham
University NHS Foundation Trust, London, E9 6SR, UK
Chest Clinic, Forest Gate, London E7 8QP, UK
5Department
of Respiratory Medicine, St Bartholomew’s and Royal London Hospitals, London
EC1A 7BE, UK
6Department
of Respiratory Medicine, Whipps Cross University Hospital, London E11 1NR, UK
7Tuberculosis
8Department
Clinic, Northwick Park Hospital, Harrow, HA1 3UJ, UK
of Respiratory Medicine, Guy’s and St Thomas’ NHS Foundation Trust, London SE1
9RT
9Department
of Respiratory Medicine, Lewisham Hospital, SE13 6LH
†
To whom correspondence should be addressed at Centre for Health Sciences, Queen Mary’s School of Medicine and Dentistry, Barts
and The London, London E1 2AT, UK, Tel: +44 207 882 2551 Fax: +44 207 882 2552, a.martineau@qmul.ac.uk.
Contributors: ARM, CJG, GHB, RND, NJW, RJW and PMT contributed to study design. ARM, YH, KI, CJG, GHB, GEP, JCM-G,
MD, RND, HJM, LVB, and RDB participated in implementation of the trial. ARM, YH, KI and CJG participated in administration
and regulatory support, data management and data collection. PMT, APC, FAD, VN, TRV, KEB, CJM and AKC developed and
performed assays of biochemical and microbiological outcome measures. CAM developed and performed genotyping assays. NJW
read chest radiographs. ARM, CMR, SME and GRD contributed to data analysis. ARM wrote the manuscript; all other authors
critically reviewed it and approved the final version.
Conflict of interest statement: Merck Serono donated €7,000 to Queen Mary, University of London, to support an academic meeting
entitled ‘Vitamin D: mechanisms of action in health and disease’; this meeting was convened by ARM and CJG. All other authors
declare that they have no conflict of interest.
Martineau et al.
Page 2
10Department
of Respiratory Medicine, Kings College Hospital, London SE5 9RS
11Department
of Radiology, Royal Free Hospital, London NW3 2QG
12Genome
13School
Centre, Barts and The London School of Medicine, London EC1M 6BQ
of Clinical Sciences, University of Liverpool, Liverpool, L7 8XP
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14HPA
National Mycobacterium Reference Laboratory, Queen Mary’s School of Medicine and
Dentistry, Barts and The London, London E1 2AT, UK
Abstract
Background—Vitamin D was used to treat tuberculosis in the pre-antibiotic era, and its
metabolites induce antimycobacterial immunity in vitro. Clinical trials investigating the effect of
adjunctive vitamin D on sputum culture conversion are lacking.
Methods—We conducted a multi-centre randomised controlled trial of adjunctive vitamin D in
adults with sputum smear-positive pulmonary tuberculosis in London, UK. 146 participants were
allocated to receive 2.5 mg vitamin D3 or placebo at baseline and at 2, 4 and 6 weeks after starting
standard tuberculosis treatment. The primary endpoint of the trial was time from initiation of
antimicrobial therapy to sputum culture conversion. Participants were genotyped for TaqI and
FokI polymorphisms of the vitamin D receptor (VDR), and interaction analyses were conducted to
determine the influence of VDR genotype on response to vitamin D. This trial is registered with
ClinicalTrials.gov (NCT00419068).
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Findings—126 participants were included in the primary efficacy analysis (62 allocated to
intervention, 64 allocated to placebo). Median time to sputum culture conversion was 36.0 days in
the intervention arm and 43.5 days in the placebo arm (adjusted HR 1.39; 95% CI 0.90-2.16,
P=0.14). TaqI genotype modified the effect of vitamin D supplementation on time to sputum
culture conversion (Pinteraction=0.03), with enhanced response seen only in participants with the tt
genotype (HR 8.09, 95% CI 1.36-48.01, P=0.02). FokI genotype did not modify the effect of
vitamin D supplementation (Pinteraction=0.85). Mean serum 25-hydroxyvitamin D at 8 weeks was
101.4 nmol/L vs. 22.8 nmol/L in intervention vs. placebo arms (95% CI for difference 68.6-88.2
nmol/L, P<0.001).
Interpretation—Administration of four doses of 2.5 mg vitamin D3 elevated serum 25hydroxyvitamin D concentrations in patients receiving intensive phase treatment for pulmonary
tuberculosis and reduced time to sputum culture conversion in participants with the tt genotype of
the TaqI VDR polymorphism.
Introduction
Tuberculosis (TB) is a major health problem: the World Health Organisation estimates that
there were 9.4 million incident cases of TB in 2008, and 1.8 million deaths due to TB
worldwide in 2008 (1). Augmentation of the immune response to Mycobacterium
tuberculosis (MTB) has the potential to allow shortening of antimicrobial therapy in drugsensitive disease, or to improve outcome in drug-resistant disease (2). Calcitriol, the active
metabolite of vitamin D, induces antimycobacterial activity in vitro (3). It modulates the
host response to mycobacterial infection by induction of reactive nitrogen and oxygen
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intermediates (4, 5), suppression of matrix metalloproteinase enzymes implicated in the
pathogenesis of pulmonary cavitation (6) and induction of the antimicrobial peptide
cathelicidin (7, 8) which induces autophagy (9). Calcitriol modulates immune responses by
binding vitamin D receptor (VDR) expressed by antigen presenting cells and activated
lymphocytes to regulate transcription of vitamin D-responsive genes. Human VDR is
polymorphic: carriage of the t allele of the TaqI VDR polymorphism associates with
enhanced calcitriol-induced phagocytosis of MTB in vitro (10) and more rapid sputum
culture conversion in patients with pulmonary TB (PTB) (11). By contrast, carriage of the f
allele of the FokI VDR polymorphism associates with reduced transcriptional activity (12),
reduced calcitriol-induced phagocytosis (10) and slower sputum culture conversion in PTB
(11).
