Prevention Surpasses Treatment: 5-year Follow-Up, Cost-Utility, and Cost-Benefit of Zeaxanthin Therapy for Neovascular Age-Related Macular Degeneration

INTRODUCTION

Oral administration of zeaxanthin (Zx) 20 mg daily in patients with unilateral neovascular age-related macular degeneration (nAMD) treated with triple therapy (photodynamic therapy/intravitreal bevacizumab/intravitreal dexamethasone) reduced fellow-eye 2-year nAMD incidence from 23 to 6% (p = 0.02) in a prior clinical trial. We questioned the long-term benefit and thus analyzed case-control 5-year patient data of trial participants and additional participants with 5-year follow-up, also performing cost-utility and cost-benefit analyses.

METHODS

Consecutive, unilateral nAMD patient outcomes for those taking 20 mg Zx supplementation orally for ≥ 5 years were compared with the Comparison of AMD Treatments Trials (CATT) 5-year historical controls for fellow-eye nAMD conversion. Eleven-year mean life expectancy, cost-utility and cost-benefit models were undertaken employing a 3% discount rate and 2020 US real dollars.

RESULTS

Among 227 consecutive patients with nAMD/Zx-supplementation, 202 (90%) had 5-year follow-up. The fellow-eye nAMD 5-year conversion incidence using a Kaplan-Meier cumulative event estimate was 22% (49/227), versus 48% (167/348) with CATT control data (p < 0.0001). An 11-year cost-utility model with estimates for years 6-11 demonstrated a 0.42 (7.7%) QALY (quality-adjusted life-year) gain, including 3 months of life saved per patient due to decreased nAMD fellow-eye conversion. This yielded a direct ophthalmic medical cost perspective, incremental cost-utility ratio (CUR) of -$576/QALY and a societal cost perspective CUR of -$125,071/QALY. Zx supplementation for all 2020 US unilateral nAMD cases would have theoretically saved society, primarily patients, $6.0 billion over 11 years, a 1531% return on investment (ROI), or 31.3% annual ROI, on Zx costs.

CONCLUSIONS

Oral zeaxanthin supplementation for unilateral nAMD patients appears to decrease fellow-eye long-term incidence and is cost-effective and financially rewarding. It is dominant vs. no supplementation in patients presenting with unilateral nAMD.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT01527435.

Zinc Supplementation May Reduce the Effects of Oral Mucositis for Patients With Cancer Receiving Either Chemotherapy or Radiotherapy

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Effects of oral supplementation in the management of oral mucositis in cancer patients: A meta-analysis of randomized clinical trials. de Menêses AG, Normando AGC, Porto de Toledo I, Reis PED, Guerra ENS. J Oral Pathol Med. 2020;49(2):117-125.

SOURCE OF FUNDING

Information not available from the study.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data.

Effects of oral versus parenteral cobalamin supplementation on methylmalonic acid and homocysteine concentrations in dogs with chronic enteropathies and low cobalamin concentrations

The objective of this study was to compare the effects of parenteral (PE) versus oral (PO) cobalamin supplementation on serum methylmalonic acid (MMA) and homocysteine (HCY) concentrations in dogs with hypocobalaminaemia. Thirty-six dogs with serum cobalamin concentrations below 285ng/L (reference interval (RI): 244-959ng/L) were treated with PO (0.25-1.0mg daily) or PE cobalamin (0.25-1.2mg/injection) using a block-randomized schedule. Serum MMA and HCY concentrations were analysed at day 0, 28 and 90 after start of supplementation. There was no significant difference between the PO and PE group regarding serum MMA or HCY concentrations at any time point. Median (range, P comparing baseline and 28 days, P comparing 28days and 90 days) serum MMA concentrations (nmol/L; RI 415-1193) were 932 (566-2468) in the PO and 943 (508-1900) in the PE group at baseline, respectively, 705 (386-1465, P<0.0001) and 696 (377-932, P<0.0001) after 28 days, and 739 (450-1221, P=0.58) and 690 (349-1145, P=0.76) after 90 days. Serum HCY concentrations (median (range), P comparing baseline and 28 days, P comparing 28days and 90 days, μmol/L; RI 5.9-31.9) in the PO and PE groups were 12.2 (3.3-62.2) and 8.4 (3.7-34.8) at baseline, 12.5 (5.0-45.0, P=0.61) and 8.0 (3.8-18.3, P=0.28) after 28 days, and 17.7 (7.3-60.0 P=0.07) and 12.4 (6.3-33.1, P=0.0007) after 90 days, respectively. Oral and parenteral cobalamin supplementation had the same effect on serum MMA concentrations in this group of dogs.

