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Year : 2018  |  Volume : 13  |  Issue : 2  |  Page : 143-144

Comments on: Vitamin D and autoimmune diseases

Department of Medicine, The Sarvajanik Medical Trust Hospital, Surat, Gujarat, India

Date of Web Publication24-May-2018

Correspondence Address:
Dr. Ankur Dalal
70, Sankalp Society, Near Jamna Nagar, Ghod-Dod Road, Surat - 395 001, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_144_17

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How to cite this article:
Dalal A. Comments on: Vitamin D and autoimmune diseases. Indian J Rheumatol 2018;13:143-4

How to cite this URL:
Dalal A. Comments on: Vitamin D and autoimmune diseases. Indian J Rheumatol [serial online] 2018 [cited 2022 Jun 28];13:143-4. Available from:

Dear Editor,

I have read the review article titled “Vitamin D and Autoimmune Diseases” written by Azrielant and Shoenfeld.[1] with interest. The authors reviewed and discussed relevant literature on the association between autoimmunity and Vitamin D deficiency, as well as summary of important recommendation for Vitamin D supplementations in patients with autoimmune diseases.[1] Few following points merits further consideration.

First, regarding Vitamin D deficiency and undifferentiated connective tissue disease (UCTD). Rheumatologists frequently see patients who present with a weakly positive antinuclear antibody and nonspecific symptoms such as arthralgia, fatigue, and cold sensitivity and a definitive diagnosis cannot always be made. In such cases, a working diagnosis of UCTD may be appropriate.[2],[3] Zold et al.[4] showed that, in patients with UCTD, serum levels of Vitamin D were significantly lower compared with healthy individuals. Moreover, critically low levels of the Vitamin D clearly correlated with the progression to well-defined CTDs. They conclude that the measurement and effective supplementation of Vitamin D is crucial in UCTD patients.[4]

Second, although not considered to be autoimmune, fibromyalgia (FM) is one of the common rheumatic conditions which may present alone or in association with other autoimmune CTDs. In rheumatology clinics, FM prevalence was expectedly higher.[5] FM has been classified as chronic widespread musculoskeletal pain ( CWP) with mechanical hyperalgesia at ≥11 tender points.[6] Recently, Yong et al.[7] and Yilmaz et al.[8] concluded that Vitamin D supplementation has provided reductions in pain scores along with improvement in pain and reduced musculoskeletal symptoms, level of depression, and an increase in quality of life, respectively, in their studies after increasing Vitamin D level in CWP. They recommended that in clinical practice patients with FM or CWP should be investigated in regard to deficiency of Vitamin D.[7],[8]

Third, regarding the selection of Vitamin D formulation and autoimmune diseases. Numerous drugs with Vitamin D activity are available for clinical use which include natural Vitamin D products (i.e., those identical to natural metabolites) and the most frequently used synthetic molecules (i.e., bioengineered molecules not-existing in nature), which are generally indicated as “analogs.” The clinical activity of some Vitamin D analogs is such that they can be employed in diseases such as cancer and autoimmunity.[9] Zold et al.[10] indicated that the dose of 1.0 μg/day alfacalcidol during 5 weeks was the optimal therapeutic regime to increase the Vitamin D levels that could normalize the elevated levels of interferon-γ expressed by the CD4+Th1 cells and the interleukin-17 expressed by Th17 cells in UCTD. Furthermore, alfacalcidol decreased the Th1- and Th17-related cytokine levels, repaired the nTreg/Th7 balance, and restored the functional activity of nTreg cells and could restore immune-regulatory changes in patients with UCTD.[10]

Although prospective studies are needed to establish actual link and to determine the guidelines for clinical implementation, above mentioned aspects of Vitamin D and autoimmune diseases should also be kept in mind during routine clinical practice along with facts and recommendations discussed by Azrielant and Shoenfeld.[1]

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Conflicts of interest

There are no conflicts of interest.

  References Top

Azrielant S, Shoenfeld Y. Vitamin D and autoimmune diseases. Indian J Rheumatol 2017;12:219-22.  Back to cited text no. 1
  [Full text]  
Bennett R. Overlap syndromes. In: Firestein GS, Budd RC, Gabriel SE, McInnes IB, O'dell JR, editors. Kelley's Textbook of Rheumatology. 9th ed. Philadelphia: Saunders, an Imprint of Elsevier Inc.; 2013. p. 1431-51.  Back to cited text no. 2
Mosca M, Tani C, Neri C, Baldini C, Bombardieri S. Undifferentiated connective tissue diseases (UCTD). Autoimmun Rev 2006;6:1-4.  Back to cited text no. 3
Zold E, Szodoray P, Gaal J, Kappelmayer J, Csathy L, Gyimesi E, et al. Vitamin D deficiency in undifferentiated connective tissue disease. Arthritis Res Ther 2008;10:R123.  Back to cited text no. 4
Wolfe F, Rasker JJ. Fibromyalgia. In: Firestein GS, Budd RC, Gabriel SE, McInnes IB, O'dell JR, editors. In: Kelley's Textbook of Rheumatology. 9th ed. Philadelphia: Saunders, an Imprint of Elsevier Inc.; 2013. p. 733-51.  Back to cited text no. 5
Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American college of rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum 1990;33:160-72.  Back to cited text no. 6
Yong WC, Sanguankeo A, Upala S. Effect of Vitamin D supplementation in chronic widespread pain: A systematic review and meta-analysis. Clin Rheumatol 2017;36:2825-33.  Back to cited text no. 7
Yilmaz R, Salli A, Cingoz HT, Kucuksen S, Ugurlu H. Efficacy of Vitamin D replacement therapy on patients with chronic nonspecific widespread musculoskeletal pain with Vitamin D deficiency. Int J Rheum Dis 2016;19:1255-62.  Back to cited text no. 8
Mazzaferro S, Goldsmith D, Larsson TE, Massy ZA, Cozzolino M. Vitamin D metabolites and/or analogs: Which D for which patient? Curr Vasc Pharmacol 2014;12:339-49.  Back to cited text no. 9
Zold E, Szodoray P, Nakken B, Barath S, Kappelmayer J, Csathy L, et al. Alfacalcidol treatment restores derailed immune-regulation in patients with undifferentiated connective tissue disease. Autoimmun Rev 2011;10:155-62.  Back to cited text no. 10


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