Numerous case series have reported that daily doses of 625 μg to 2.5 mg vitamin D enhance
response to antimicrobial therapy for PTB (13). Randomised controlled trials investigating
doses of vitamin D ≤125 μg/day or equivalent in active TB have shown no clinical benefit
(14-17), but one trial investigating a higher dose regimen (250 μg/day) did report reduced
time to sputum smear conversion in the intervention arm (18). Sputum smear conversion is
of limited value as a biomarker of treatment response in PTB however, because microscopy
is less sensitive and less specific than culture for the detection of viable MTB bacilli in the
sputum (19). Consequently multivariable analysis reveals that sputum culture conversion,
but not sputum smear conversion, is an independent correlate of risk of long-term treatment
failure or relapse (20). We therefore conducted a clinical trial to determine the effect of
high-dose vitamin D on time to sputum culture conversion in patients receiving intensive
phase antimicrobial therapy for PTB; sub-group analyses were performed to investigate
whether the effect of adjunctive vitamin D on time to sputum culture conversion was
modified by TaqI or FokI VDR genotype.
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Results
We assessed 464 patients for eligibility to participate in the trial between 25th January 2007
and 3rd July 2009: 214 were ineligible, 104 were eligible but declined randomisation and
146 were randomised. Reasons for ineligibility are presented in Table S1, Supplementary
Material. There was no significant difference in median age between randomised
participants vs. potentially eligible individuals who declined randomisation (31.2 years vs.
29.1 years respectively, P=0.07), but females were slightly under-represented among
randomised participants vs. those declining randomisation (35/146 vs. 39/104 female
respectively, P=0.02). The trial ended on the date of the final study visit of the last
participant to be randomised. MTB complex was cultured from baseline sputum samples of
135 participants: follow-up sputum culture results were available for 126 participants (62
allocated to vitamin D, 64 allocated to placebo) who entered the primary efficacy analysis
(Figure 1). Clinical and demographic characteristics of these participants were comparable
for intervention vs. control group at baseline (Table 1). The majority of these participants
were profoundly vitamin D deficient (serum 25(OH)D<20 nmol/L in 75/126) and almost all
were vitamin D insufficient (serum 25(OH)D<75 nmol/L in 122/126) at baseline.
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The median time to sputum culture conversion was 36 days (95% CI 31.8-40.2 days) in the
intervention arm and 43.5 days (95% CI 36.5-50.5 days) in the control arm (Figure 2;
unadjusted P=0.41, logrank test). White/Latin American ethnic origin, presence of >3 AFBs
per high-power field on baseline sputum smear, baseline neutrophil count ≥7.5×106/ml and
older age were associated with delayed sputum culture conversion on univariate analysis
(table 2); the hazard ratio (HR) for effect of allocation after adjustment for these factors in
the Cox regression model was 1.39 (95% CI 0.90-2.16, P=0.14). The effect of allocation on
time to sputum culture conversion was significantly modified by TaqI genotype
(Pinteraction=0.03): vitamin D significantly hastened sputum culture conversion in
participants with the tt genotype (HR 8.09, 95% CI 1.36-48.01, P=0.02), but not in those
with Tt genotype (HR 0.85, 95% CI 0.45-1.63, P=0.63) or TT genotype (HR 1.13, 95% CI
0.60-2.10, P=0.71). There was no evidence that participants’ FokI genotype modified the
effect of adjunctive vitamin D on time to sputum culture conversion however
(Pinteraction=0.85).
Non-statistically significant trends towards faster rise in DTP in the intervention arm (9%
faster rise; 95% CI −23%-43%, P=0.57; Fig S2) and faster sputum smear conversion in the
intervention arm (adjusted HR 1.26, 95% CI 0.83-1.93, P=0.28; Fig S3) were also seen. The
proportion of participants with negative sputum culture on solid medium at 8 weeks was
similar in intervention and control arms of the study (41/52 vs. 45/56 respectively, P=0.85).
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Mean serum 25(OH)D concentration at 8 weeks was 101.4 nmol/L in the intervention arm of
the study vs. 22.8 nmol/L in the control arm (95% CI for difference 68.6-88.2 nmol/L,
P<0.001; Fig 3A). Allocation to the intervention arm of the study also induced an increase in
urinary calcium:creatinine ratio from the 4-week timepoint onwards (P<0.001, GEE; Fig
3B). Mean serum corrected calcium fell in both arms over the course of the study (P<0.001,
GEE), but the rate of fall was not influenced by allocation (P=0.67, GEE; Fig 3C).
