Bronchopulmonary dysplasia and pulmonary hypertension: a meta-analysis

OBJECTIVE

Pulmonary hypertension (PH) is a complication of bronchopulmonary dysplasia (BPD) but the true impact of PH in patients with BPD remains unclear. We sought to systematically review and meta-analyze incidence of PH in BPD and compare clinical outcomes of BPD patients with PH to those without PH in preterm infants.

STUDY DESIGN

Medline, Embase, PsychINFO and CINAHL were searched from January 2000 through December 2015. Cohort, case-control and randomized studies were included. Case-reports, case-series and letters to editors and studies with high risk of bias were excluded. Study design, inclusion/exclusion criteria, diagnostic criteria for BPD and PH and outcomes were extracted independently by two co-authors.

RESULTS

The pooled incidence of PH in patients with BPD (any severity) was 17% (95% confidence interval (CI) 12 to 21; 7 studies) and 24% (95% CI 17 to 30; 9 studies) in moderate-severe BPD. Patients with BPD have higher unadjusted odds of developing PH compared to those without BPD (odds ratio (OR) 3.00; 95% CI 1.18 to 7.66; 4 studies). Patients with BPD and PH were at higher odds of mortality (OR 5.29; 95% CI 2.07 to 13.56; 3 studies) compared with BPD without PH, but there was no significant difference in duration of initial hospitalization, duration of supplemental oxygen requirement or need for home oxygen. No studies included in this review reported on long-term pulmonary or neurodevelopmental outcomes.

CONCLUSIONS

PH occurs in one out of 4 to 5 preterm neonates with BPD. Patients with BPD and PH may have higher odds of mortality; however, there is urgent need for high quality studies that control for confounders and provide data on long-term outcomes.

Accessing completeness of pregnancy, delivery, and death registration by Accredited Social Health Activists [ASHA] in an innovative mHealth project in the tribal areas of Gujarat: A cross-sectional study

Background:

The Innovative Mobile-phone Technology for Community Health Operation (ImTeCHO) is a mobile-phone application that helps Accredited Social Health Activists (ASHAs) in complete registration through the strategies employed during implementation that is linking ASHAs’ incentives to digital records, regular feedback, onsite data entry, and demand generation among beneficiaries.

Objective:

To determine the proportion of pregnancies, deliveries, and infant deaths (events) being registered through the ImTeCHO application against actual number of events in a random sample of villages.

Materials and Methods:

Five representative villages were randomly selected from the ImTeCHO project area in the tribal areas of Gujarat, India to obtain the required sample of 98 recently delivered women. A household survey was done in the entire villages to enumerate each family and create a line-listing of events since January 2014; the line-listing was compared with list of women registered through the ImTeCHO application. The proportion of events being registered through the ImTeCHO application was compared against the actual number of events to find sensitivity of the ImTeCHO application.

Result:

A total of 844 families were found during household enumeration. Out of actual line-listing of pregnancies (N = 39), deliveries (N = 102), and infant deaths (N = 5) found during household enumeration, 38 (97.43%), 101 (99.01%), and 5 (100%) were registered by ASHAs through the ImTeCHO application.

Conclusion:

The use of mobile-phone technology and strategies applied during the ImTeCHO implementation should be upscaled to supplement efforts to improve the completeness of registration.

Modification of tumor cell exosome content by transfection with wt-p53 and microRNA-125b expressing plasmid DNA and its effect on macrophage polarization

