Clin Rheumatol
DOI 10.1007/s10067-014-2713-0
BRIEF REPORT
25-hydroxy vitamin D and its relationship with clinical
and laboratory parameters in patients with rheumatoid arthritis
F. E. Abourazzak & S. Talbi & N. Aradoini & K. Berrada &
S. Keita & T. Hazry
Received: 15 January 2014 / Revised: 30 May 2014 / Accepted: 3 June 2014
# Clinical Rheumatology 2014
Abstract The objective of this study is to evaluate the prev-
alence of vitamin D insufficiency in patients with rheumatoid
arthritis (RA) and its association with disease activity, severity
and physical disability. We included patients with rheumatoid
arthritis followed in Rheumatology Department of Hassan II
University Hospital, Fez, Morocco. Patients suffering from
liver and kidney insufficiency and those who had received
vitamin D in the previous 12 months have been excluded.
Statistical analysis was done using SPSS v 18. A bivariate
analysis and logistic regression were used to identify factors
associated with vitamin D deficiency. One hundred seventy
patients were included with a mean age of 50±12.1 [17–83]
years, and a female predominance (88.1 %). All of our patients
had hypovitaminosis D. The prevalence of 25(OH)-D insuffi-
ciency and deficiency was 64.5 and 35.5 % successively. In
unadjusted analysis, vitamin D concentration was inversely
associated with pain visual analog scale VAS score (p<0.001),
asthenia VAS (p<0.001), morning stiffness (p=0.03), number
F. E. Abourazzak (*) : S. Talbi : N. Aradoini : K. Berrada :
T. Hazry
Rheumatology Department, Hassan II University Hospital, Fez,
Morocco
e-mail: f.abourazzak@yahoo.fr
S. Talbi
e-mail: talbi-sofia1@hotmail.fr
N. Aradoini
e-mail: naradoini@netcourrier.com
K. Berrada
e-mail: khadija_medica@hotmail.com
T. Hazry
e-mail: t_harzy@yahoo.fr
S. Keita
Epidemiology Department, Hassan II University Hospital, Fez,
Morocco
e-mail: saliakeil@gmail.com
of tender joints (p = 0.004), number of swollen joints
(p<0.001), inflammatory markers (p=0,012), Disease Activ-
ity Score (p=0.009), physical disability using Health Assess-
ment Questionnaire (HAQ) (p=0.001), and severity of the
disease (p<0.001). After logistic regression persisted associ-
ation with female sex (OR=4.3, CI=[0.94 to 20.976], p=
0.05), asthenia VAS (OR=1.029, CI=[1.011 to 1.046], p=
0.001), and with the severity of the disease (OR=2.910,
CI=[1.314–6.441], p=0.008). The vitamin D deficiency is
common in our patients with RA. This deficiency is associated
with female sex, severe asthenia, and the severity of the
disease.
Keywords Disease activity . Disease severity . Rheumatoid
arthritis . Vitamin D
Introduction
The past decade has seen a growing realization that vitamin D
is not just a vitamin, but a steroid hormone controlling the
intestinal absorption of calcium and phosphorous and mineral
metabolism. It has been suggested that vitamin D in its phys-
iologically active form (1,25(OH)2D3) has immunoregulatory
activities [1]. Vitamin D can inhibit the synthesis of mRNA of
macrophages-derived cytokines such as IL-1, IL-6, IL-12, and
tumor necrosis factor alpha (TNF-alpha), decrease the
antigen-presenting activity of macrophages to lymphocytes
and suppress the IL-2 secretion of Th1 cells [2]. Likewise,
vitamin D receptors (VDR) are constitutively expressed on
activated lymphocytes, synoviocytes, macrophages, and
chondrocytes in the rheumatoid arthritis (RA) lesions [3].
Also, vitamin D metabolites are increased in RA synovial
fluid [4]. 25 (OH) Vitamin D deficiency is reported to be
common in patients with rheumatoid arthritis (RA) [5]. It
has been demonstrated in the Women’s Iowa Health Study

