Redefining the Role of Vitamin D

- A Multifaceted Entity in Health and Disease

Dr Anoosha P Bhandarkar
Diabetologist, Dharwad

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Table Of Contents

DeMystify Sunshine Vitamin D Basics

DeCoding Association Of Vitamin D & Comorbidities

DeScribing Management of Vitamin D deficiency

DeLineate Nanotechnology & Vitamin D

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DeMystify Sunshine Vitamin
Vitamin D Basics

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Vitamin D: The Sunshine Vitamin
Sunlight: Best source of Dietary sources of
Vitamin D 1 Vitamin D2
• UV-B photons ((290–315 nm) causes
photolysis of 7-dehydrocholesterol to
previtamin D3

• At 37 °C, 80% of previtamin D3 is

converted to vitamin D3 within 8 hrs

• Vitamin D3 releases into the

extracellular space and binds to DBP
Only vegetarian source:
Sun-exposed mushrooms 2

ABUNDANT SUNSHINE: Exposing 18% of body surface area to mid day sun for 30-45 minutes
(without sunscreen) for obtaining Vitamin D 3.
1. Wacker M, Holick MF. Sunlight and Vitamin D: A global perspective for health. Dermatoendocrinol. 2013 Jan 1;5(1):51-108. doi:
10.4161/derm.24494. PMID: 24494042; PMCID: PMC3897598.
2. Ritu G, Gupta A. Vitamin D Deficiency in India: Prevalence, Causalities and Interventions. Nutrients 2014, 6, 729-775
3. Srinivasa PM, Harinarayan CV. Vitamin D deficiency in India: fortify or let the sun shine in. Journal of Clinical and Scientific Research.
Proprietary and confidential — do not distribute 2015;4(3):220-6. | 04/09/202 | 4
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Vitamin D Metabolism And Function
Sunshine Diet

Vitamin D
Storage Liver Extra-renal
Liver, muscle & 25-hydroxyvitamin D3 Skin, colon, brain, lymph
25(OH)D3
adipose tissue nodes and pancreas
Kidney
Increased Secretion
1,25(OH)2D3
Low Calcium Levels
Calcitroic acid
Effects
Decreases\
secretion Excreted in
Parathyroid gland
urine or bile

Regulation Of Calcium Action on Vitamin D

metabolism receptor (VDR)

Intestinal Calcium Calcium bone Muscle Immune

absorption resorption strength function Bone health

Laird E, Ward M, McSorley E, Strain JJ, Wallace J. Vitamin D and bone health: potential mechanisms. Nutrients. 2010 Jul;2(7):693724. doi:
Proprietary and confidential — do not distribute 10.3390/nu2070693. Epub 2010 Jul 5. 04/09/202 | 5
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Do Indians have sufficient levels of Vitamin D ????
Retrospective analysis of records of 4624 patients across India
Up to 76.9 Indians have
insufficient Vitamin D levels!!!!
Highest incidence of Vitamin
D insufficiency:
Age group: 18 – 30 years

Vitamin D insufficiency
marginally higher in males
(77.3%) than females (76.5%)

Proprietary and confidential — do not distribute Goel S. Vitamin D status in Indian subjects: a retrospective analysis. Int J Res Orthop. 2020 May;6(3):603-610 | 04/09/202 | 6
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Decoding challenge of daily dose of Vitamin D from
Sun and Diet
Best time to soak yourself in the sun: 10 am to 3 pm: people are usually busy
at this time

Indians have a darker skin tone (more melanin pigment) and need a
prolonged exposure (~ 45-60 min)

Lack of Vitamin D fortified foods in India

Diet is a poor source of Vitamin D – need for additional supplementation to

bridge the nutritional gap!

https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/the-right-way-to-get-vitamin-d-from-the-sun/
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 Risk Factors of Vitamin D Deficiency

Advanced age Institutionalized Use of sunscreen Heavily pigmented

or home-bound with sun protection skin
factor 15

Air pollution Prolonged, Northern latitudes Smoking

exclusive
breastfeeding

Obesity Malabsorption Renal or liver Antiepileptic or HIV

syndromes disease medications

1. Mcgreevy et al. New insights about vitamin D and cardiovascular disease: a narrative review: Ann Intern Med. 2011 Dec
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Factors affecting Vitamin D status