Lack of impact of dietary inclusion of dried Artemisia annua leaves for cattle on infestation by Rhipicephalus (Boophilus) microplus ticks

The present study evaluated whether a natural dietary additive, dried Artemisia annua leaves, may be useful to control Rhipicephalus (Boophilus) microplus on naturally infested cattle. Twenty heifers of the Canchim breed, weighing around 250 kg, were divided into two equally sized experimental groups: 1) control animals and 2) animals receiving 200 g/day of dried A. annua leaves for two months. Before treatment began, the animals were homogeneously distributed in control and treatment groups based on their pre-treatment weight and tick infestation level. Counts of engorged female ticks then occurred weekly during the two-month experimental period. We also monitored cattle weight gain and packed cell volume (PCV). Artemisinin (0.96%) was quantified in the plant material by high-performance liquid chromatography with refractive index detector (HPLC-IR). No statistical differences between the control and treatment groups were observed for engorged female counts (log averages of 1.3 ticks and 1.4 ticks per animal, respectively), daily cattle weight gain (0.910 kg and 0.888 kg, respectively) or PCV (33.5% and 33.0%, respectively). We conclude that the oral supplementation of cattle feed with dried A. annuna leaves did not control natural infestation of R. (B.) microplus. The hypothesis of artemisinin's action on cattle ticks by ingestion through the animals' blood was not confirmed at the evaluated dose.

Efficacy of Long-Term Oral Vitamin B12 Supplementation after Total Gastrectomy: Results from a Prospective Study

BACKGROUND/OBJECTIVES

Vitamin B12 (VB12) deficiency is a common complication after total gastrectomy which may be associated with megaloblastic anemia and potentially irreversible neurologic symptoms. Intramuscular supplementation of VB12 has been considered the standard treatment, although it is associated with high costs and patient discomfort.

PATIENTS/METHODS

We performed a prospective uncontrolled study (ACTRN12614000107628) in order to evaluate the clinical and laboratory efficacy of long-term oral VB12 supplementation in patients submitted to total gastrectomy. All patients received daily oral VB12 (1 mg/day) and were evaluated every 3 months (clinical and laboratory evaluation: hemoglobin, VB12, total iron, ferritin, and folate).

RESULTS

A total of 26 patients were included with a mean age of 64 years (29-79). Patients were included with a mean period of 65 months (3-309) after total gastrectomy. At inclusion time, 17/26 patients were under intramuscular VB12, and 9 had not started supplementation yet. There were normal serum VB12 levels in 25/26 patients (mean VB12 serum levels: 657 pg/mL). The mean follow-up period was 20 (8.5-28) months. During follow-up, all patients had normal VB12 levels and there was no need for intramuscular supplementation. The patient with low VB12 levels had an increase to adequate levels, which remained stable. There were no differences with statistical significance among VB12 levels at 6 (867 pg/mL), 12 (1,008 pg/mL), 18 (1,018 pg/mL), and 24 (1,061 pg/mL) months. Iron and folate supplementation was necessary in 21 and 7 patients, respectively.

CONCLUSIONS

Oral VB12 supplementation is effective and safe in patients who underwent total gastrectomy and should be considered the preferential form of supplementation.