with data from 29,368 women that vitamin D intake was
inversely associated with the risk of rheumatoid arthritis [6].
This deficiency is also reported to be associated with disease
activity [7–11], and physical disability [7, 12] in patients with
RA.
In Morocco, most of the women even unveiled wear a scarf
and a Djellaba which is a long, loose-fitting, and hooded
garment with long sleeves that is worn over casual clothes.
Thus, their sunlight exposure might be insufficient. In light of
the increased prevalence of hypovitaminosis D in our popu-
lation and the reported associations with risk for and disease
progression of RA, we examined the prevalence of vitamin D
insufficiency/deficiency and its associations with disease ac-
tivity, severity, and physical disability of RA in patients with
RA.
Materials and methods
Patients
We included in this cross-sectional study patients with RA
diagnosed according to ACR 1987 or ACR/EULAR clas-
sification criteria at the Rheumatology Department of
Hassan II University Hospital, Fez, Morocco. All of pa-
tients suffering from liver and kidney insufficiency and
those who had received vitamin D in the previous
12 months were excluded.
Rheumatoid arthritis characteristics
Disease-specific variables were collected: disease dura-
tion, duration of morning stiffness, patient, and physi-
cian’s assessment of pain and fatigue by the visual ana-
logue scale (VAS 0-100), tender and swollen joint count,
anti-cyclic citrullinated peptide antibody (anti-CCP) posi-
tivity, rheumatoid factor positivity, the presence or ab-
sence of radiographic erosions detected on plain radio-
graphs of hands, and drug use (DMARDS, biotherapy,
glucocorticoid).
The Disease Activity Score including 28 joints (DAS28)
was used. A score of DAS28 between 2.6 and 3.2 indicates
low disease activity, between 3.2 and 5.1 indicates moderate
activity, and >5.1 a high disease activity. The disease severity
was assessed by the presence of two or more of the following
criteria: acute onset, extra-articular manifestations, high level
of rheumatoid factor and anti-CCP, early erosions, important
biologic inflammation. To evaluate functional disability, we
used the health assessment questionnaire HAQ. The HAQ
score can range from 0 (no disability) to 3 (greatest possible
disability).
Clin Rheumatol
Vitamin D Status
The vitamin D serum concentrations were expressed as
nanogram per milliliter (ng/ml). According to the GRIO
recommendations, 25(OH)-D insufficiency was defined as
25(OH) vitamin D ranging from 10 to 30 ng/ml, and
deficiency as 25(OH) vitamin D <10 ng/ml [13]. Serum
25 (OH) vitamin D levels were measured using CMIA
method (chemiluminescence immune assay technique),
ARCHITECT PLUS.
Statistical Analysis
Statistical analysis was done using SPSS v 18. We ana-
lyzed first the descriptive section, then the associations
of vitamin D deficiency with different parameters (dis-
ease activity and severity) using univariate regression
analysis. After that, a multivariate analysis and logistic
regression were used to identify factors associated with
vitamin D deficiency. Significant level was considered to
be p≤0.05.
Results
The sociodemographic and clinical characteristics
We included 170 patients with a mean age of 50±12.1 [17–
83] years. Most of patients were female (88.2 %). Patients had
mean disease duration of 7.6±5.7 [1–29] years. Anti-CCP
antibody were positive in 77.5 %, and 81.7 % were RF
positive, while 73.4 % had erosions detected on plain radio-
graphs of hands. A majority of patients (67 %) had received
glucocorticoid therapy, 78 % were receiving DMARDs, and
30 % were receiving biotherapy.
Prevalence of vitamin D insufficiency and deficiency
Vitamin D levels were found to be reduced in all of our
patients, with 35.5 % having deficiency and 64.5 % having
insufficiency.
Associations between vitamin D and disease activity
and severity parameters
Characteristics of patients with RA who had vitamin D
insufficiency and deficiency are presented in Table 1. In
univariate analysis, vitamin D concentrations were in-
versely associated with pain VAS score (p<0.001), asthe-
nia VAS (p<0.001), duration of morning stiffness (p=
0.03), number of tender joints (p = 0.004), number of
swollen joints (p < 0.001), inflammatory markers (p =
Clin Rheumatol