Reduction In UV-B Radiations

• Aerosols, water vapour, particulate pollutants and cloud matter.
• Black carbon particulates generated in urban places reduces surface UV –B radiation

Ageing
• An age-related decline in skin 7-dehydrocholesterol content.
• Intestinal resistance of calcium absorption to circulating 1,25(OH)2D
• Decreased renal production of 1,25(OH)2D by the aging kidney

Melanin pigmentation
• Melanin competes with 7-dehydrocholesterol for UVB photons

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Factors affecting Vitamin D status

Alcohol Consumption1
• Effects metabolism of vitamin D by depleting enzymes involved in converting 25
(OH)D3 to 1, 25 (OH)2 D3

Smoking2
• Metabolic derivatives of nathphalane, a metabolite in cigarette smoke can inhibit
CYP27A1, which converts vitamin D into 25(OH)D, the major circulating form

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1. Ogunsakin O, Hottor T, Mehta A, Lichtveld M, McCaskill M. Chronic ethanol exposure effects on vitamin D levels among
subjects with alcohol use disorder. Environmental health insights. 2016 Jan;10:EHI-S40335.
2. Kim SH, Oh JE, Song DW, Cho CY, Hong SH, Cho YJ, Yoo BW, Shin KS, Joe H, Shin HS, Son DY. The factors associated with
Vitamin D deficiency in community dwelling elderly in Korea. Nutrition research and practice. 2018 Oct 1;12(5):387-95.| 04/09/202 | 10
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Factors affecting Vitamin D status

Any process resulting in malabsorption of

Gastrointestinal absorption of vitamin D intestinal fat may impair the absorption of
vitamin D
1 Gastric, pancreatic and biliary secretions,
• Celiac disease
2 Micelle formation • Biliary obstruction absorption
• Chronic pancreatitis
3 Diffusion through the unstirred-water layer
• Cystic fibrosis
4 Brush-border-membrane uptake • Crohn’s disease
• Gastric bypass.
5 Transport out of the intestinal cell • Individuals taking bile acid-binding
medications (such as colestyramine and
colestipol for hypercholesterolemia)

Proprietary and confidential — do not distribute Tsiaras W, Weinstock MA. Factors influencing vitamin D status. Acta dermato-venereologica. 2011 Feb 7;91(2):115-24. | 04/09/202 | 11
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Factors affecting Vitamin D status
Two Possible Mechanism Linking OBESITY & Vitamin D

1. Obesity leads to low 2. Low Vitamin D status leads

Vitamin D status to obesity
Adipose tissue accumulation Lower 25(OH)D levels promote lower
absorb and sequestrate vitamin D, calcium absorption increase in PTH
which is fat-soluble, decreasing calcium influx into the adipocytes.
circulating 25(OH)D
Intracellular calcium enhances
lipogenesis

Kim SH, Oh JE, Song DW, Cho CY, Hong SH, Cho YJ, Yoo BW, Shin KS, Joe H, Shin HS, Son DY. The factors associated with
Proprietary and confidential — do not distribute Vitamin D deficiency in community dwelling elderly in Korea. Nutrition research and practice. 2018 Oct 1;12(5):387-95.| 04/09/202 | 12
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Diagnostic cut off levels for Vitamin D

< 20ng/ml Deficiency

21-29 ng/ml Insufficiency
Greater than 30 Sufficiency

Institute of Medicine (IOM) committee

Endocrine society of Clinical guidelines

1. Mithal A et al Vitamin D deficiency in India. Recommendation for prevention & treatment: Endocrine society of India
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 Preferential Range Of Vitamin D levels

Results from multiple studies regarding the association

>40 ng/ml Preferred Range2
between 25(OH)D and various diseases.1

Optimize Cell-level Physiology

Ensures skeletal and extra-

skeletal benefits

Maximum benefit for

reduced all-cause mortality
has been observed at 40 to Significant reductions in disease risk
60 ng/mL3 at >40 ng/ml levels.