Comparison of efficacy of oral and parenteral cobalamin supplementation in normalising low cobalamin concentrations in dogs: A randomised controlled study

The aim of this study was to compare the efficacies of parenteral and oral cobalamin supplementation protocols in dogs with chronic enteropathies and low cobalamin concentrations. It was hypothesised that both treatments would increase serum cobalamin concentrations significantly. Fifty-three dogs with chronic enteropathies and serum cobalamin concentrations<285ng/L (reference interval 244-959ng/L) were enrolled. Dogs were randomised to treatment with either daily oral cobalamin tablets (0.25-1.0mg cyanocobalamin daily according to body weight) or parenteral cobalamin (0.4-1.2mg hydroxycobalamin according to body weight). Serum cobalamin concentrations were analysed 28±5days and 90±15days after initiation of supplementation. After 28 days, all dogs had serum cobalamin concentrations within the reference interval or above. In the parenteral group (n=26), median (range) cobalamin concentrations were 228 (150-285) ng/L at inclusion, 2107 (725-10,009) ng/L after 28days and 877 (188-1267) ng/L after 90 days. In the oral group (n=27), median (range) serum cobalamin concentrations were 245 (150-285) ng/L at inclusion, 975 (564-2385) ng/L after 28days and 1244 (738-4999) ng/L after 90 days. In both groups, there were significant differences in serum cobalamin concentrations between baseline and 28 days, and between 28days and 90days (P<0.001). In conclusion, both parenteral and oral cobalamin supplementation effectively increase serum cobalamin concentrations in dogs with chronic enteropathies and low cobalamin concentrations.

Impact of humic acids on the colonic microbiome in healthy volunteers

AIM

To test the effects of humic acids on innate microbial communities of the colon.

METHODS

We followed the effects of oral supplementation with humic acids (Activomin^®) on concentrations and composition of colonic microbiome in 14 healthy volunteers for 45 d. 3 × 800 mg Activomin^® were taken orally for 10 d followed by 3 × 400 mg for 35 d. Colonic microbiota were investigated using multicolor fluorescence in situ hybridization (FISH) of Carnoy fixated and paraffin embedded stool cylinders. Two stool samples were collected a week prior to therapy and one stool sample on days 10, 31 and 45. Forty-one FISH probes representing different bacterial groups were used.

RESULTS

The sum concentration of colonic microbiota increased from 20% at day 10 to 30% by day 31 and remained stable until day 45 (32%) of humic acid supplementation (P < 0.001). The increase in the concentrations in each person was due to growth of preexisting groups. The individual microbial profile of the patients remained unchanged. Similarly, the bacterial diversity remained stable. Concentrations of 24 of the 35 substantial groups increased from 20% to 96%. Two bacterial groups detected with Bac303 (Bacteroides) and Myc657 (mycolic acid-containing Actinomycetes) FISH probes decreased (P > 0.05). The others remained unaffected. Bacterial groups with initially marginal concentrations (< 0.1 × 10⁹/mL) demonstrated no response to humic acids. The concentrations of pioneer groups of Bifidobacteriaceae, Enterobacteriaceae and Clostridium difficile increased but the observed differences were statistically not significant.

CONCLUSION

Humic acids have a profound effect on healthy colonic microbiome and may be potentially interesting substances for the development of drugs that control the innate colonic microbiome.

Benefits of post-operative oral protein supplementation in gastrointestinal surgery patients: A systematic review of clinical trials

AIM: To evaluate published trials examining oral post-operative protein supplementation in patients having undergone gastrointestinal surgery and assessment of reported results.

METHODS: Database searches (MEDLINE, BIOSIS, EMBASE, Cochrane Trials, Cinahl, and CAB), searches of reference lists of relevant papers, and expert referral were used to identify prospective randomized controlled clinical trials. The following terms were used to locate articles: “oral’’ or “enteral’’ and “postoperative care’’ or “post-surgical’’ and “proteins’’ or “milk proteins’’ or “dietary proteins’’ or “dietary supplements’’ or “nutritional supplements’’. In databases that allowed added limitations, results were limited to clinical trials that studied humans, and publications between 1990 and 2014. Quality of collated studies was evaluated using a qualitative assessment tool and the collective results interpreted.

RESULTS: Searches identified 629 papers of which, following review, 7 were deemed eligible for qualitative evaluation. Protein supplementation does not appear to affect mortality but does reduce weight loss, and improve nutritional status. Reduction in grip strength deterioration was observed in a majority of studies, and approximately half of the studies described reduced complication rates. No changes in duration of hospital stay or plasma protein levels were reported. There is evidence to suggest that protein supplementation should be routinely provided post-operatively to this population. However, despite comprehensive searches, clinical trials that varied only the amount of protein provided via oral nutritional supplements (discrete from other nutritional components) were not found. At present, there is some evidence to support routinely prescribed oral nutritional supplements that contain protein for gastrointestinal surgery patients in the immediate post-operative stage.