Exosomes are responsible for intercellular communication between tumor cells and others in the tumor microenvironment. These microvesicles promote oncogensis and can support towards metastasis by promoting a pro-tumorogenic environment. Modifying the exosomal content and exosome delivery are emerging novel cancer therapies. However, the clinical translation is limited due to feasibility of isolating and delivery of treated exosomes as well as an associated immune response in patients. In this study, we provide proof-of-concept for a novel treatment approach for manipulating exosomal content by genetic transfection of tumor cells using dual-targeted hyaluronic acid-based nanoparticles. Following transfection with plasmid DNA encoding for wild-type p53 (wt-p53) and microRNA-125b (miR-125b), we evaluate the transgene expression in the SK-LU-1 cells and in the secreted exosomes. Furthermore, along with modulation of wt-p53 and miR-125b expression, we also show that the exosomes (i.e., wt-p53/exo, miR-125b/exo and combination/exo) have a reprogramed global miRNA profile. The miRNAs in the exosomes were mainly related to the activation of genes associated with apoptosis as well as p53 signaling. More importantly, these altered miRNA levels in the exosomes could mediate macrophage repolarization towards a more pro-inflammatory/antitumor M1 phenotype. However, further studies, especially in vivo studies, are warranted to assess the direct influence of such macrophage reprogramming on cancer cells and oncogenesis post-treatment. The current study provides a novel platform enabling the development of therapeutic strategies affecting not only the cancer cells but also the tumor microenvironment by utilizing the 'bystander effect' through genetic transfer with secreted exosomes. Such modification could also support antitumor environment leading to decreased oncogenesis.

Coupling of transient near infrared photonic with magnetic nanoparticle for potential dissipation-free biomedical application in brain

Combined treatment strategies based on magnetic nanoparticles (MNPs) with near infrared ray (NIR) biophotonic possess tremendous potential for non-invasive therapeutic approach. Nonetheless, investigations in this direction have been limited to peripheral body region and little is known about the potential biomedical application of this approach for brain. Here we report that transient NIR exposure is dissipation-free and has no adverse effect on the viability and plasticity of major brain cells in the presence or absence superparamagnetic nanoparticles. The 808 nm NIR laser module with thermocouple was employed for functional studies upon NIR exposure to brain cells. Magnetic nanoparticles were characterized using transmission electron microscopy (TEM), X-ray diffraction (XRD), dynamic laser scattering (DLS), and vibrating sample magnetometer (VSM). Brain cells viability and plasticity were analyzed using electric cell-substrate impedance sensing system, cytotoxicity evaluation, and confocal microscopy. When efficacious non-invasive photobiomodulation and neuro-therapeutical targeting and monitoring to brain remain a formidable task, the discovery of this dissipation-free, transient NIR photonic approach for brain cells possesses remarkable potential to add new dimension.

Diffusion Tensor Imaging of the Normal Cervical and Thoracic Pediatric Spinal Cord

BACKGROUND AND PURPOSE

DTI data of the normal healthy spinal cord in children are limited compared with adults and are typically focused on the cervical spinal cord. The purpose of this study was the following: to investigate the feasibility of obtaining repeatable DTI parameters along the entire cervical and thoracic spinal cord as a function of age in typically developing pediatric subjects; to analyze the DTI parameters among different transverse levels of the cervical and thoracic spinal cord; and to examine the sex differences in DTI parameters along the cervical and thoracic spinal cord.

MATERIALS AND METHODS

Twenty-two subjects underwent 2 identical scans by using a 3T MR imaging scanner. Axial diffusion tensor images were acquired by using 2 overlapping slabs to cover the cervical and thoracic spinal cord. After postprocessing, DTI parameters were calculated by using ROIs drawn on the whole cord along the entire spinal cord for both scans.

RESULTS

An increase in fractional anisotropy and a decrease in mean diffusivity, axial diffusivity, and radial diffusivity were observed with age along the entire spinal cord. Significantly lower fractional anisotropy and higher mean diffusivity values were observed in the lower cervical cord compared with the upper cervical cord. Axial diffusivity values in the cervical cord were higher compared with the thoracic cord. No statistically significant sex differences were observed for all DTI parameters. There was a moderate-to-strong repeatability for all DTI parameters.

CONCLUSIONS

This study provides an initial understanding of DTI values of the spinal cord relevant to age and sex and shows that obtaining repeatable DTI values of the entire cord in children is feasible.