https://vitamindwiki.com/Vitamin+D+charts+from+GrassrootsHealth+-+May+2016. Last accessed on 03Jan,2022. 2. Heaney

RP. Toward a physiological referent for the vitamin D requirement. Journal of endocrinological investigation. 2014
Proprietary and confidential — do not distribute Nov;37(11):1127-30. 3. Hollick MF. The Death D-fying Vitamin. Mayo Clin Proc. 2018 Jun;93(6):679-681 | 04/09/202 | 14
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Signs and Symptoms for Vitamin D Deficiency

Majority of people with

Vitamin D deficiency do not Chronic Chronic Low Vague Aches
present with any symptoms! Fatigue Back Ache and Pains

However, a few may present

with non-specific signs
Repeated upper Depressed
respiratory Mood
infections

Zhang R, Naughton DP. Vitamin D in health and disease: Current perspectives. Nutrition Journal 2010, 9:65
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Ritu G, Gupta A. Vitamin D Deficiency in India: Prevalence, Causalities and Interventions. Nutrients 2014, 6, 729-775
| 15
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Laboratory & Radiographic Findings for Vitamin D
Deficiency
Laboratory Radiographic
• Low 24-hour urine calcium excretion • Decreased bone mineral density
(in the absence of thiazide use) (osteopenia or osteoporosis)
• Elevated parathyroid hormone level • Nontraumatic (fragility) fracture
• Elevated total or bone alkaline • Skeletal pseudo fracture
phosphatase level
• Low serum calcium and/or serum
phosphorus level

Kennel KA, Drake MT, Hurley DL. Vitamin D deficiency in adults: when to test and how to treat. Inmayo clinic proceedings
Proprietary and confidential — do not distribute 2010 Aug 1 (Vol. 85, No. 8, pp. 752-758). Elsevier. | 04/09/202 | 16
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Diagnostic Methods to assess Vitamin D levels

Methods used to assess serum Serum 25 (OH) D level is

Vitamin D levels preferred

• Competitive protein-binding (CPB) assays • Longer half life of about 3 weeks

• Radioimmunoassays (RIA) • Stronger affinity to D-binding
• Chemiluminescence immunoassays (CLIA) proteins

• Liquid chromatography (LC) with UV detection • Higher blood concentration than

other metabolites
• Liquid chromatography-mass spectrometry (LC-
MS) or tandem mass spectrometry (LC-MS/MS) • Represents convergence of all forms
[Gold Standard] of vitamin D

Stokes CS et al. Analytical Methods for Quantification of Vitamin D and Implications for Research and Clinical Practice.
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DeCoding
Association Of Vitamin D
& Comorbidities

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Prevalence of Vitamin D deficiency in Diabetes
and Hypertension
Adults with a diagnosis of Type 2 DM and hypertension enrolled across 29 sites to evaluate
prevalence of Vitamin D deficiency among diabetics and hypertensives.

Prevalence of vitamin D
Prevalence Of Vitamin D Deficiency
defiecncy
Hypertensive 82.6 % Hypertension

Diabetics 84.2%
Type 2 Diabetes Mellitus

0 20 40 60 80 100 120
Vitamin D deficiency Series 2

PG Talwalkar, Vaishali Deshmukh, M.C. Deepak. Prevalence and Clinico-Epidemiology of Vitamin D deficiency in Patients with
Type-2 Diabetes Mellitus and Hypertension: A Cross-sectional, Observational, Pan-India Study. Indian Journal of Diabetes and
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Association Of Vitamin D
& Comorbidities
1. Diabetes

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 What causes Micronutrient deficiency in DM
Disease related – T1DM, T2DM, Pancreatic diabetes
Poor nutritional status, Economical reasons
Peri-operative, Infections, Pregnancy/Gestational Diabetes
Alcoholism, smoking
Co-morbidities – Obesity, kidney disease, liver disease,
osteoporosis, celiac disease
Bariatric surgery
Medications

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 Quick Riddle

What is made with the help of sun and is

associated with everything under the sun?