Allocation to vitamin D was associated with an increase in lymphocyte count and a
borderline significant decrease in monocyte count (Table 3), such that mean lymphocyte:
monocyte ratio was significantly higher in the intervention vs. control arm of the study at 8
weeks (3.52 vs. 2.70, 95% CI for difference 0.16-1.11, P=0.009). No statistically significant
effect of allocation on body mass index, extent of CXR involvement, CRP or ESR was
observed at 8 weeks (Table 3).
Two patients died during the study, one in each arm; neither death was attributed to study
medication (Table 4). Eight serious adverse events (SAE) were observed in 7 out of the 71
participants who received at least one dose of vitamin D; two SAE were observed in 2 out of
the 70 participants who received at least one dose of placebo. Study medication was
discontinued in three participants in the intervention arm of the study who experienced
adverse events (AE) that were judged to be potentially related to vitamin D by physicians
blinded to allocation. One of these participants experienced a paradoxical upgrading reaction
(enlarging paraspinal abscess) and mild hypercalcaemia (corrected calcium 2.68 mmol/L)
after receiving two doses of 2.5 mg vitamin D; one experienced a paradoxical upgrading
reaction (enlarging psoas abscess) without hypercalcaemia after receiving two doses of 2.5
mg vitamin D; and one experienced asymptomatic mild hypercalcaemia (corrected calcium
2.72 mmol/L) after receiving 2 doses of 2.5 mg vitamin D. Participants with paradoxical
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upgrading reaction underwent drainage of collections and made a good recovery; corrected
serum calcium normalised within 2 weeks of discontinuing vitamin D in both participants
who experienced hypercalcaemia. The frequency of all other AEs was similar between arms
with the exception of symptoms of upper respiratory tract infection, which were reported by
1/71 patients receiving ≥1 dose of vitamin D vs. 6/70 patients receiving ≥1 dose of placebo.
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Discussion
We report that administration of four doses of 2.5 mg vitamin D3 to patients receiving
intensive phase treatment for smear-positive PTB significantly hastened sputum culture
conversion in a sub-group of participants with the tt genotype of the TaqI vitamin D receptor
polymorphism. A large increase in mean serum 25(OH)D concentration was observed
among participants in the intervention arm of the trial.
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Our study has several strengths. Participants in the intervention arm of the trial received a
preparation with verified vitamin D3 content at a dose sufficient to increase mean serum
25(OH)D concentration >100 nmol/L, while those in the placebo arm of the trial were
almost universally vitamin D insufficient throughout the study; the very high prevalence of
vitamin D deficiency among TB patients in London has previously been reported, and has
been attributed to lack of sunshine at latitude 51°N(21). We determined the effect of
adjunctive vitamin D on sputum culture conversion - the only phase II TB trial outcome
measure shown to correlate with long-term risk of relapse (27). We also demonstrated an
inverse relationship between MTB CFU/ml and DTP in liquid medium, and investigated the
effect of vitamin D supplementation on the speed of elimination of bacilli from sputum, as
estimated by rate of rise of DTP in liquid culture of serial sputum specimens. This represents
an important methodological advance, and builds on the work of the Oflotub Consortium
who have utilised non-linear mixed effects modelling of serial sputum colony counts to
assess sterilising activity of fluoroquinolones (28). All sputum samples in our study were
analysed in a single laboratory that was close to study sites, ensuring standardisation of
culture and microscopy methods and minimising loss of bacillary viability in transit.
Additionally, we investigated the effect of adjunctive vitamin D on numbers of different
circulating leucocyte populations, and observed an increase in lymphocyte: monocyte ratio
in participants in the intervention arm of the study - a biomarker of disease resolution in
animal models of TB (29). Finally, we explored the possibility that the effect of vitamin D
supplementation might be modified by VDR genotype, and found that individuals with tt
genotype of the TaqI polymorphism have enhanced responsiveness to vitamin D
supplementation. The hypothesis that carriage of the t allele for this synonymous single
nucleotide polymorphism might associate with increased VDR mRNA stability (30) has
been refuted by two subsequent studies demonstrating no influence of the TaqI
polymorphism on mRNA stability (31, 32); the mechanism by which this gene: environment
interaction is mediated remains to be determined.
Our study has some limitations. Serum 25(OH)D concentration > 75 nmol/L was not
attained in all participants in the intervention arm at 8 weeks, suggesting that some
participants may not have taken all doses of study medication. Moreover, the 8-week
duration of the study did not allow follow-up after completion of intensive phase therapy;
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this precluded analysis of the effect of adjunctive vitamin D on risk of relapse posttreatment.
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Randomised trials have not previously investigated the effects of adjunctive vitamin D on
sputum culture conversion in TB patients, to our knowledge, but trials using other primary
outcome measures have been performed. The largest of these (17) reported that
administration of three doses of 2.5 mg vitamin D3 at baseline, 5 and 8 months, did not
influence clinical severity score or time to sputum smear conversion in 365 patients in
Guinea Bissau; however in that trial, participants’ mean baseline 25(OH)D was >70 nmol/L,
and the dosing regimen utilised was too low to influence serum 25(OH)D concentrations at
follow-up. A smaller trial conducted in 67 patients in Indonesia (18) reported enhanced
sputum smear conversion at 6 weeks, but not at 8 weeks, after initiation of antimicrobial
treatment in patients receiving 250 μg vitamin D daily. The clinical significance of this
finding is hard to interpret as sputum smear conversion, unlike sputum culture conversion, is
not an independent correlate with long-term risk of treatment failure or relapse (20).