Epidemiology of Posthemorrhagic Ventricular Dilatation in Canadian Neonatal Intensive Care Units

BACKGROUND: Severe intraventricular hemorrhage (IVH) is a common cause of neonatal morbidity and mortality .The incidence and management of post-hemorrhagic ventricular dilatation (PHVD) vary among different centres.

OBJECTIVES: To assess the incidence, temporal trend, management and associated outcomes of PHVD in Canadian NICUs.

DESIGN/METHODS: We conducted a retrospective review of all pre-term infants (22+0 -32+6 weeks) who were admitted to NICUs participating in the Canadian Neonatal Network between 2010 and 2014. Infants with severe IVH (IVH with ventricular dilatation or parenchymal bleeding) who survived ≥ 72 hours were included. We compared the rates of severe IVH, PHVD and VP shunting between the 5 Canadian regions. Short-term outcomes of infants who developed PHVD (ventricles size ≥10 mm) were compared with those who did not.

RESULTS: Of 16600 eligible infants, 1964 (11.8%) developed severe IVH. Of 1815 infants with severe IVH who survived ≥72 hours, 616 (34%) developed PHVD and 91 (5%) treated with VP shunt. No significant difference in the incidence of severe IVH, PHVD or VP shunting over the last five years was noted. There was a statistically significant difference in the rates of severe IVH (p<0.0001) and PHVD (p=0.02) among the 5 Canadian regions. VP shunts rates were variable with some Canadian regions with higher rates of PHVD had low rates of VP shunts. [figure 1]. Infants with PHVD had significantly higher mortality and short term morbidities. [table 1]. On regression analysis, PHVD is an independent predictor of death in infants with severe IVH [adjusted OR 1.55, 95% CI (1.18, 2.04)]. Infants with VP shunt had significantly higher rates of severe ROP (p<0.0001), meningitis (p<0.0001), and hospitalization (89 vs 41 days, p<0.0001).

CONCLUSION: PHVD is an independent predictor of death and is associated with adverse short- term outcomes. Variability exists between different regions in managing PHVD. Further studies are needed to investigate the impact of this variability on long-term outcomes.

Collapse

Neurodevelopmental Outcomes Following Extensive Cardiopulmonary Resuscitation in the Delivery Room for Infants Born <29 Weeks’ Gestational Age

BACKGROUND: Neurodevelopmental outcomes of preterm infants who receive extensive CPR (ECPR), defined as chest compression with or without epinephrine in the delivery room, remain unclear.

OBJECTIVES: To compare the neurodevelopmental outcomes of preterm infants admitted to Canadian NICUs requiring ECPR versus those who did not require ECPR in the delivery room.

DESIGN/METHODS: Preterm infants born at <29 weeks GA between January 1, 2010 and September 30, 2011 and evaluated at CNFUN centers were retrospectively evaluated. The primary outcome was a composite of death or neurodevelopmental impairment (NDI) at 18-21 months CA defined as presence of any one or more of the following: definitive cerebral palsy or Bayley- III cognitive, language, motor scores <85 on any one of the components or hearing impairment or visual impairment. Demographic factors, neurodevelopmental status including Bayley III cognitive, language and motor scores and sensory impairments were compared between the ECPR and the no ECPR group using univariate and multivariate analyses. RESULTS: Of 2488 eligible infants, 197 (7.9%) received ECPR. 83% of surviving infants had follow-up data. Demographic and outcomes data are summarized below in Table 1 and 2 respectively.

Neurodevelopmental Outcomes in Preterm Infants with Intraventricular Hemorrhage in Canada

BACKGROUND: Conflicting evidence exists in regards to outcomes of infants with mild IVH [subependymal hemorrhage (SEH) and IVH without ventricular dilatation (VD)] with recent reports suggesting poor outcomes.