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 T1DM
T2DM
GDM CVD
Cancer
CKD

Vit. D
Cognitive
Aging insufficie impairment
ncy

Bone
IBD
health
Immune
dysfunction
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 How much sun exposure should I have?

UVB radiation
Wavelength –– 290 to 320nm

20 min exposure = 3000 IU Vit.D

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 Who are at RISK for Vit D and Calcium deficiency?

Inadequate Dietary intake

Inadequate sun exposure, dark skin, temperate climatic region

Elderly, Post-menopausal women, prolonged inactivity, obesity

Pregnancy / GDM

H/O osteoporosis, fractures, neuropathy, CKD, CLD,

Malabsorption – pancreatic diabetes, celiac disease, GI surgery (bariatric)

Diabetics treated with Pioglitazone, Canagliflozin, PPIs, glucocorticoids

Drug induced def. – Anti-Tubercular Rx, Antiepileptics (phenytoin, CBZ,

Barbiturates)
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 Red flags of Vit. D Deficiency

Mood changes

Fatigue
Muscle cramps, weakness

↑ tendency to fall in elderly

Non-specific bone & joint pains

LFT report – isolated ↑ in ALP

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 Role of Vitamin D

Improve insulin sensitivity among Prediabetics, T2DM

RDA – 600 - 800 IU / day

In case of Deficiency (25 OH cholecalciferol <12ng/ml) and

Insufficiency (< 30ng/ml)
• 60,000 IU of Cholecalciferol per week X 4-12 weeks (orally with fatty
meals)
• Maintenance dose of 1000 - 2000 IU per day OR 60K IU every month

CLD, CKD, Malabsorptive states – routine supplementation with

Calcitriol (0.25
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— do not distribute
 Role of calcium
Vit. D necessary for Calcium absorption from gut; So supplemented together

Adequate levels of Ca - to reduce the risk of fractures and sarcopenia in DM

Helps to overcome metformin-induced Vit B12 deficiency
Low levels  risk of hyperglycemia & metabolic syndrome
RDA – 1000-1200 mg / day

For Rx: 500 mg/day with meals plus Diet rich in Calcium
250 mg of Cal. Carbonate supplements - in chronic constipation
PPIs – reduce absorption of Cal. Carbonate (Tab. ShelCal has Cal. Carbonate)
Patients on PPIs – give Calcium citrate (CCM)

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 What should you eat to get Vit. D and Calcium?

Salmon fish Tuna fish ‘+F’ Milk & Milk products

Egg whites
‘+F’ cereals ‘+F’ cereals
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 Multiple clinical studies have reported an increased incidence of fractures in
patients with type 2 DM as compared to normal adults

Multiple clinical studies

have reported an increased
incidence of fractures in
patients with type 2 DM as
compared to normal adults

Matthew P. Gilbert, Richard E. Pratley, The Impact of Diabetes and

Diabetes Medications on Bone Health, Endocrine Reviews, Volume
36, Issue 2, 1 April 2015, Pages 194–213,

Proprietary and confidential — do not distribute Matthew P. Gilbert, Richard E. Pratley, The Impact of Diabetes and Diabetes Medications on Bone
Health, Endocrine Reviews, Volume 36, Issue 2, 1 April 2015, Pages 194–213,
 Pathophysiology: Increased fracture risk in Type 2 DM

Matthew P. Gilbert, Richard E. Pratley, The Impact of Diabetes and Diabetes Medications on Bone Health, Endocrine Reviews, Volume 36, Issue 2, 1 April 2015, Pages 194–213,
https://doi.org/10.1210/er.2012-1042 31
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 Relationship between the accumulation of AGEs within the bone and
Diabetic Bone Disease

AGE: Advanced Glycation End-products; RAGE: Receptor for Advanced Glycation End-products; ROS: Reactive Oxygen Species
Sanches, C.P., Vianna, A.G.D. & Barreto, F.d. The impact of type 2 diabetes on bone metabolism. Diabetol Metab Syndr 9, 85 (2017)
Sanguineti R, Puddu A, Mach F, Montecucco F, Viviani GL. Advanced glycation end products play adverse proinflammatory activities in osteoporosis. Mediators Inflamm.
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2014;2014:975872 32
 Impact of AGEs on Osteoblast and Osteoclast function