Moreover, vitamin D content of study medication used in this study was not verified, and
serum 25(OH)D concentrations in participants in this study were not reported before or after
supplementation.
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The incidence of hypercalcaemia in our study is much lower than that seen by Narang et al,
who reported hypercalcaemia in 19/30 patients with smear positive pulmonary TB taking a
daily dose of 10-95 μg vitamin D (15). The actual dose of vitamin D administered in the
Narang study has been called into question, however (33); if it was significantly higher than
reported, this would explain the discordance in reported incidence of hypercalcaemia
between that study and our own. We also found that serum corrected calcium declined in
both intervention and control groups following initiation of antimicrobial therapy. This may
have occurred due to a reduction in granulomatous burden in patients responding to therapy,
resulting in a decrease in extra-renal 1-alpha hydroxylation of 25(OH)D and a fall in serum
1,25-dihydroxyvitamin D concentrations. Paradoxical upgrading reactions were seen in two
participants in the intervention arm vs. none in the control arm of our study. We
discontinued study medication in these patients as a precaution, as some case series have
reported an association between paradoxical upgrading reaction and administration of
vitamin D (13). The incidence of paradoxical upgrading reaction in the intervention arm of
our study (3%) was considerably lower than the 10% previously reported in HIV uninfected
patients (34), and a causal relationship between vitamin D supplementation and paradoxical
upgrading reaction is not demonstrated. The observation that symptoms of upper respiratory
tract infection (URTI) were markedly less frequent in the intervention arm of our study is in
keeping with that reported by Aloia et al who observed a reduction in URTI symptoms
among vitamin D-supplemented participants in an osteoporosis trial (35).
In conclusion, we report that administration of four oral doses of 2.5 mg vitamin D corrected
deficiency safely and quickly in patients receiving intensive phase therapy for pulmonary
TB, but did not significantly enhance response to therapy in the study population as a whole.
However, vitamin D supplementation did significantly reduce time to sputum culture in
conversion among participants with the tt genotype of the TaqI VDR polymorphism,
suggesting that this sub-group of TB patients may derive clinical benefit from vitamin D
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supplementation. Investigation of the mechanism by which this gene: environment
interaction is mediated is warranted.
Methods
Participants
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Study participants were recruited at 10 National Health Service Trusts in London, UK.
Patients with newly-diagnosed PTB and acid-fast bacilli (AFB) visible on sputum smear
microscopy were assessed for eligibility to participate. Individuals were excluded if they
were aged less than 18 years; if they were known to be intolerant of vitamin D or first-line
antituberculous therapy; if they were known to have a diagnosis of sarcoidosis,
hyperparathyroidism, nephrolithiasis, HIV infection, pulmonary silicosis, malignancy or
renal or hepatic failure at screening; if they had taken oral corticosteroid therapy, cytotoxic
drugs or other immunosuppressant therapy in the month preceding enrolment; if they had
taken antituberculous therapy for more than 7 days in the 6 months preceding enrolment; if
they were taking antituberculous therapy other than rifampicin, isoniazid, pyrazinamide or
ethambutol at enrolment; if molecular testing of MTB in their sputum indicated presence of
a rpoB mutation conferring rifampicin resistance; if serum corrected calcium >2.65 mmol/L,
aspartate transaminase or alanine transaminase >120 IU/L, total serum bilirubin > 40
micromol/L or serum creatinine > 250 micromol/L; or if they were pregnant or
breastfeeding. The study was approved by East London and The City Research Ethics
Committee 3 (REC ref 06/Q0605/83), and written informed consent was obtained from all
participants before enrolment.
Procedures
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Participants were randomly assigned to receive either four oral doses of 2.5 mg vitamin D
(Vigantol® oil, Merck Serono, Darmstadt, Germany) or organoleptically identical placebo
(Miglyol® oil, Caesar and Loretz, Hilden, Germany) with allocation ratio 1:1. We have
previously demonstrated that an oral dose of 2.5 mg vitamin D elevates serum 25hydroxyvitamin D (25[OH]D) > 75 nmol/L in TB patients at one week post-administration
[1]. Randomisation was stratified according to presence / absence of cavitation on baseline
chest radiograph, and assigned by permuted block randomisation with blocks of ten. The
first dose of study medication was administered within 7 days of starting antimicrobial
treatment, and subsequent doses were administered at 2, 4 and 6 weeks after the start of
antimicrobial treatment. Study medication was discontinued if a participant’s sputum culture
grew a non-tuberculous mycobacterium after randomisation. Nova Laboratories Ltd,
Wigston, UK, generated the randomisation sequence and bottled study medication according
to Good Manufacturing Practice; they had no other involvement in the study. Vitamin D3
content of a random sample of active and placebo medication was determined by high
performance liquid chromatography at the end of the study; active medication was found to
contain 97.7% to 99.8% of its original vitamin D3 content, and placebo medication was
confirmed to contain no detectable vitamin D3. Treatment allocation was concealed from
participants and study staff. All participants received intensive phase antimicrobial therapy
comprising isoniazid, rifampicin, pyrazinamide and ethambutol according to UK national
guidelines [2] in addition to study medication; after completion of 8 weeks of treatment,
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participants were discharged from the study and continuation-phase antimicrobial therapy
was initiated.
