缺乏維生素D和膝蓋骨關節炎的疼痛及殘疾有關


  Oct. 19, 2004(聖安東尼奧) - 一項針對221位老年膝蓋關節炎患者的試驗顯示,經過30個月的研究結果發現,治療維生素D缺乏症可以降低殘疾的機率及疼痛的程度。
  
  麻州波士頓大學醫學院的David T. Felson醫師表示,相較於其他患者,在初期就患有維生素D缺乏症的患者,會感覺到較激烈的疼痛;兩組的WOMAC疼痛指標(Western Ontario and Mcmaster Universities Osteoarthritis)分別為8.0(維生素D缺乏組)及6.6;兩組的殘疾指標分別為26.9及21.7;至於肌肉強度方面,兩組並無顯著差異。
  
  血清維生素D濃度較低的患者,在經過30個月的矯正治療後,殘疾指標有著大幅的進步;亦即,由26.9降至21.8;疼痛及虛弱指標也有降低的傾向,這兩項趨勢在統計上並沒有顯著的差異。
  
  Felson醫師催促其他醫師們去尋找抱怨膝蓋疼痛且缺乏維生素D的年長患者,並予以治療;Felson醫師在美國風濕病學學會(American College of Rheumatology)第67屆科學年會的記者會中表示,我或許對,也或許不對,但是在這些患者身上,維生素D缺乏的現象的確是一個問題,而且必須給予補充。
  
  參與試驗的患者平均年齡為67歲,他們都來自波士頓退伍軍人醫學中心(Boston Veterans Affairs Medical Center),及其附近的社區;男性患者佔了三分之二,有將近一半的患者(48%)在試驗初期顯示了維生素D缺乏的症狀;維生素D缺乏的定義為,低於20 nm/mL。
  
  維生素D被認為在北部的幾個州會比較普遍,因為陽光比較少,而老年人也比較不常在戶外;但是,Felson醫師建議,低緯度的地區也不應該被忽略;Felson醫師在接受Medscape訪問時指出,我們所談的是在美國境內,梅生迪克生(Mason-Dixon)分隔線以上地區內所有60歲以上的人,也可能包含了梅生迪克生(Mason-Dixon)分隔線以下的地區,維生素D缺乏症是很流行的。
  
  提升維生素D的水平很簡單,Felson醫師建議了三個方法:每天補充800國際單位的維生素D(兩顆400國際單位)、喝牛奶、每週到戶外曬幾次15分鐘的太陽。
  
  當被問到曬黑是不是也是一項選擇時,Felson醫師表示,這是一個令人振奮的問題,同時也具有相當的爭議性,他寧願不去探討;他在記者簡報會議中表示,很難去確定多少的陽光曝曬量可以補足維生素D,或多少量是屬於過量,因為我們不想讓人們暴露在皮膚癌的風險之下。
  
  Felson對醫師提出警告,醫生們應該詢問病人是否有腎結石,或曾經有此家庭病史;因為高劑量的維生素D會導致腎結石。
  
  他同時指出,維生素D並不是一個萬靈丹,維生素D對症狀只有輕微的影響,一般而言,並不會因此而讓人膝蓋疼痛的現象一下子好轉,因此只能作出次要的貢獻;但是這是很容易做到的,何樂而不為。
  
  俄亥俄州Musculosdeletal Medical Specialists Inc.,的Joseph Flood醫師表示,對於關節炎的維生素D缺乏症狀而言,本項研究讓原本就日益增多的報告又加重了份量;他表示,你應該先確定患者是否有維生素D方面的問題,至少我是這麼作的。
  
  根據Flood醫師表示,有一個實際上的問題,那就是大家對人體所需的最低維生素D濃度還沒有共識,標準試驗所訂定的最低濃度為8至40 ng/mL;我認為,患者的維生素D濃度最少應有25ng/mL。

Vitamin D Deficiency Linked to

By Jane Salodof MacNeil
Medscape Medical News

Oct. 19, 2004 (San Antonio) — Results from a 30-month study of 221 elderly patients with osteoarthritis of the knee suggest that remedying a vitamin D deficiency can reduce disability and possibly pain as well.

David T. Felson, MD, MPH, from Boston University Medical Campus in Massachusetts, reported that patients with low baseline vitamin D levels had significantly more pain compared with patients with higher levels: 8.0 on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scale compared with 6.6 for patients with sufficient vitamin D levels (P < .0001). They also had significantly higher scores on the WOMAC disability scale: 26.9 vs 21.7 (P < .0001) but were not substantially weaker in tests of muscle strength.

In patients whose low serum vitamin D levels showed correction over 30 months, disability scores improved significantly, from 26.9 to 21.8 (P = .05). While trends toward reduced pain and weakness were also documented, they did not reach statistical significance.

Dr. Felson urged physicians to look for and treat vitamin D deficiency in all elderly patients complaining of knee pain. "I may be right or wrong, but the vitamin D deficiency is a problem in those patients.... It needs to be replenished," he said yesterday during a press conference at the 68th annual scientific meeting of the American College of Rheumatology.

Patients in the study were an average age of 67 years and were recruited from the Boston Veterans Affairs Medical Center and surrounding community. Almost two thirds of patients were men. Nearly half (48%) had deficient baseline vitamin D levels defined as 20 ng/mL or less.

Although vitamin D deficiency is believed to be more common in northern states where sunlight is less pronounced and the elderly spend less time out of doors, Dr. Felson advised that it should not be ignored in lower latitudes. "We're talking about everybody [age] 60 and over in the United States above the Mason-Dixon line and maybe even below the Mason-Dixon line. The prevalence of vitamin D deficiency is extremely high," he told Medscape in an interview.

Raising vitamin D levels is relatively easy, according to Dr. Felson. He recommended three methods: at least 800 international units of vitamin D (two 400 IU pills) in a daily vitamin supplement, drinking milk, and/or going out for up to 15 minutes of sun exposure a few times a week.

Asked whether tanning was an option, he called the question a "provocative and controversial area" he would rather not explore. "There are very difficult issues of when sun exposure is enough to give vitamin D sufficiency and when it is too much, so that you put people at risk of getting cancer," he said during the press briefing.

Afterward, in the interview, he added the caveat that physicians should ask patients whether they have kidney stones or a history of kidney stones in their families, because high doses of vitamin D are thought to cause kidney stones, according to Dr. Felson.

He also cautioned that vitamin D is not a panacea. "The effect of vitamin D on symptoms is relatively small," he said. "This is not going to make someone with a lot of knee pain feel all better usually. It's a minor contributor, but it's such an easy correctible, it would be silly not to pursue [it]."

Press conference moderator Joseph Flood, MD, FACR, president of Musculoskeletal Medical Specialists Inc. in Columbus, Ohio, and a faculty member at Ohio State University, said the study adds weight to a small but growing number of reports supporting treatment of vitamin D deficiency in arthritis. "I think you should first ascertain whether [patients] have a problem with vitamin D — I do it," he said.

A practical problem, according to Dr. Flood, is that the cut-off for a low vitamin D level has not been agreed upon. The standard test uses a scale of 8 to 40 ng/mL. "I think [a patient's vitamin D level] should be at least 25," he said.

ACR 68th Annual Scientific Meeting: Abstract 1755. Press briefing held Oct. 18, 2004; presented Oct. 20, 2004.

Reviewed by Gary D. Vogin, MD

    
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