OBJECTIVES: To compare 1) neurodevelopmental (ND) outcomes of infants < 29 wks GA with normal head ultrasound scan findings (Group 1: no IVH/PVL/VD to those with a) Group 2: SEH or IVH without VD, b) Group 3: IVH with VD (ventricle size > 10 mm) and c) Group 4: persistent intraparenchymal echogenicity (IPE) or lucency with or without IVH and 2) composite outcome of death or ND impairment (NDI)/severe NDI (SNDI) at 18-24 months in these groups.

DESIGN/METHODS: Retrospective cohort study of data from Canadian Neonatal Network (CNN)and Canadian Neonatal Follow-up Network (CNFUN) from April 2010 to September 2011. NDI was defined as any one of Bayley III score < 85 (cognition, language or motor), cerebral palsy (CP) or visual/hearing impairment. SNDI was defined as Bayley III score < 70 for any of the 3 components, CP with GMFCS > 3, severe visual impairment <20/200 or hearing impairment needing aids/cochlear implants. Data for the 4 groups were compared using Chi-squared test or ANOVA as appropriate. Multivariable regression was conducted to obtain adusted OR (95% CI).

RESULTS: See tables on page e51.

Severe ocular trauma-The hidden danger of plastic bottles when throwing out the rubbish

This is the first reported case of ocular trauma caused by a plastic bottle cap occurring accidentally without misuse. The mechanism involved an un-emptied plastic bottle containing orange juice being thrown away with other rubbish. The combination of this minor impact and the pressure built up within the bottle through fermentation caused expulsion of the cap at high velocity. This cap caused severe ocular trauma requiring urgent ophthalmic assessment and intervention. Our simple recommendation is that plastic bottles have their caps removed and are emptied before being thrown away.

ID: 13: BILATERAL UPPER EXTREMITY ECCHYMOTIC, BRUISING, AND BLEEDING IN A PATIENT ON ALIROCUMAB, RIVAROXABAN, AND ANTI-PLATELET THERAPY

Background

LDL cholesterol (LDLC) lowering has been revolutionized by PCSK9 inhibitors, which have approved indications as an adjunct to diet-maximally tolerated cholesterol lowering therapy in heterozygous (HeFH) or homozygous (HoFH) familial hypercholesterolemia, and/or clinical atherosclerotic cardiovascular disease (CVD) where LDLC lowering is insufficient despite maximal tolerated therapy. Injection site reactions occur in approximately 7.2% of patients (alirocumab) vs. 5.1% (placebo) and allergic reactions are 8.6% (alirocumab) vs. 7.8% (placebo). There is no drug to drug interaction data or warnings when using alirocumab or evolocumab in conjunction with anti-coagulants and/or anti-platelet therapy.

Methods

Patient was 70 year old Caucasian male with history of coronary artery disease, transient ischemic attack, amaurosis fugax associated with the G20210A prothrombin gene mutation, and normal carotid artery imaging, atrial fibrillation and mixed hyperlipidemia. Because of daily recurrent amaurosis fugax, he was given rivaroxaban (3 years) and subsequently added clopidogrel after a TIA. Despite rosuvastatin 40 mg and ezetimibe 10 mg, LDL cholesterol (LDLC) was 144 mg/dL (above target goal <70 mg/dL). Alirocumab 150 mg/mL was started subcutaneously every two weeks to achieve a LDLC target <70 mg/dL.

Results

After three doses of alirocumab, he presented with a diffuse ecchymotic-hemorrhagic bruising-rash on bilateral arms (see image) which started with an area of central clearing followed by blood spreading out in a circular fashion. Blood oozed out from ecchymotic rash sites at times, but there was no pain or tenderness. Platelet count was 175, hemoglobin 14.7, and hematocrit 44.7 which were all normal and there was no evidence of systemic bleeding. Previous to development of the ecchymotic-brusing, and four weeks after starting alirocumab, total cholesterol had fallen from 211 to 87 mg/dL, and LDLC from 144 to <4 mg/dL. All other labs including complete blood count with differential and comprehensive metabolic panel were normal at four weeks. At week seven, after three doses of alirocumab and appearance of ecchymotic rash, we discontinued clopidogrel, rivaroxaban, and alirocumab and the ecchymosis-bruising faded and receded. Because symptoms of amaurosis fugax accelerated off anticoagulants, clopidogrel and rivaroxaban were uneventfully restarted, without worsening of the skin.

