key: cord-0865352-29hw69ki
authors: Wenban, Charlotte; Heer, Randeep S.; Baktash, Vadir; Kandiah, Pirabakaran; Katsanouli, Theodora; Pandey, Asmita; Goindoo, Ryan; Ajaz, Afiyah; Van den Abbeele, Koenraad; Mandal, Amit K. J.; Missouris, Constantinos G.
title: Dexamethasone treatment may mitigate adverse effects of vitamin D deficiency in hospitalized Covid‐19 patients
date: 2021-08-11
journal: J Med Virol
DOI: 10.1002/jmv.27215
sha: 158628329c557b990d7975b5597412b123d27433
doc_id: 865352
cord_uid: 29hw69ki

AIMS: We have previously demonstrated that vitamin D deficiency might be associated with worse outcomes in hospitalized Covid‐19 patients. The aim of our study was to explore this relationship with dexamethasone therapy. METHODS: We prospectively studied two cohorts of hospitalized Covid‐19 patients between March and April and between September and December 2020 (n = 192). Patients were tested for serum 25‐hydroxyvitamin D (25‐OH‐D) levels during admission. The first cohort not treated with dexamethasone (n = 107) was divided into vitamin D deficient (25‐OH‐D ≤ 30 nmol/L) (n = 47) and replete subgroups (25‐OH‐D > 30 nmol/L) (n = 60). The second cohort treated with dexamethasone (n = 85) was similarly divided into deficient (25‐OH‐D ≤ 30 nmol/L) (n = 27) and replete subgroups (25‐OH‐D > 30 nmol/L) (n = 58). Primary outcome was in‐hospital mortality and secondary outcomes were elevation in markers of cytokine storm and ventilatory requirement. RESULTS: No mortality difference was identified between cohorts and subgroups. The “no dexamethasone” cohort 25‐OH‐D deplete subgroup recorded significantly higher peak d‐Dimer levels (1874 vs. 1233 µgFEU/L) (p = 0.0309), CRP (177 vs. 107.5) (p = 0.0055), and ventilatory support requirement (25.5% vs. 6.67%) (p = 0.007) compared to the replete subgroup. Among the 25‐OH‐D deplete subgroup higher peak neutrophil counts, peak CRP, peak LDH, peak ferritin, and lower trough lymphocyte counts were observed, without statistical significance. In the “dexamethasone” cohort, there was no apparent association between 25‐OH‐D deficiency and markers of cytokine storm or ventilatory requirement. Conclusion: Vitamin D deficiency is associated with elevated markers of cytokine storm and higher ventilatory requirements in hospitalized Covid‐19 patients. Dexamethasone treatment appears to mitigate adverse effects of vitamin D deficiency.

The emergence of coronavirus disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has fueled global efforts to identify risk factors for adverse outcomes, of which vitamin D is one potential marker subject to scientific interest.

Vitamin D is a secosteroid with important immunomodulatory, antiinflammatory, antifibrotic, and antioxidant actions. There is growing evidence of a relationship between vitamin D insufficiency and worse outcomes in Covid-19. 1 Indeed, Covid-19 hospitalization and mortality rates appear to be higher at northern latitudes compared with equatorial regions and the disease disproportionately affects people from ethnic minorities. These factors may suggest correlation between sun exposure, vitamin D levels, and Covid-19 outcomes. 2, 3 We previously assessed the potential relationship between vitamin D deficiency and Covid-19 disease severity in hospitalized adults and demonstrated that patients with lower serum concentrations of vitamin D during active Covid-19 were more likely to develop features of cytokine storm and require ventilatory support. 4 The RECOVERY trial 5 demonstrated a reduction in all-cause reduction in mortality amongst Covid-19 patients after 28 days treated with dexamethasone. In light of these data, we aimed to identify the impact of dexamethasone therapy on the association between vitamin D deficiency and Covid-19 severity, as defined by markers of cytokine storm and ventilatory requirement in hospitalized patients.