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Participants completed a baseline clinical assessment including chest radiography,
measurement of height and weight and collection of a sputum sample for microscopy and
culture, a urine sample for determination of urinary calcium:creatinine ratio and a blood
sample for determination of full blood count (FBC), erythrocyte sedimentation rate (ESR)
and serum concentrations of calcium, albumin, C reactive protein (CRP) and 25hydroxyvitamin D (25[OH]D). Participants were reviewed at 2, 4, 6 and 8 weeks after
starting antituberculous therapy to assess clinical status and to monitor for adverse events.
At each timepoint, an overnight sputum specimen was collected from all patients who were
able to expectorate spontaneously, weight was measured and urine and blood samples were
collected as above. Sputum samples were transported to the microbiology laboratory by
research staff at ambient temperature immediately after collection, and processed within 24
hours of arrival in the laboratory. Sputum samples awaiting processing in the laboratory
were stored at 4°C. All units were within 16 miles (25 kilometres) of the laboratory. Chest
radiography was repeated at 8 weeks.
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Sputum specimens were digested and decontaminated with the N-acetyl-L-cysteine-NaOH
procedure [3] using BBL MycoPrep kits (Becton Dickinson Microbiology Systems,
Cockeysville, Md. USA). A drop of the concentrated decontaminated sputum sample was
stained with auramine-phenol and examined for the presence of acid-fast bacilli by
fluorescence microscopy. [4] The remainder of the sample was resuspended in a final
volume of 1.25 ml of water; 1 ml of this suspension was inoculated into a MB/BacT bottle
(Organon Teknika, Boxtel, The Netherlands) which was placed in a MB/BacT incubator for
continuous monitoring until it signalled positive, when Gram and Ziehl-Nielsen (ZN) stains
were performed. Where microscopy indicated contamination with another organism, bottles
were re-treated with MycoPrep and culture was extended for a further 42 days; if these
bottles subsequently grew another contaminant the culture was discarded. The number of
days from inoculation to positive signal for mycobacteria was recorded for each
uncontaminated sample; samples that did not signal positive within 42 days of inoculation
were deemed culture negative, unless AFB were visible on microscopy of the original
inoculum, in which case culture was extended to 60 days post-inoculation. Additionally, at
baseline and 8 weeks, 0.25 ml of the resuspended sample was inoculated onto a LöwensteinJensen slope (Media for Mycobacteria, Penarth, UK). Slopes were incubated at 37°C and
examined visually for growth; those that were not positive within 56 days of inoculation
were deemed culture negative. The presence of mycobacteria on positive slopes was
confirmed by ZN staining and microscopy. Isolates were speciated using the Genotype
Mycobacterium CM kit (Hain Lifesciences, Nehren, Germany), and drug susceptibility
testing of all baseline cultures growing MTB was performed by the resistance ratio or
proportion methods [4]. An inverse relationship between colony forming units / ml of
inoculum vs. days from inoculation to positive signal (DTP) was demonstrated by
inoculating MB/BacT bottles with 10-fold serial dilutions of a suspension of MTB H37Rv
(Supplementary Figure S1).
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Concentrations of 25(OH)D2 and 25(OH)D3 were determined by isotope-dilution liquid
chromatography–tandem mass spectrometry [5] and summed to give values for total
25(OH)D. Sensitivity for this assay was 10 nmol/l. CRP, albumin and total serum calcium
concentrations were determined using an Architect ci8200 analyser (Abbott Diagnostics,
Chicago, IL, USA). Calcium concentration was corrected for serum albumin concentration
using the formula: corrected calcium (mmol/l) = total calcium (mmol/l) + 0.02 × (40 −
albumin [g/l]). Full blood counts were performed using a LH750 haematology analyser
(Beckman Coulter, Brea, CA, USA) and ESR was measured by the Wintrobe method using
a s2000 analyser (Desaga, Wiseloch, Germany). DNA was extracted from whole blood
using the Promega Wizard® SV 96 Genomic DNA Purification System on the Biomek FX
robot (Beckman Coulter), quantified using the Nanodrop spectrophotometer and normalised
to 5ng/ml. 10ng DNA was used as template for 5 ml TaqMan assays (Applied Biosystems,
Foster City, CA, USA) performed on the ABI 7900HT platform in 384-well format and
analysed with Autocaller software. A pre-developed assay was used to type the TaqI
polymorphism of the vitamin D receptor; a customised assay was used for FokI typing
(forward primer sequence TGGCCTGCTTGCTGTTCTTA, reverse primer sequence
GGGTCAGGCAGGGAAGTG, reporter sequences ATTGCCTCCGTCCCTG and
TTGCCTCCATCCCTG). Alleles at all loci conformed to the Hardy-Weinberg equilibrium.
Chest radiographs were read by a consultant radiologist blinded to participant allocation.