CONCLUSION: The optimal level of protein supplementation required to maximise recovery in gastrointestinal surgery patients is effectively unknown, and may warrant further study.

Optimal vitamin D3 daily intake of 2000IU inferred from modeled solar exposure of ancestral humans in Northern Tanzania

Recently, high serum 25-hydroxyvitamin D concentration (~110nmol/L) was found in the Hadza tribe still keeping ancient hunter-gather life style. This level could serve as optimal vitamin D level that was built during millennia of human evolution. The personal vitamin D3 effective solar exposures of the Hadza adults are estimated using radiative model simulations with input from the satellite observations over lake Eyasi (3.7°S, 35.0°E). The calculations are carried out assuming the Hadza typical clothing habits and specific scenarios of the out-door activity comprising early morning and late afternoon working time in sun and prolonged midday siesta in the shade. The modeled doses received by the Hadza are converted to the vitamin D3 effective daily doses pertaining to the lighter skinned persons. We propose a novel formula to get adequate vitamin D level - exposure of 1/3 MED around local noon to 1/3 part of the whole body during warm sub-period of the year in the low- and mid-latitude regions. Such daily solar exposure is equivalent to ~2000IU of vitamin D3 taken orally. For many contemporary humans with limited out-door activity habit achieving such daily norm requires vitamin D3 supplementation of 2000IU throughout the whole year.

Oral Cobalamin Supplementation in Dogs with Chronic Enteropathies and Hypocobalaminemia

Background

Cobalamin deficiency is commonly associated with chronic enteropathies (CE) in dogs and current treatment protocols recommend parenteral supplementation. In humans, several studies have reported equal efficacy of oral and parenteral cobalamin administration of cobalamin.

Objectives

To retrospectively evaluate whether oral cobalamin supplementation can restore normocobalaminemia in dogs with CE and hypocobalaminemia.

Animals

Fifty‐one client‐owned dogs with various signs of CE and hypocobalaminemia.

Material and Methods

Retrospective study based on a computerized database search for dogs treated at Evidensia Specialist Animal Hospital, Helsingborg, Sweden during January 2012–March 2014. Inclusion criteria were dogs with signs of CE, an initial serum cobalamin ≤270 ng/L (reference interval: 234–811 ng/L) and oral treatment with cobalamin tablets. Serum cobalamin for follow‐up was analyzed 20–202 days after continuous oral cobalamin supplementation started.

Results

All dogs became normocobalaminemic with oral cobalamin supplementation. The mean increase in serum cobalamin concentration after treatment was 794 ± 462 ng/L. Serum cobalamin concentrations were significantly higher after supplementation (mean 1017 ± 460 ng/L; P < .0001) than at baseline (mean 223 ± 33 ng/L).

Conclusion and Clinical Importance

Our results suggest that oral cobalamin supplementation is effective in normalizing serum cobalamin concentrations in dogs with CE. Prospective studies comparing cellular cobalamin status in dogs being treated with parenteral versus oral cobalamin supplementation are warranted before oral supplementation can be recommended for routine supplementation.

Influence of dietary components on Aspergillus niger prolyl endoprotease mediated gluten degradation

Celiac disease (CD) is caused by intolerance to gluten. Oral supplementation with enzymes like Aspergillus niger propyl-endoprotease (AN-PEP), which can hydrolyse gluten, has been proposed to prevent the harmful effects of ingestion of gluten. The influence of meal composition on AN-PEP activity was investigated using an in vitro model that simulates stomach-like conditions. AN-PEP optimal dosage was 20 proline protease units (PPU)/g gluten. The addition of a carbonated drink strongly enhanced AN-PEP activity because of its acidifying effect. While fat did not affect gluten degradation by AN-PEP, the presence of food proteins slowed down gluten detoxification. Moreover, raw gluten was degraded more efficiently by AN-PEP than baked gluten. We conclude that the meal composition influences the amount of AN-PEP needed for gluten elimination. Therefore, AN-PEP should not be used to replace a gluten free diet, but rather to support digestion of occasional and/or inadvertent gluten consumption.