Oral Vitamin D and Toll Like Receptor in Spondylitis Tuberculosis
Study Details
Study Description
Brief Summary
Background :
The toll-like receptor is an essential receptor that stimulates the innate immunity response. In tuberculosis, toll-like receptors, particularly the TLR-2, and TLR-4 are crucial in recognizing various ligands with a lipoprotein structure in the bacilli. Vitamin D deficiency leads to lower expression of these receptors, Hence the immune response against Mycobacterium tuberculosis will be altered. Various studies addressed the importance of vitamin D supplementation in pulmonary tuberculosis but the effect of vitamin D in extrapulmonary tuberculosis, particularly spondylitis tuberculosis is not sufficiently identified.
Objectives:
To assess the effect of oral vitamin D supplementation on the expression of TLR-2, TLR-4, and clinical outcomes in spondylitis tuberculosis patients.
Methodology:
This study proposes a randomized clinical trial of oral vitamin D supplementation in spondylitis tuberculosis patients. Multiple arms will be established with different doses and control groups. The outcome of interest includes the clinical outcomes, the expression of TLR-2, and TLR 4
Hypothesis :
It is assumed that oral supplementation of Vitamin D will increase the activation of Toll-Like Receptors and improves the clinical condition of Spondylitis Tuberculosis patients
Condition or Disease | Intervention/Treatment | Phase |
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Phase 2/Phase 3 |
Detailed Description
Target population:
Patients with spondylitis tuberculosis without the involvement of lung and other extrapulmonary infection
Design:
Randomized Clinical Trial with 3 arms
Primary Intervention:
Standardized Tuberculosis treatment with oral Vitamin D3 Supplementation daily for 8 weeks
Outcome:
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Toll-Like Receptors (TLR) 2 and 4 levels from the blood sample, measured using Enzyme-linked Immunoassay (ELISA).
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Clinical Evaluation with Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI).
The outcomes will be measured three times at 4-week intervals (baseline, week 4, and week 8)
Sample Size and Recruitment Participants will be recruited from hospitals and allocated by simple randomization
Biological Sample and consent
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Participants are aware that clinical data collection and biological samples will be obtained by researchers. This is mentioned in informed consent prior to study recruitment
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Blood sample will be obtained in a standardized phlebotomy procedure and will not be retained after the study is finish.
Hypothesis Sample Size Calculation:
The trial will be designed to compare 2 experimental treatments to a shared control arm.
The sample size was estimated based on the mathematical calculation by a study below Grayling, M.J et al
With the assumption of :
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K=2 experimental treatments will be included in the trial.
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A significance level of α=0.05 will be used, in combination with no multiple comparison correction.
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The event rate in the control arm will be assumed to be: λ0=5.
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The marginal power for each null hypothesis will be controlled to level 1-β=0.8 under each of their respective least favorable configurations.
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The interesting and uninteresting treatment effects will be δ1=2.5 and δ0=0 respectively.
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The target allocation to each of the experimental arms will be the same as the control arm.
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The sample size in each arm will not be required to be an integer.
Hence total sample should be 37 participants
Proposed Statistical Analysis
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Descriptive Statistics
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Bivariate Analysis
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The study will apply intention-to-treat analysis
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Linear Mixed model to measure the effect of intervention adjusted by fixed and random factors.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Active Comparator: Control Group This group will be given standardized tuberculosis drug with 400 IU of oral Vitamin D3 |
Dietary Supplement: 400 IU
An Oral Vitamin D3 400 IU will be given once daily for a total of 8 weeks
Other Names:
Drug: Fixed Drug Combination
Standard Tuberculosis Regimen in a form of Fixed Drug Combination (FDC) given for Spondylitis Tuberculosis.
Other Names:
|
Experimental: Moderate Dose This group will be given standardized tuberculosis drug with 5000 IU of oral Vitamin D3 |
Dietary Supplement: 5000 IU
An Oral Vitamin D3 5000 IU will be given once daily for a total of 8 weeks
Other Names:
Drug: Fixed Drug Combination
Standard Tuberculosis Regimen in a form of Fixed Drug Combination (FDC) given for Spondylitis Tuberculosis.