Body mass index (BMI) was calculated using the formula: BMI = weight (kg) / [height
(m)].2
Statistical analysis
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The primary endpoint of the study was time from initiation of antituberculous therapy to
sputum culture conversion, estimated as the mid-point between the last positive sputum
culture in broth and the first negative sputum culture in broth thereafter. Participants who
were unable to expectorate spontaneously were deemed to be culture negative. Assuming a
median time to sputum culture conversion of 5 weeks in the control group [6], follow-up of
8-weeks and accrual time of 2.5 years we calculated that a total of 122 patients (61 patients
in each group) would need to be recruited in order to detect a 2-week difference in median
time to culture conversion (equivalent to a hazard ratio of 1.67) between intervention and
control groups with 80% power using a 2-sided test at the 5% significance level [7]. This
number was increased by 20% to compensate for loss to follow-up, giving a total sample
size of 146. Time to sputum smear conversion was a secondary endpoint, as were rate of rise
in days-to-positivity in broth culture, proportion of participants with negative sputum culture
on solid medium at 8 weeks, change in serum corrected calcium concentration and urinary
calcium: creatinine ratio during the study and 8-week 25(OH)D concentration, full blood
count parameters, radiographic response to treatment and BMI. The primary safety endpoint
was incidence of hypercalcaemia (defined as serum corrected calcium > 2.65 mmol/L).
Efficacy analysis was by modified intention-to-treat (ITT), and excluded participants whose
baseline sputum culture was negative or grew non-tuberculous mycobacteria. All
participants who took at least one dose of study medication were included in the safety
analysis.
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Analyses were performed using SPSS (version 16.0, 2007), STATA (version 10.1, 2008)
and R (version 2.8.1, 2009) software packages. Significance was tested at the 5% level. The
primary analysis for effect of allocation on time to sputum culture conversion was conducted
using a logrank test stratified according to presence / absence of cavitation on baseline chest
radiograph. A multivariable Cox proportional hazards regression model stratified according
to presence / absence of cavitation on baseline chest radiograph was obtained by fitting
additional potential predictors of time to sputum culture conversion in turn; those whose
addition resulted in a significant reduction in the −2logL statistic for the model were
retained [8]. Time to sputum smear conversion was similarly analysed. Proportional hazards
assumptions for Cox regression models were checked using Grambsch and Therneau’s
methods [9]. A single pre-specified interim efficacy analysis of time to sputum culture
conversion was performed after enrolment of 73 participants. The influence of allocation on
categorical and continuous outcome measures compared at 8 weeks was evaluated using χ2
tests and analysis of covariance respectively. Analysis of the effect of allocation on rate of
rise of DTP was conducted using a linear mixed effects model; longitudinal changes in
urinary calcium:creatinine ratio and serum corrected calcium were analysed using
generalised estimating equations (GEE) with the assumption of an unstructured correlation
matrix [10]. Median age among randomised participants vs. potentially eligible individuals
who declined randomisation was compared using a Mann Whitney test.
Supplementary Material
Refer to Web version on PubMed Central for supplementary material.
Acknowledgments
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The study was funded by the British Lung Foundation (ref TB05/11). Merck Serono donated Vigantol® and
Miglyol® oil, and assayed vitamin D3 concentrations in vials of placebo and active study medication; they had no
role in the design, conduct or analysis of the study. We thank the members of our Data Monitoring Committee, Dr
Guy E. Thwaites (Chair), Dr Brenda E. Jones and Dr Tuan Q. Phung. We also thank Professor Denis A. Mitchison
for advice regarding trial design; Dr Thomas C. Stokes, Queen Elizabeth Hospital, London, and Dr Stefan
Lozewicz, North Middlesex Hospital, London, for acting as Principal Investigators; Ms. June Parris, Ms. Olubisi
Tunde-Adebayo and Ms. Wai-Yee James for assistance with patient recruitment and follow-up; Ms. Leena BhawRosun and Ms. Rosamond Nuamah, Genome Centre, Barts and The London School of Medicine, for assistance
with genotyping assays; pharmacy staff at Homerton University NHS Trust and Northwick Park Hospital for
overseeing dispensing of study medication; and all TB nurses and administrative staff who referred patients to the
study. Finally, we thank all patients who participated in the trial.
Role of the funding source: The British Lung Foundation was not involved in the design, conduct or analysis of
the study, and did not review or approve the manuscript. Merck Serono donated Vigantol® and Miglyol® oil for
the trial but did not influence study design, execution or analysis. The decision to publish was made solely by the
authors, and the corresponding author had full access to all data in the study.
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Methods References
[1]. Martineau AR, Nanzer AM, Satkunam KR, Packe GE, Rainbow SJ, Maunsell ZJ, et al. Influence
of a single oral dose of vitamin D(2) on serum 25-hydroxyvitamin D concentrations in
tuberculosis patients. Int J Tuberc Lung Dis. Jan; 2009 13(1):119–25. [PubMed: 19105889]
[2]. National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical diagnosis and
management of tuberculosis, and measures for its prevention and control. Royal College of
Physicians; London: 2006.
[3]. Kubica GP, Dye WE, Cohn ML, Middlebrook G. Sputum digestion and decontamination with Nacetyl-L-cysteine-sodium hydroxide for culture of mycobacteria. Am Rev Respir Dis. May.1963
87:775–9. [PubMed: 13927224]
[4]. Collins, CH.; Grange, JM.; Yates, MD. Tuberculosis bacteriology. 2nd ed.. ButterworthHeinemann; Oxford: 1997.