Patients treated for active Covid-19 at our institution were recruited during two separate time periods. Active Covid-19 infection was defined as those with positive real-time reverse-transcriptase polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 on nasopharyngeal swab or those being treated for Covid-19 on clinical and radiological evidence. 6 During the first recruitment period between March 2020-April 2020, no patients received dexamethasone for Covid-19. In the second recruitment period between October 2020-December 2020, standard treatment for Covid-19 in patients with an oxygen requirement was 6 mg dexamethasone daily for 7-10 days.

Patients were grouped into those who received dexamethasone and those who did not. Each group was subsequently divided into subgroups for vitamin D-deficient (25-OH-D ≤ 30 nmol/L) and -replete (25-OH-D > 30 nmol/L), as per national guidelines and local laboratory standards. 7 Patients found vitamin D-deficient were supplemented in accordance with national guidelines.

Patient demographics and comorbidities were extracted from patient records. Vitamin D (25-OH-D) levels were measured for all patients during admission. Biochemical/hematological markers of cytokine storm measured throughout the admission were recorded, including peak values for neutrophils, C reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, troponin T, D-dimer, and trough values for lymphocyte count. The primary outcome was in-hospital mortality whilst secondary outcomes included ventilatory support (defined as continuous positive airway pressure, non-invasive ventilation, or mechanical invasive ventilation) and laboratory markers of cytokine storm.

All statistical analyses were performed on GraphPad Prism version 8.

Continuous variables were assessed for normality using Shapiro-Wilk and Kolmogorov-Smirnov tests and tested for significance with either an unpaired t test if parametric or a Mann-Whitney U test if non-parametric. If possible, outcome sets were normalized by logarithmic transformation and tested for significance using a parametric method. A p < 0.05 (two-tailed test) was considered statistically significant. 

During both recruitment periods, a total of 192 Covid-19 patients were recruited to the study; 85 patients (44%) received dexamethasone and 107 patients (56%) did not ( Figure 1 ). In the "dexamethasone" group", 27 patients had 25-OH-D levels ≤30 nmol/L, with 58 patients having levels >30 nmol/L. In the "no dexamethasone" group, 47 patients were found to have a 25-OH-D level ≤30 nmol/L, while 60 had levels >30 nmol/L.

Overall, the mean age of the entire study population was 77.7 years ±12.2. Demographics (age, gender, frailty, and body mass index) and comorbidities between the "dexamethasone" and "no dexamethasone groups" and between the subgroups divided by 25-OH-D levels were comparable (Table 1) . Among the entire cohort, only 7 patients required treatment in the intensive care unit (ICU).

There was no significant difference in mortality rate between all groups or subgroups. In the "no dexamethasone" group, low 25-OH-D levels were associated with statistically significant higher peak CRP (177 vs. 107.5 mg/L, p = 0.006) and D-dimer (1874 vs.

1233 µgFEU/L, p = 0.03) values ( Table 2 ). The low 25-OH-D subgroup produced higher peak neutrophil counts, peak LDH, peak ferritin, and lower trough lymphocyte counts without reaching statistical significance. Amongst patients with lower 25-OH-D levels, there was a greater incidence in ventilatory requirement (25.5% vs.

6.67%, p = 0.007). However, in the "dexamethasone" group, there was no apparent association between 25-OH-D deficiency and markers of cytokine storm, including neutrophils, CRP, LDH, ferritin, troponin T, D-dimer, and lymphocytes; or ventilatory requirement. Rockwood Frailty Score Median (IQR) 6 (6-7) 6 (4-6) 0. 

We have previously demonstrated that, in the absence of dexamethasone therapy, patients with vitamin D deficiency recorded increased markers of cytokine storm release (namely CRP and D-dimer) which are associated with severe Covid-19. Furthermore, low vitamin D levels were associated with worsened patient outcomes defined by ventilatory requirement. 4 Our current data suggest that, in the presence of dexamethasone, the impact of vitamin D deficiency on cytokine storm markers and ventilatory requirement is reduced. Both legs of our study were performed in the same center and given similarities in demographics and comorbidities between patient populations treated with and without dexamethasone, it is likely that dexamethasone independently mitigates the effects of vitamin D deficiency on cytokine storm and ventilatory requirements.