Other Names:
|
Experimental: High Dose This group will be given standardized tuberculosis drug with 10000 IU of oral Vitamin D3 |
Dietary Supplement: 10000 IU
An Oral Vitamin D3 10000 IU will be given once daily for a total of 8 weeks
Other Names:
Drug: Fixed Drug Combination
Standard Tuberculosis Regimen in a form of Fixed Drug Combination (FDC) given for Spondylitis Tuberculosis.
Other Names:
|
Outcome Measures
Primary Outcome Measures
- The Oswestry Disability Index [Changes of Score from Baseline to 8 weeks]
This questionnaire assess the impact of back pain to the daily life. This questionnaire contains 10 6-likert scale questions with the score ranging from 0-5 for each questions. The total score ranging from 0-50. The index is calculated as raw score per total score and presented as percentage. Below is the classification and interpretation of the score: 0% -20%: Minimal disability 21%-40%: Moderate Disability 41%-60%: Severe Disability 61%-80%: Crippling back pain 81%-100%: These patients are either bed-bound or have an exaggeration of their symptoms
- The Visual Analogue Scale [Changes of Score from Baseline to 8 weeks]
This scale represent the pain according to a visual score measured using 10-likert scale. Maximum number indicates extreme/intractable pain
- Toll-Like Receptor 2 (TLR-2) [Changes of TLR-2 level from Baseline to 8 weeks]
The level of TLR-2 in blood measured using ELISA
- Toll-Like Receptor 4 (TLR-2) [Changes of TLR-4 level from Baseline to 8 weeks]
The level of TLR-4 in blood measured using ELISA
Eligibility Criteria
Criteria
Inclusion Criteria:
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Diagnosed as Spondylitis Tuberculosis (Clinically and Laboratory confirmed)
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Level of Total Vitamin D <50 nmol/L at baseline
Exclusion Criteria:
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Participants with pulmonary tuberculosis or other extrapulmonary tuberculosis
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Participants with osteoporosis, malignancy, cardiovascular disease, diabetes mellitus, and autoimmune disease
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Participants with liver and kidney dysfunction
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Participants who received Vitamin D prior to enrollment
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
---|---|---|---|---|---|
1 | Wahidin Sudirohusodo General Hospital | Makassar | South Sulawesi | Indonesia | 76124 |
Sponsors and Collaborators
- Hasanuddin University
Investigators
- Principal Investigator: Jainal Arifin, MD, Hasanuddin University
- Study Chair: Nasrum Massi, MD. Ph.D, Hasanuddin University
- Principal Investigator: Firdaus Hamid, MD. Ph.D, Hasanuddin University
- Principal Investigator: Andi Alfian Zainuddin, MD. Ph.D, Hasanuddin University
Study Documents (Full-Text)
None provided.More Information
Publications
- Grayling MJ, Wason JM. A web application for the design of multi-arm clinical trials. BMC Cancer. 2020 Jan 31;20(1):80. doi: 10.1186/s12885-020-6525-0.
- Ojaimi S, Skinner NA, Strauss BJ, Sundararajan V, Woolley I, Visvanathan K. Vitamin D deficiency impacts on expression of toll-like receptor-2 and cytokine profile: a pilot study. J Transl Med. 2013 Jul 22;11:176. doi: 10.1186/1479-5876-11-176.
- Panwar A, Garg RK, Malhotra HS, Jain A, Singh AK, Prakash S, Kumar N, Garg R, Mahdi AA, Verma R, Sharma PK. 25-Hydroxy Vitamin D, Vitamin D Receptor and Toll-like Receptor 2 Polymorphisms in Spinal Tuberculosis: A Case-Control Study. Medicine (Baltimore). 2016 Apr;95(17):e3418. doi: 10.1097/MD.0000000000003418.
- Tang L, Liu S, Bao YC, Gao RX, Han CF, Sun XC, Zhang WL, Feng SQ. Study on the relationship between vitamin D deficiency and susceptibility to spinal tuberculosis. Int J Surg. 2017 Aug;44:99-103. doi: 10.1016/j.ijsu.2017.05.077. Epub 2017 Jun 16.
- Yu, Fang & Cailiang, Shen. (2019). Effect of vitamin D combined with anti-tuberculosis drugs on serum IL-1β, IFN-γ and TH17 cell-associated cytokines for the management of spinal tuberculosis. Tropical Journal of Pharmaceutical Research. 18. 1141-1147. 10.4314/tjpr.v18i5.32.
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