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[5]. Maunsell Z, Wright DJ, Rainbow SJ. Routine Isotope-Dilution Liquid Chromatography–Tandem
Mass Spectrometry Assay for Simultaneous Measurement of the 25-Hydroxy Metabolites of
Vitamins D2 and D3. Clin Chem. 2005; 51(9):1683–90. [PubMed: 16020493]
[6]. Gonzalez-Montaner LJ, Natal S, Yongchaiyud P, Olliaro P, Rifabutin Study Group. Rifabutin for
the treatment of newly-diagnosed pulmonary tuberculosis: a multinational, randomized,
comparative study versus Rifampicin. Tuber Lung Dis. Oct; 1994 75(5):341–7. [PubMed:
7841427]
[7]. Schoenfeld DA, Richter JR. Nomograms for calculating the number of patients needed for a
clinical trial with survival as an endpoint. Biometrics. Mar; 1982 38(1):163–70. [PubMed:
7082758]
[8]. Collett, D. Modelling Survival Data in Medical Research. 2nd ed.. Chapman and Hall; Bristol:
2003.
[9]. Grambsch PM, Therneau TM. Proportional hazards tests and diagnostics based on weighted
residuals. Biometrika. 1994; 81(3):515–26.
[10]. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes.
Biometrics. Mar; 1986 42(1):121–30. [PubMed: 3719049]
[11]. Pocock SJ, Clayton TC, Altman DG. Survival plots of time-to-event outcomes in clinical trials:
good practice and pitfalls. Lancet. May 11; 2002 359(9318):1686–9. [PubMed: 12020548]
Europe PMC Funders Author Manuscripts
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Figure 1. Trial Profile
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Figure 2. Time to sputum culture conversion by allocation.
Error bars, 95% confidence intervals. The number of participants with positive sputum
culture remaining in follow-up (number at risk) at 0, 2, 4, 6 and 8 weeks is presented (36).
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Figure 3.
A. Serum 25-hydroxyvitamin D concentration by allocation at baseline and 8 weeks. B.
Mean urinary calcium: creatinine molar ratio by allocation at baseline and 2, 4, 6 and 8
weeks. Error bars, standard errors of the mean. C. Mean serum corrected calcium by
allocation at baseline and 2, 4, 6 and 8 weeks. Error bars, standard errors of the mean.
Europe PMC Funders Author Manuscripts
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Table 1
Baseline characteristics by allocation
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Vitamin D
N
Placebo
N
Median age, years (IQR)
30.7 (24.5 to 41.5)
62
30.5 (24.8 to 38.4 )
64
Female
14 (23%)
62
14 (22%)
Ethnic group
62
- Asian / Asian British
30 (48%)
25 (39%)
- Black / Black British
17 (27%)
26 (41%)
- White / Latin American
15 (24%)
Occupation
13 (20%)
62
64
- Student
10 (16%)
9 (14%)
- Employed
46 (74%)
49 (77%)
- Unemployed
6 (10%)
HIV status
64
64
6 (9%)
62
64
- Sero-positive
3 (5%)
2 (3%)
- Sero-negative
43 (69%)
39 (61%)
- Undetermined
16 (26%)
23 (36%)
Diabetes mellitus
3 (5%)
62
2 (3%)
64
Median duration of symptoms pre-diagnosis, months (IQR)
2.0 (1.5 to 4.0)
62
2.0 (1.0 to 3.0)
64
Median duration of treatment pre-enrolment, days (IQR)
2.0 (0.0 to 4.0)
62
2.0 (0.0 to 3.8)
64
Administration of antimicrobial treatment
62
64
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- Daily, self-administered
61 (98%)
62 (97%)
- 3 × weekly, directly-observed
1 (2%)
2 (3%)
Baseline sputum smear
62
- ≤3 AFB per high-power field
- >3 AFB per high-power field
64
27 (44%)
31 (48%)
35 (57%)
33 (52%)
Rifampicin-resistant isolate
0 (0%)
62
4 (6%)
64
Serum 25(OH)D, nmol/L
21.1 (20.0)
62
21.3 (19.0)
64
Serum 25(OH)D <20 nmol/L
36 (58%)
62
39 (61%)
64
Serum 25(OH)D <75 nmol/L
59 (95%)
62
63 (98%)
64
Serum corrected calcium, mmol/L
2.45 (0.08)
62
2.45 (0.09)
64
Urinary calcium:creatinine ratio
0.34 (0.28)
59
0.37 (0.26)
58
Haemoglobin, g/dL
12.6 (1.9)
62
12.6 (1.8)
64
Mean corpuscular volume, fl
82.7 (7.2)
59
82.7 (7.1)
61
Total white blood cell count × 109/L
9.2 (3.1)
62
8.1 (2.6)
64
Neutrophil count × 109/L
6.8 (2.8)
62
5.7 (2.3)
64
Lymphocyte count × 109/L
1.4 (0.6)
62
1.4 (0.5)
64
0.8 (0.4)
62
0.8 (0.3)
64
409 (136)
62
381 (149)
64
Monocyte count ×
Platelet count ×
109/L
109/L
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Erythrocyte sedimentation rate, mm/h
Vitamin D
N
Placebo
N
62.1 (23.1)
57
60.9 (17.4)
60
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C reactive protein, mg/L
71.4 (49.5)
62
60.5 (45.0)
62
Body mass index, kg/m2
20.1 (3.1)
60
20.2 (2.7)
64
- Cavities present
36 (58%)
62
36 (56%)
64
- Zones affected
2.8 (1.3)
47
2.8 (1.3)
Baseline chest radiograph
TaqI vitamin D receptor genotype
62
- TT
30 (48%)
29 (45%)
- Tt
27 (44%)
28 (44%)
- tt
5 (8%)
FokI vitamin D receptor genotype
49
64
7 (11%)
62
64
- FF
29 (47%)
27 (42%)
- Ff
25 (40%)
24 (38%)
- ff
8 (13%)
13 (20%)
Data are number (%) or mean (standard deviation) except where stated. IQR, inter-quartile range.
