1. MOAB02
Impacts of vitamin D and calcium supplementation on bone mineral density among perinatally HIV-infected adolescents: A 48-week randomized clinical trial
Tavitiya Sudjaritruk, Linda Aurpibul, Torsak Bunupuradah, Suparat Kanjanavanit, Tawalchaya Chotecharoentanan, Sineenart Taejaroenkul, Pradthana Ounchanum, Piyarat Suntarattiwong, Thanyawee Puthanakit, on behalf of CAL-D Study Group
NCT:

2. Background
Adverse bone health is one of the common non-communicable conditions during the course of life-long HIV treatment1
Prevalence of low bone mineral density (BMD z-score <-2) among children and adolescents living with HIV ranged from 4-8% in high-income countries, up to 16-32% in middle income countries1
Several factors have been reported to be associated with bone demineralization1
Adverse bone health during adolescence may result in adult osteoporosis and bone fragility2
1Sudjaritruk T, et al. J Virus Erad. 2015;1: Young B, et al. Clin Infect Dis. 2011;52:1061–8.

3. Background
Vitamin D is critical for calcium homeostasis and bone metabolism
Adapted from Holick MF. Curr Opin Endocrinol Diabetes. 2002;9:87-98; Deluca HF. Am J Clin Nutr 2004;80: S.

4. Background
Vitamin D is critical for calcium homeostasis and bone metabolism
Clinical evidence supporting the benefit of vitamin D and calcium (VitD/Ca) supplementation on bone mineral status among HIV-infected youth is scarce

5. Objective
To evaluate the impacts of VitD/Ca supplementation on BMD and bone metabolism among perinatally HIV-infected Thai adolescents
Hypothesis: Dosage of vitamin D supplementation affects the changes of BMD and bone metabolism
High-dose VitD/Ca supplement: A total of vitamin D 3,200 IU plus calcium 1.2 gm daily
Normal-dose VitD/Ca supplement: A total of vitamin D 400 IU plus calcium 1.2 gm daily

6. Methods: Study design and population
Study design: An ongoing, multicenter, 48-week, randomized, open-label study
Study site: 5 pediatric HIV centers in Thailand
Study population:
Inclusion criteria:
Exclusion criteria:
Aged years
Perinatally acquired HIV infection
Had a history of virologic suppression (plasma viral load <400 copies/ml)
Received VitD/Ca supplement (VitD >400 IU and/or Ca >1 gm daily)
Received pharmacologic treatment for low BMD
Received medication that affects bone metabolism
Had a history of bone fracture
Pregnancy or breastfeeding

7. Methods: Randomization
Randomization ratio 1:1 (computer-generated), open-labeled fashion,
balanced within site
FDC: fixed dose combination.

8. Methods: Outcome measurements
BMD: Lumbar spine dual-energy X-ray absorptiometry (LS DXA) technique
BMD z-score <-2 was defined as low BMD
Bone biochemical markers:
Bone metabolism-related hormone: 25-hydroxyvitamin D (25OHD), intact parathyroid hormone (iPTH)
Bone turnover marker: alkaline phosphatase (ALP), C-terminal cross-linked telopeptide of type I collagen (CTX), procollagen type I amino-terminal propeptide (PINP)

9. Methods: Statistical analysis
An interim analysis was performed
Intention-to-treat analysis
Stratified by baseline BMD z-score (low BMD vs. normal BMD)
Wilcoxon rank sum test: between group comparison analysis
Wilcoxon signed rank test: within group comparison analysis
We conducted an interim analysis, using ITT
The analysis were stratified by baseline BMD of participants

10. Results

11. Figure 1. Flow of study participants*
Between April 2015 and October 2016:
166 HIV-infected adolescents were enrolled (Figure 1)
83 participants were randomly assigned to receive either high-dose or normal-dose VitD/Ca supplementation
67 participants (40%) had low baseline BMD
99 participants (60%) had normal baseline BMD

12. Table 1. Baseline characteristics of perinatally HIV-infected Thai adolescents
Total
(n = 166)
High-dose group
(n = 83)
Normal-dose group P†
Age, years
16.0 ( )
16.6 ( )
15.5 ( )
0.08
Male
79 (47.6)
40 (48.2)
39 (47.0)
0.88
WHO stage prior to ART
Stage 1-2
Stage 3-4
74 (47.1)
79 (50.3)
35 (44.9)
40 (51.3)
39 (49.4)
0.51
CD4 T-cell percentage prior to ART, %
12 (3 - 20)
10 (3 - 20)
13 (3 - 20)
0.57
Current ART regimen
NNRTI-based
PI-based
105 (63.3)
61 (36.7)
52 (62.7)
31 (37.3)
53 (63.9)
30 (36.1)
0.62
Duration of ART, years
10.0 ( )
10.7 ( )
9.0 ( )
0.21
Current CD4 T-cell count, cells/mm3
711 ( )
710 ( )
711 ( )
0.69
Current plasma viral load, log10 copies/ml
1.6 ( )
0.46
Adherence to VitD/Ca supplementation, %
80 ( )
90 ( )
80 ( )
0.28
*Data presented as n (%) for categorical data and median (interquartile range) for continuous data.
†The comparisons were performed using Pearson Chi-square for categorical data, and Wilcoxon rank sum tests for continuous data.