Conclusion

We speculate that the reduction of LDLC from 144 to <4 mg/dL on alirocumab may have affected platelet membrane cholesterol, and platelet aggregation, especially in the concurrent presence of clopidogrel and rivaroxaban. In patients with cardiovascular disease and LDLC >70 (target) despite aggressive conventional cholesterol lowering drugs, alirocumab and evolocumab have revolutionary power in lowering LDLC with trivial side effects. For patients with cardiovascular disease and suboptimal LDLC lowering despite maximal tolerated conventional therapy, requiring concurrent anti-platelet and Xa inhibition, further studies need to be done to determine whether extraordinary LDLC lowering mediated by PCSK9 therapy may affect platelet function, leading to bruising-bleeding into the skin.

Abstract ID: 13 Figure 1

ID: 19: ELIGIBILITY FOR PCSK9 TREATMENT IN 734 HYPERCHOLESTEROLEMIC PATIENTS REFERRED TO A REGIONAL CHOLESTEROL TREATMENT CENTER WITH LDL CHOLESTEROL ≥70 MG/DL DESPITE MAXIMAL TOLERATED CHOLESTEROL LOWERING THERAPY

Background

LDL cholesterol (LDLC) lowering has been revolutionized by PCSK9 inhibitors, Alirocumab (Praluent) and Evolocumab (Repatha), which have approved indications as an adjunct to diet-maximally tolerated cholesterol lowering therapy in heterozygous (HeFH) or homozygous (HoFH) familial hypercholesterolemia, and/or clinical atherosclerotic cardiovascular disease (CVD) where LDLC lowering is insufficient despite maximal tolerated therapy.

Methods

We applied FDA approved and commercial insurance eligibility criteria for PCSK9 inhibitor use in 734 patients serially referred over 3 years who then received ≥2 months maximally tolerated LDLC lowering diet-drug therapy with follow up LDLC ≥70 mg/dl, as well as in 37 patients approved by commercial insurance for PCSK9 inhibitors. We obtained estimates of the percentage of patients with HeFH and/or CVD who meet FDA and commercial insurance eligibility for PCSK9 inhibitors using LDLC goal-based guidelines.

Results

Of the 734 patients with LDLC ≥70 mg/dl after ≥2 months maximally tolerated LDLC lowering therapy, 220 (30%) had HeFH and/or CVD events with LDLC >100 mg/dl, meeting both FDA and commercial insurance criteria for PCSK9 inhibitor therapy. Sixty-six (9%) patients were statin intolerant, without HeFH or CVD events. Of the 37 patients whose PCSK9 inhibitor therapy was approved for coverage by medical insurance carriers, 34 (92%) had LDLC>100 mg/dl after ≥2 months on maximally tolerated LDLC lowering therapy. Sixteen (43%) of these 37 patients had HeFH without CVD (LDLC on maximally tolerated conventional treatment 181±48 mg/dl), 11 (30%) had CVD without HeFH (LDLC on maximally tolerated conventional treatment 122±22 mg/dl), and 8 (22%) had both HeFH and CVD (LDLC on maximally tolerated conventional treatment 204±56 mg/dl).

Conclusion

Of the 734 patients referred for high LDLC treatment, with LDLC ≥70 mg/dl after ≥2 months on maximally tolerated therapy, 220 (30%) had HeFH and/or CVD with LDLC >100 mg/dl, meeting both FDA and insurance criteria for PCSK9 inhibitor therapy. If 30% of patients with high LDLC and HeFH-CVD are eligible for PCSK9 inhibitors, then specialty pharmaceutical pricing models (∼$14,300/year) will collide with an estimated 16–21 million HeFH-CVD patients. Although the costs for PCSK9 inhibitors given to an estimated 16 to 21 million patients are extraordinary ($228–300 billion), we speculate that, when weighed against direct and indirect costs of CVD, on balance, the cost to society might be either none, or that society would, in fact, save money by an anticipated 50% reduction of CVD events with PCSK9 inhibitors. Whether the health care savings arising from the anticipated reduction of CVD on the PCSK9 inhibitors justify the broad population use of these agents remains to be determined.