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Table 2
Cox regression analysis, time to sputum culture conversion
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Univariate analysis
N
Allocation
Ethnic group
Baseline chest radiograph
Baseline sputum smear
Baseline neutrophil count
Baseline serum 25(OH)D
TaqI genotype
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FokI genotype
HR (95% CI)
P
HR (95% CI)
P
1
Active
62
1.18 (0.77 to 1.80)
0.46
1.39 (0.90 to 2.16)
0.14
Placebo
64
ref
-
ref
-
126
0.97 (0.95 to 0.99)
0.006
0.97 (0.95 to 1.00)
0.02
Female
28
1.23 (0.75 to 2.02)
0.41
-
-
Male
98
ref
-
-
-
Asian / Asian British
55
2.84 (1.45 to 5.59)
0.002
2.80 (1.40 to 5.62)
0.004
Black / Black British
43
2.66 (1.34 to 5.26)
0.005
2.65 (1.33 to 5.27)
0.005
White / Latin American
28
ref
-
ref
-
Age, yr
Sex
Multivariable analysis
Cavitation present
72
0.97 (0.64 to 1.49)
0.89
1.15 (0.73 to 1.80)
0.54
Cavitation absent
54
ref
-
ref
-
≤3 AFB per HPF
58
2.03 (1.31 to 3.15)
0.002
1.85 (1.16 to 2.97)
0.01
>3 AFB per HPF
68
ref
-
ref
-
92
1.97 (1.18 to 3.29)
0.01
1.88 (1.09 to 3.25)
0.02
<7.5 ×
106/ml
≥7.5×106/ml
34
ref
-
ref
-
<20 nmol/L
75
1.27 (0.82 to 1.96)
0.28
-
-
≥20 nmol/L
51
ref
-
-
-
TT
59
1.30 (0.61 to 2.78)
0.50
-
-
Tt
55
1.22 (0.57 to 2.62)
0.62
-
-
tt
12
ref
-
-
-
FF
56
1.00 (0.57 to 1.78)
0.99
-
-
Ff
49
0.66 (0.36 to 1.22)
0.19
-
-
ff
21
ref
-
-
-
Ref, reference category. AFB, acid-fast bacilli. HPF, high power field.
1
Adjusted for age, ethnicity, baseline sputum smear, neutrophil count and presence / absence of cavitation on baseline chest radiograph
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Table 3
Secondary outcome measures at 8 weeks, by allocation
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Haemoglobin, g/dL
Vitamin D
Placebo
95% CI for difference
P
13.27 (1.64)
13.35 (1.54)
−0.49 to 0.31
0.67
Mean corpuscular volume, fl
85.45 (7.25)
83.78 (6.99)
0.06 to 2.59
0.04
Total white blood cell count × 109/L
7.32 (2.71)
6.82 (2.11)
−0.70 to 0.84
0.85
Lymphocyte count × 109/L
1.80 (0.71)
1.60 (0.60)
0.03 to 0.40
0.02
Monocyte count × 109/L
0.57 (0.26)
0.66 (0.25)
−0.17 to 0.01
0.09
Neutrophil count × 109/L
4.61 (2.34)
4.24 (1.94)
−0.78 to 0.65
0.86
Platelet count × 109/L
304 (104)
294 (105)
−30 to 37
0.83
Erythrocyte sedimentation rate, mm/hr
29.90 (25.91)
30.11 (25.22)
−9.27 to 9.76
0.96
C reactive protein, mg/L
19.59 (25.23)
17.82 (22.73)
−7.14 to 9.71
0.76
Body mass index
21.29 (2.72)
21.18 (2.75)
−0.28 to 0.46
0.63
Chest radiograph: zones affected
2.30 (1.29)
2.28 (1.18)
−0.45 to 0.27
0.62
Data are mean (standard deviation)
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Table 4
Adverse events
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Vitamin D (n=71)
Placebo (n=70)
0
1
1
0
Paradoxical upgrading reaction
2
0
Nausea / vomiting
1
0
1
0
1
0
3
1
0
COPD exacerbation
1
0
Non-compliance with medication
0
1
Number experiencing any serious adverse event
7
2
Nausea / vomiting
9
7
Pruritis
5
5
Arthralgia
4
7
Hepatitis
4
1
Upper respiratory tract infection
1
6
Hypercalcaemia
2
0
Hypocalcaemia
5
2
Urinary calcium:creatinine molar ratio ≥1
16
9
Other non-serious adverse event
21
21
Number experiencing any non-serious adverse event
37
32
Serious adverse events
1
2
Multi-organ failure secondary to alcoholic liver disease
Lobar pneumonia
2
Epistaxis
Rifampicin-induced haemolytic anaemia
Bowel perforation
3
Non-serious adverse events
1
Adverse events were classified as serious if they caused death or were life-threatening, or if they required hospitalisation or prolongation of
existing hospitalisation
2
These adverse events were fatal
3
Both adverse events were experienced by the same participant
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