Effect on Osteoblasts Effect on Osteoclasts

Yamagishi S. Chapter 5: Mechanism for the Development of Bone Disease in Diabetes: Increased Oxidative Stress and Advanced Glycation End Products.
Proprietary
In: M. and
Inaba (ed.), confidential —
Musculoskeletal do not
Disease distribute
Associated with Diabetes Mellitus. 33
Proprietary and confidential — do not distribute
Dubey P, Thakur V, Chattopadhyay M. Role of Minerals and Trace Elements in Diabetes and Insulin Resistance. Nutrients. 2020; 12(6):1864. https://doi.org/10.3390/nu12061864
Proprietary and confidential — do not distribute
Defining association: Type 2 Diabetes Mellitus &
Vitamin D deficiency

Vitamin D deficiency
contributes towards insulin
resistance and development
of Type 2 DM via :
1. Direct effect: decreased
binding to vitamin D receptor
(VDR)
2. Indirect effect: aberrant
calcium flux

Huang et al. Lipoprotein lipase links vitamin D, insulin resistance, and type 2 diabetes: a cross-sectional epidemiological
Proprietary and confidential — do not distribute study. Cardiovascular Diabetology 2013, 12:17 | 04/09/202 | 36
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 Molecular mechanisms of Vitamin D deficiency and development of
Insulin resistance
Altered calcium flux

1. Impaired pancreatic β-cell function

Reduced expression of insulin gene via CREB *

Vitamin D deficiency

Decreased activation of PPAR-delta

Indirectly via increased PTH & altered Calcium

2. Impaired insulin signaling & sensitivity
flux

3. Impaired hepatic lipogenesis and

RAAS pathway activation
gluconeogenesis

4. Impaired cellular bioenergetics via impaired

* CREB: cAMP-responsive Element-binding protein – transcriptional element
mitochondrial function
involved in the maintenance of efficient insulin gene transcription, glucose sensing,
pancreatic β-cells survival, and insulin exocytosis
Szymczak-Pajor I, Śliwińska
Proprietary A. Analysis of Association
and confidential — do notbetween Vitamin D Deficiency and Insulin
distribute
Resistance. Nutrients. 2019;11(4):794
Incidence Rates of Type-2 Diabetes with low Serum
Vitamin D levels
Annual incidence rate of type 2
diabetes was
Group :1
3.7 per 1000 in Group: 1
Median 25(OH)D
concentration41 ng/ml (N = 4933) as compared to
9.3 per 1000 in group: 2
Group : 2
Median 25(OH)D concentration
22 ng/ml (N = 4078)

Incidence rate of type 2 diabetes is >50% lower in

Group : 1 than in Group: 2

McDonnell SL, Baggerly LL, French CB, Heaney RP, Gorham ED, Holick MF, Scragg R, Garland CF. Incidence rate of type 2 diabetes is> 50% lower in
GrassrootsHealth cohort with median serum 25–hydroxyvitamin D of 41 ng/ml than in NHANES cohort with median of 22 ng/ml. The Journal of Steroid
Proprietary and confidential — do not distribute Biochemistry and Molecular Biology. 2016 Jan 1;155:239-44. | 04/09/202 | 38
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Impact of vitamin D supplementation on
Insulin Resistance

100 patients with T2DM
Assessed for serum insulin,
25(OH)D concentration, and
HOMA-IR was calculated at
the beginning and the end of
the study.
Patients received 50,000 unit Effects of vitamin D on
of vitamin D3 orally per week insulin resistance was
for eight weeks significant when
vitamin D concentration
was 40–60 ng/ml
(100–150 nmol/l)

25 (OH)
<20 ng/ml 20-30 ng/ml 30-45 ng/ml 40-60 ng/ml >60 ng/ml
D levels (Baseline)