Table 1 Characteristics of pa-

tients with vitamin D deficiency Characteristics Vitamin D deficiency Vitamin D insufficiency P
and vitamin D insufficiency n=109 n=61

Sociodemographic and health measures

Age (years) 51.50±12.03 50.08±12.29 NS
Femel (%) 96 83.5 0.012
Duration of RA at enrollment (years) 8±6 7.3±5.5 NS
RA-related measures
Pain VAS (0-100) 60.25±22.8 40.37±28.3 0.008
Asthenia VAS (0–100) 59±18.7 41±23.4 <0.001
Morning stiffness (min) 76.1±48.2 57.3±58 0.03
Tender joint count (0–28) 15.42±8.87 9.04±10.44 <0.001
Swollen joint count (0–28) 7.58±6.3 4.50±7.1 0.004
ESR(mm/h) 47.12±29.4 36.08±25.7 0.012
Active disease (DAS28≥2,6)(%) 68.3 42.2 0.009
Severity of the disease (%) 70 46.8 <0.001
HAQ (% of disability) 55 25.7 0.001
Anti-CCP antibody-positive (%) 80 76.1 NS
RF-positive (%) 86.7 78.9 NS
Medication use
DMARDs (%) 73.3 81.7 NS
Biologic therapy (%) 31.7 29.4 NS
Prednisone (%) 71.7 64.2 NS

0.012), Disease Activity Score (DAS-28) (p = 0.009), Discussion

physical disability (HAQ) (p=0.001), and severity of the
disease (p<0.001) (Fig. 1). However, there was no signif-
icant correlation between vitamin D and age, disease
duration of RA, immunological tests, radiological erosion,
and treatments. After logistic regression and adjusting on
age persisted association with female sex (OR = 4.3,
CI=[0.94 to 20.976], p=0.05), with asthenia VAS (OR=
1.02, CI=[1.01 to 1.04], p=0.001), and with the severity
of the disease (OR=2.91, CI=[1.31-6.44], p=0.008).
Our data confirm that vitamin D deficiency is common in our
Moroccan patients with RA. Vitamin D levels were found to
be reduced in all of our patients, with deficiency in 35.5 % of
cases and insufficiency in 65.5 % of cases. This result is in
agreement with previous reports on patients with RA from
other ethnic groups. Indeed, studies report a prevalence of
vitamin D deficiency ranging from 30 to 63 % [5, 14, 15].
Vitamin D has a very important role in immunity. It decreases