Vitamin D is a secosteroid synthesized in the skin, liver, and kidneys, and its active hormone, 1,25(OH) 2 D 3 , controls phosphate and calcium homeostasis under physiological conditions. As well as being essential for musculoskeletal health, vitamin D plays an important role in interacting with the innate and adaptive immune system. This study adds to the growing body of evidence that vitamin D deficiency is associated with worsened outcomes in Covid- 19 . As yet, the underlying pathophysiological mechanism have not been fully elucidated. It has been postulated that vitamin D switches the adaptive immune reaction phenotype 8,9 and downregulates differentiation into proinflammatory Th17 cells, 10, 11 which may reduce the cytokine storm in Covid-19. Vitamin D also exerts a protective effect on alveolar cells by preserving endothelial integrity and reducing vascular permeability. 12 Combined evidence suggests that dexamethasone should be considered standard of care for critically ill patients with Covid-19 pneumonitis requiring supplemental oxygen therapy or ventilatory support. Dexamethasone is presently the only corticosteroid to show a statistically significant reduction in all-cause mortality at 28 days. 13 The mortality benefit was specifically recognized in patients with supplemental oxygen or mechanical ventilatory requirements.

Dexamethasone is a corticosteroid used in a range of conditions for its anti-inflammatory and immunosuppressive properties with which are mediated by an intracellular vitamin D receptor (VDR). 15 The VDR regulates a variety of metabolic pathways including those involved in the immune response. 16 Both vitamin D and dexamethasone share many VDR pathways. 17 On the basis of these shared VDR attributes, it is reasonable to assume that interplay be- As a study with a limited sample size, the power of our results is reduced. Even though statistical significance was achieved for certain variables, the lack of significance in others does not necessarily mean that there was no association; instead, it may be attributed to the small sample size. Since multiple comparisons were performed in this study, the likelihood of observing a significant difference due to chance is increased. In addition, outcomes may have also been influenced by the changing local and national protocols on management of Covid-19. 20 We acknowledge that data collection through medical notes requires individual interpretation of those records which despite best efforts, may not demonstrate the full clinical picture. Data collection was performed by more than one individual to reduce such interpretation bias.

We understand that sun exposure may affect the levels of vitamin D and unfortunately, it was a factor we could not accurately quantify or account for. 21 Our study recruited patients over a 5-month period during which exposure to sunlight greatly varied.

Our study demonstrates that dexamethasone therapy may lessen adverse effects of vitamin D deficiency in terms of cytokine release and ventilation requirement in hospitalized patients with Covid-19. However, it is undisputed that vitamin D is a safe and cost-effective intervention with multiple health benefits and efforts to achieve reference nutrient intakes should be encouraged. Further research might focus on the impact of Vitamin D supplementation in the community and the prevention of hospitalization of Covid-19 patients.

Low vitamin D status is associated with coronavirus disease 2019 outcomes: a systematic review and meta-analysis

Ethnicity and clinical outcomes in COVID-19: a systematic review and meta-analysis

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25-Dihydroxyvitamin D3 has a direct effect on naive CD4+ T cells to enhance the development of Th2 cells

Calcitriol suppresses antiretinal autoimmunity through inhibitory effects on the Th17 effector response

Immune modulatory treatment of trinitrobenzene sulfonic acid colitis with calcitriol is associated with a change of a T helper (Th) 1/Th17 to a Th2 and regulatory T cell profile

Dietary vitamin D and its metabolites non-genomically stabilize the endothelium

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Dexamethasone enhances 1α,25-dihydroxyvitamin D3 effects by increasing vitamin D receptor transcription*

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Dexamethasone treatment May mitigate adverse effects of vitamin D deficiency in hospitalised Covid-19 patients

The authors declare that there are no conflict of interests.

This study was approved by our institution's Research, Quality Improvement, and Audit Department with reference FH119. This study does not fall under the remit of the National Health Service Research Ethics Committees. This statement is also present in the methods section of our manuscript. It was not appropriate or possible to involve patients or the public in the design, or conduct, or reporting, or dissemination plans of our research. 

The data that support the findings of this study are available from the corresponding author upon reasonable request.

http://orcid.org/0000-0002-4416-7393Randeep S. Heer http://orcid.org/0000-0002-6094-6389Amit K. J. Mandal http://orcid.org/0000-0003-0986-5927