13. Table 2. Baseline bone mineral density and bone biochemical markers of perinatally HIV-infected Thai adolescents
Laboratory parameters*
Total
(n = 166)
High-dose group
(n = 83)
Normal-dose group P†
Bone mineral density
BMD z-score
-1.5 (-2.3 to -0.3)
-1.6 (-2.3 to -0.4)
-1.5 (-2.3 to -0.2)
0.75
BMD z-score <-2
67 (40.4)
35 (42.2)
32 (38.6)
0.64
Bone biochemical markers
Calcium, mg/dl
9.6 ( )
9.6 ( )
0.73
Phosphorus, mg/dl
4.4 ( )
4.4 ( )
4.5 ( )
0.20
25OHD, ng/ml
25.3 ( )
27.6 ( )
24.8 ( )
0.04
iPTH, pg/ml
41.7 ( )
41.4 ( )
42.5 ( )
0.30
Alkaline phosphatase, U/l
178 ( )
163 ( )
195 ( )
0.17
CTX, ng/l
1,350 ( ,040)
1,270 ( ,040)
1,390 ( ,050)
0.26
PINP, μg/l
330 ( )
312 ( )
337 ( )
0.37
*Data presented as n (%) for categorical data and median (interquartile range) for continuous data.
†The comparisons were performed using Pearson Chi-square tests for categorical data, and Wilcoxon rank sum tests for continuous data.

14. Change from baseline to week 48 Between group comparison P†
Figure 2. Changes from baseline of bone mineral density and bone biochemical markers over the 48-week study follow-up (ITT analysis)
Low BMD
(n = 67)
Normal BMD
(n = 99)
High-dose
(n = 35)
Normal-dose
(n = 32)
High-dose
(n = 48)
Normal-dose
(n = 51)
Parameters
Change from baseline to week 48
Between group comparison P†
BMD z-score
0.71 (0.29 to 1.11)‡
0.49 (-0.40 to 1.19)‡
0.10 (-0.25 to 0.66)
-0.07 (-0.51 to 0.43)
0.07
25OHD, ng/ml
5 (-2 to 12)‡
6 (3 to 12)‡
5 (1 to 11)‡
6 (2 to 10)‡
0.41
iPTH, pg/ml
-10 (-20 to 0)‡
-15 (-23 to -6)‡
-6 (-21 to 1)‡
-12 (-22 to -3)‡
0.04
ALP, U/l
-22 (-123 to 0)‡
-65 (-96 to -26)‡
-44 (-81 to -9)‡
-50 (-119 to -21)‡
0.09
CTX, ng/l
-170 (-450 to 0)‡
-420 (-720 to -130)‡
-330 (-740 to 6)‡
-320 (-620 to 30)‡
0.39
PINP, µg/l
-48 (-216 to 0)‡
-137 (-317 to -30)‡
-81 (-202 to 8)‡
-73 (-249 to 16)‡
0.24
*Data is presented as median change from baseline (interquartile range).
†P-value evaluates the overall difference in median change from baseline to week 48 between the two treatment groups (between group difference).
‡Indicates the median change from baseline to week 48 within the treatment groups (within group difference) is a statistical significant (P <0.05).

15. Discussions Parameter Our study Arpadi SM, et al3 (2012) Age
10-20 years
6-16 years
Intervention
VitD/Ca 3,200 IU/ 1.2 gm daily or
VitD/Ca 400 IU/ 1.2 gm daily
VitD/Ca 1,600 IU/ 1 gm daily or
Placebo
Duration
48 weeks
96 weeks
BMD change
LS BMD z-scores in adolescents with low BMD in both treatment groups
No between-group differences in change of BMD z-scores from baseline
TB BMD, TB BMC, LS BMD and LS BMC in both treatment groups
No between-group differences in change of TB BMD and TB BMC from baseline
Bone marker change
iPTH, ALP, CTX, PINP in adolescents with low and normal baseline BMD in both treatment groups
No between-group differences in change of bone markers, except for iPTH
25OHD in VitD/Ca supplemented group, but not in the placebo group
Abbreviations: LS, Lumbar spine, TB, total body, TH, total hip.
3Arpadi SM, et al. Am J Clin Nutr. 2012;95:

16. Limitations
Potential to differential measurement errors: open labeled fashion
Total body DXA was not performed: a gold standard for evaluate BMD in adolescents
Short duration of follow-up: too early to evaluate long-term outcomes
Limited generalizability of results: focused on only perinatally acquired HIV infection, virologic suppressed, Asian population

17. Conclusions With the preliminary results:
LS BMD z-scores were significantly increased in HIV-infected Thai adolescents with low baseline BMD who received VitD/Ca supplementation, regardless of dosage, over 48-week follow-up
Bone biochemical markers were re-established in adolescents with low as well as normal baseline BMD in both treatment groups
Supplementation of high-dose VitD/Ca did not show significant differences in the changes of BMD and bone metabolism outcomes compared to normal-dose VitD/Ca
A prospective study with longer follow-up is warranted to confirm our findings

18. Acknowledgements Participants, study staffs, and laboratory staffs at
Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
Nakornping Hospital, Chiang Mai, Thailand
Chiang Rai Prachanukroh Hospital, Chiang Rai, Thailand
Queen Sirikit National Institute of Child Health, Bangkok, Thailand
Charoon Bhesaj Co., Ltd. for Oskept® (FDC tablet of vitamin D3 and calcium) supply throughout the study
Funding support: The National Research University Project under Thailand's Office of the Higher Education Commission and the Chiang Mai University Fund