Fig. 1 Results of univariate 120

analysis
100

80

60

40

20

0
Femal Disease severity of HAQ Asthenia Pain VAS
Acvity the disease VAS
Score-28

Vitamin D deficiency Vitamin D Insufficiency


the proliferation of activated lymphocyte B expressing VDR,
inhibits T cell proliferation and differentiation, inhibits the
Th1 response (IL2, and interferon gamma), stimulate Th2
response by increasing the production of IL-5 and IL-10, as
well as indirectly by diminishing the production of interferon
gamma, inhibits the Th17 response (IL17) by blocking the
production of IL6 and IL23, and stimulates Treg induction by
increased IL10 production by dendritic cells [14, 16]. In
summary, vitamin D inhibits the Th1 and Th17 proinflamma-
tory responses and promotes the Th2, and Treg,
immunomodulating responses. The net result is downregula-
tion of the effector T-cell immune response. In consequent,
vitamin D deficiency could contribute to the increased levels
of proinflammatory cytokines (IL6, IL17, interferon gamma,
TNF alpha…) observed in RA. Further, studies suggest that
vitamin D supplementation prevents the initiation and pro-
gression of inflammatory arthritis, and vitamin D supplemen-
tation has been proposed to induce immune tolerance and
prevent the development of autoimmune diseases, particularly
RA [17]. Vitamin D plays a very important role in the reduc-
tion of inflammation, including suppression of prostaglandin
(PG) action, inhibition of p38 stress kinase signaling, and the
subsequent production of proinflammatory cytokines and in-
hibition of NF-κB signaling [16].
In our study, we observed a significant association between
vitamin D deficiency and female gender. Previous studies
have shown that RA patients with vitamin D deficiency are
more likely to be female [8–10]. In addition, vitamin D
deficiency in Moroccan women seems to be strongly related
in our context to poor sunlight exposure and excessive out-
door clothing due to sociocultural and religious reasons [18].
Also, in multivariate analysis, vitamin D deficiency was
significantly associated with asthenia VAS and severity of
RA. This result may not be surprising because previous stud-
ies have recognized that vitamin D deficiency can cause
diffuse pain and muscle weakness [19, 20], and some have
even suggested that patients with chronic pain should be
routinely screened for hypovitaminosis D [21]. The interpre-
tation of these findings is difficult. While vitamin D deficiency
might influence pain, it is also likely that pain can affect
vitamin D status by influencing physical capacity. Indeed,
severe disease with inflammatory pain and asthenia was noted
in our patients. That may conduct to disability and limit their
daily activities, conducting to less length of time spent outside
and then to less sunlight exposure. On the other hand, Craig
and al concluded in their study that there were no strong
associations of 25 (OH) D concentrations with disease sever-
ity [8]. This association was not analyzed in others studies [22,
23].
Poor data related to associate factors in multivariate analy-
sis exist in the literature. We will be interested to results in
univariate analysis. In our study, we demonstrated that pa-
tients with a very low level of serum vitamin D had very high
Clin Rheumatol
levels of erythrocyte sedimentation rate. This finding is in
agreement with previous reports [10]. It can be explained by
antiinflammatory effects of vitamin D. In inverse, no associ-
ation between 25(OH)D and the CRP level or the ESR was
found in other studies [13, 15]. Haque et al. reported that 25
(OH) D levels were inversely associated with active RA
(DAS28≥2.6) in 62 RA patients [9], and we confirmed these
results in our study. The association between vitamin D defi-
ciency and DAS28 was not observed in two studies [10, 11].
Recently, the combination of antirheumatic drugs with vita-
min D has been suggested for RA [8, 16]. Vitamin D supple-
mentation has been proposed for patients with RA for the
prevention and treatment of osteoporosis as well as for its
possible effects on disease activity [24]. No relationship was
found between 25(OH)D and rheumatoid factor or anti-cyclic
citrullinated peptide antibodies positivity. This finding is in
agreement with others studies [25]. Several previous studies
reported that HAQ disability score is significantly inversely
associated with 25(OH)D levels [7–10]. Most of these previ-
ous studies used univariate analysis, which is consistent with
our study [8, 9]. On the other hand. there was no association of
vitamin D status with treatment of RA. This is an expected
result because we found no correlation after multivariate anal-
ysis between vitamin D deficiency and disease activity espe-
cially with DAS 28. In a recent study, the authors could not
demonstrate an association between baseline vitamin D level
and response to therapy in RA which can be explained by the
absence of association between vitamin D and DAS28 at
baseline [11].
In our study, there were a number of limitations mainly
related to the absence of a control group which could make
stronger our findings. We were limited to a comparison be-
tween RA patients with vitamin D insufficiency and deficien-
cy. Also, this is a cross-sectional study, and we cannot address
whether vitamin D status has any longer-lasting effects in RA
patients. Our population includes only patients with vitamin D
insufficiency or deficiency. This could explain the absence of
association between vitamin D status and disease activity in
multivariate analysis.
Despite its limitations, the study has notable strengths. We
consider clinical and laboratory assessment measurements of
disease activity and severity in patients with RA, examine
their relationship with vitamin D status, and we conduct a
multivariate analysis. This methodology makes our results
stronger comparing to a lot of similar studies that have
assessed vitamin D status in RA.
Conclusion
Vitamin D deficiency appears to be common in our Moroccan
patients with RA, as previously reported for patients of other
ethnicities. This deficiency is associated with female sex,
Clin Rheumatol
severe asthenia, and the disease severity. We suggest that with
the increasing adverse health outcomes associated with
hypovitaminosis D, screening and supplementation should
be performed routinely in the RA patient population. There
is presently no evidence that supplementation therapy with
vitamin D may have an effect on the treatment effect or
outcome in RA patients. However, more studies are needed
to support our data, and this calls for prospective studies on the
effect of vitamin D on the treatment of RA.
Disclosure None.
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