IR (Before) 3.6±1.2 3.2±4.05 3.8±3.7 3.6±3.05 2.6±2.09

IR (After)
3.05±1.6 5.8±6.4 3.5±3.6 2.2±2.6 1.79±1.38
Treatment

Talaei A, Mohamadi M, Adgi Z. The effect of vitamin D on insulin resistance in patients with type 2 diabetes.
Diabetology & metabolic syndrome. 2013 Dec;5(1):1-5.
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Impact of vitamin D supplementation on HbA1C

 Diabetic patients i.e., patients who were on stable anti-

diabetes medications were enrolled Change in HbA1C after
12 weeks
 Patients with Vitamin D deficiency were supplemented 10.00%
with Vitamin D and were followed over 12 weeks
5.00%

0.00%
 Mean HbA1c decreased significantly from baseline HbA1C
(8.11%) to week 12 (6.49%) (P = 0.0143)
0 weeks 12 weeks

Tiwaskar M, Soratia Z, Karmakar A et al. Evaluation of patient profiles, treatment paradigms and clinical efficacy, and safety outcomes in adult patients with vitamin D deficiency or insufficiency in India: A multicenter, prospective, non-interventional
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study. F1000Research 2023, 12:250
 Role of Anti-diabetic
medications on increased
fracture risk

Long-term use of some Anti-

diabetic medications can
negatively impact bone mineral
density, thereby increasing
fracture risk

Vitamin D supplementation
may be useful in such patients

Lin DPL, Dass C. Weak bones in diabetes mellitus – an update on

pharmaceutical treatment options. Journal of Pharmacy and
Proprietary
Pharmacology, and confidential
70 (2018), pp. 1–17 — do not distribute
 Multiple studies have demonstrated that Vitamin D supplementation in Type 2 DM with deficiency
can reduce the expression of RAGE as well as reduce the accumulation of AGEs in various tissues,
thereby delaying onset of complications in these patients

Author Study Design Results

Talmor Y etal, Calcitriol may act as a vascular protective agent counteracting the probable
In-vitro study
20081 deleterious actions of AGEs on endothelial cell activities

Serum 25(OH)D3 was significantly and inversely associated with AGEs as

Chen J et al, 20182 Population-based cohort study measured by SAF (skin autofluorescence technique), independently of known risk
factors and medication intake

Vitamin D supplementation could down-regulate RAGE mRNA [fold change = 0.72

Omidian M et al, Randomized controlled trial in vitamin D vs. 0.95 in placebo) P = 0.001)]. In addition, AGES and TNF-α serum
20193 involving 48 diabetic patients levels significantly reduced in vitamin D group, but they were unchanged in the
placebo group.

1. Talmor Y et al. Calcitriol blunts the deleterious impact of advanced glycation end products on endothelial cells. Am J Physiol Renal Physiol. 2008 May;294(5):F1059-64
2. Chen J et al. Serum 25-hydroxyvitamin D3 is associated with advanced glycation end products (AGEs) measured as skin autofluorescence: The Rotterdam Study. Eur J Epidemiol. 2019 Jan;34(1):67-77
3. Omidian M et al. Effects of vitamin D supplementation on advanced glycation end products signaling pathway in T2DM patients: a randomized, placebo-controlled, double blind clinical trial. Diabetol Metab Syndr. 2019 Oct 26;11:86
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Association Of Vitamin D
& Comorbidities
2. Hypertension

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Potential mechanisms underlying role of Vitamin D
deficiency and development of Hypertension

Vitamin D deficiency can

result in hypertension via

Effect on Vascular
RAAS pathway Role of Parathormone
endothelium

Ullah MI, et al. Does Vitamin D Deficiency Cause Hypertension? Current Evidence from Clinical Studies and Potential
Proprietary and confidential — do not distribute Mechanisms. International Journal of Endocrinology 2011 | 04/09/202 | 45
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Role of Vitamin D Deficiency and development of
Hypertension
1. RAAS pathway
Vitamin D:
Potent suppressor of Renin gene expression, leading to decreased renin production 8,9,10,11