ID: 73: ATHEROTHROMBOSIS, THROMBOPHILIA, AND RELENTLESS PROGRESSION OF CORONARY ARTERY DISEASE

Introduction

Atherothrombosis involves a complex pathway often initiated by ulceration of an atherosclerotic plaque with platelet aggregation and thrombus formation. In the concurrent presence of familial and acquired thrombophilia, coronary artery disease (CAD) is often accelerated despite conventional lipid lowering, anti-platelet, and vascular interventions (stents, angioplasty, bypass). In a cohort of 30 patients with premature CAD and atherothrombosis, often worsening despite maximal conventional medical-surgical intervention, our specific aim was to describe major concurrent thrombophilia as a treatable component of atherothrombosis.

Methods

In 30 patients with premature, severe, and progressive CAD and atherothrombosis, despite maximal lipid lowering, anti-platelet therapy, and direct intervention (stents, angioplasty, coronary artery bypass grafts), we assessed for the presence of familial and acquired thrombophilia, with comparison to 110 healthy normal controls without CAD, and to 110 patients without CVD but with previous venous thromboembolism (VTE).

Results

The 30 patients (21 men, 9 women) had severe CAD despite anti-platelet treatment, maximal lipid lowering therapy (mean±SD LDLC was 82±46, median 72 mg/dl), and direct arterial intervention. The patients' first cardiac event occurred at age 46±12, median 47 years, and current age was 59±12, median 59 years. Most patients had suffered from multiple myocardial infarctions (12 had multiple stents, 8 were post cardiac bypass), 8 had previous VTEs, 3 had TIAs and one had preeclampsia.

Compared with 110 healthy normal controls, the 30 patients with CAD-atherothrombosis were more likely to have high homocysteine (20% vs 5%, P=0.014), Factor Leiden Heterozygosity (23% vs 2, P=0.006), lupus anticoagulant (27% vs 2%, P=0.003), high anticardiolipin antibody IgM (17% vs 3%, P=0.005), high factor VIII (30% VS 7%, P=0.007), high Factor XI (25% vs 3%, P=0.003), low antigenic protein C (26% vs 6%, P=0.18) and low antigenic protein S (21% vs 2%, P=0.007). Of the 8 patients who had CABG, 2 had multiple early venous graft failure (25%) compared to the historical one year graft failure of 10–15%. Thrombophilia did not differ across the atherothrombosis/CAD and VTE groups, except that the lupus anticoagulant was more common in the CAD-atherothrombosis patients than in the VTE patients (27% VS 4%, P=0.002).

Conclusion

In the presence of premature-aggressive CAD, despite maximal lipid lowering, anti-platelet therapy, and angioplasty-stent-bypass interventions, it is clinically valuable to assess for anticoagulant-treatable thrombophilia, which interacts with the atherosclerosis with resultant atherothrombosis. The patterns of thrombophilia in atherothrombotic patients do not differ from those in VTE without CAD, except for the lupus anticoagulant.

ID: 86: SAFETY OF 50,000-100,000 UNITS OF VITAMIN D3 PER WEEK IN VITAMIN D DEFICIENT, HYPERCHOLESTEROLEMIC PATIENTS, WITH STATIN INTOLERANCE

Background

In ∼85–90% of statin intolerant patients, vitamin D deficiency (serum 25 (OH) D <32 ng/ml) is a reversible cause of statin intolerance, usually requiring 50,000 to 100,000 units of vitamin D/week continuously to normalize serum vitamin D, and thus successfully allow reinstitution of statins which previously could not be tolerated because of myalgia-myositis.

Specific Aim

In 274 statin intolerant patients, all with low entry serum vitamin D (<32 ng/ml, median 21 ng/ml), we assessed safety and efficacy of vitamin D supplementation (50,000–100,000 units/week) over treatment periods of 3 months (n=274), 3 and 6 months (n=161), 3, 6, and 9 months (n=58), and 3, 6, 9, and 12 months (n=22).

Results

In the 385 patients with 3 month follow-up, taking mean 61,000 and median 50,000 IU of vitamin D3/week, median serum vitamin D rose from 20 to 42 ng/ml (p<0.0001); vitamin D became high (>100 ng/ml) but not toxic-high (>150 ng/ml) in 4 patients (1.0%) (101, 102, 106, 138 ng/ml). Median serum calcium was unchanged from entry (9.6 mg/dl) to 9.6 at 3 months. On vitamin D supplementation, the trend of change in serum calcium from normal-to-high or from high-to-normal did not significantly differ (McNemar S=1.0, p=0.32), and there was no significant trend in change of the calculated glomerular filtration rate (eGFR) from entry to follow-up (McNemar S=2.6, p=0.11).

In the 161 patients with 3 and 6 month follow-up, taking mean 67,000 and median 50,000 IU of vitamin D3/week, median entry serum vitamin D rose from 21 to 42 to 44 ng/ml (p<0.0001), serum vitamin D was high (>100 but <150 ng/ml) in 2 patients at 3 months (1.2%, 101, 102 mg/ml) and in 3 (1.9%) at 6 months (101, 140, 140 ng/ml). Median serum calcium was unchanged from entry (9.7 mg/dl), at 3 and 6 months (9.7, 9.6 mg/dl, p>0.05). On vitamin D supplementation, the change in serum calcium from normal-to-high or high-to-normal was no significant trend (McNemar S=0.7, p=0.41), and no trend in change of eGFR (McNemar S=1.3, p=0.26).

In the 58 patients with 3, 6, and 9 month follow-up on mean and median 71,000 and 100,000 IU of D3/week, median entry vitamin D rose from 20 to 37, 41, and 44 ng/ml (p<0.0001), with 1 (1.7%, 102 ng/ml), 2 (3.5%, 140, 140 ng/ml), and 0 (0%) patients high. Median serum calcium was unchanged from entry, median 9.7, 9.8, 9.6, and 9.6 mg/dl. On vitamin D supplementation, the trend of change in serum calcium from normal-to-high or high-to-normal was not significant (McNemar S=1.8, p=0.18), and no trend in change of eGFR (McNemar S=2, p=0.16).

In the 22 patients with follow-up at 3, 6, 9, and 12 months on mean and median 70,000 and 75,000 IU of D3/week, median serum vitamin D rose from 20 to 37, to 41, to 44, and to 43 ng/ml (p<0.0001), with 1 (5%, 102 ng/ml) high, 2 (9%, 140, 140) high, 0 (0%) high, and 1 (5%, 126 ng/ml) high. Serum calcium was unchanged, median at entry 9.6, and then at 3, 6, 9, and 12 months 9.7, 9.7, 9.5, and 9.7 mg/ml. At entry serum calcium was normal in 21, none high, and one became high at 12 month follow-up. The trend of change in eGFR was insignificant, McNemar S=1.0, p=0.32.

When serum D rose above 100 ng/ml in the few cases, as above, it fell into the normal range within 2 weeks by reducing the vitamin D dose by 50%.

Conclusions

When 50,000–100,000 units of vitamin D/week are given to reverse statin intolerance in statin intolerant patients with low entry vitamin D (<32 ng/ml), it appears to be safe over up to 1 year follow-up, without toxic high serum vitamin D levels >150 ng/ml, and levels rarely >100 ng/ml, and without changes in serum calcium or eGFR.