Tomaschitz A et al12
• Reported a steady increase of plasma renin concentration
across a declining concentration of calcidol or calcitriol in
3296 subjects (LURIC study)

Forman et al13
• Reported significantly higher angiotensin-II levels in
patients with Vitamin D insufficiency and deficiency, as
compared to those with sufficient Vitamin D levels

8. Ullah MI, et al. Does Vitamin D Deficiency Cause Hypertension? Current Evidence from Clinical Studies and Potential Mechanisms. International
Journal of Endocrinology 2011 9. Y. C. Li, G. Qiao, M. Uskokovic et l. Vitamin D: a negative endocrine regulator of the reninangiotensin system and blood
pressure,” Journal of Steroid Biochemistry and Molecular Biology, vol. 89-90, pp. 387–392, 2004. 10. LI C J, KONG J, WEI M et al. 2002 1,2-
dihydroxyvitamin D3 is a negative endocrine regulator of the renin-angiotensin system. J Clin Invest 110: 229–238. 11. Li YC. Vitamin D regulation of the
renin-angiotensin system. J Cell Bio-chem. 2003;88:327–331. 12. TOMASCHITZA, PILZ S, RITZE et al. 2010 Independent association between 1,25-
dihydroxyvitamin D, 25-hydroxyvitamin D and the renin-angiotensin system: The Ludwigshafen risk and cardiovascular (LURIC) study. Clin Chim Acta 411:
1354–1360. 13. Forman JP, Williams JS, Fisher ND. Plasma 25-hydroxyvitamin D and regulation of the renin-angiotensin system in humans. Hypertension.
Proprietary and confidential — do not distribute 2010;55:1283–1288. | 04/09/202 | 46
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Role of Vitamin D Deficiency and development of
Hypertension
2. Effect on Vascular endothelium (Vaso protective effects) 5,6,7

Reduces effect of Increases release and Reduces pro-inflammatory and

advanced glycation activity of NO pro-atherosclerotic cytokines
end-products

5 Tahawi Z, Orolinova N, Joshua IG, Bader M, Fletcher EC. Altered vascular reactivity in arterioles of chronic intermittent hypoxic rats. J Appl
Physiol. 2001;90:2007–2013; discussion, 2000. 6. Talmor Y, Bernheim J, Klein O, Green J, Rashid G. Calcitriol bluntspro-atherosclerotic parameters
through NFkappaB and p38 in vitro. Eur J Clin Invest. 2008;38:548 –554. 7. Talmor Y et al. Calcitriol blunts the deleterious impact of advanced
Proprietary and confidential — do not distribute glycation end products on endothelial cells. Am J Physiol Renal Physiol. 2008;294:F1059–F1064 | 04/09/202 | 47
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Role of Vitamin D Deficiency and development of
Hypertension
3. Role of Parathormone

Increase in Parathormone

Pro-stimulatory effect on
vascular smooth muscle
Release of Endothelin-1 3,4 ? Release of Renin 3
cells via changes in calcium
flux 2,3

Increased peripheral vascular resistance

Increase in blood pressure

Pavlovic D, et al. Vitamin D and hypertension. PERIODICUM BIOLOGORUM 2011;113:299-302. 2. Zittermann A. Vitamin D and disease
prevention with special reference to cardiovascular disease. Prog Biophys Mol Biol 2006;92:39–48. 3. Fitzpatrick LA, et al. Parathyroid Hormone
and the Cardiovascular System. Curr Osteoporos Rep. 2008 Jun;6(2):77-83. 4.Lakatos P, Tatra A, Foldes J, et al.: Endothelin concentrations are
Proprietary and confidential — do not distribute elevated in plasma of patients with primary and secondary hyperparathyroidism. Calcif Tissue Int 1996, 58: 70– 71.5 | 04/09/202 | 48
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Impact of Vitamin D supplementation on
Blood Pressure
8155 participants evaluated to investigate the association between serum (25(OH)D)
status and (BP) and the influence of vitamin D supplementation on hypertension

At baseline, 592 participants (7.3%) were hypertensive. Vitamin D supplementation

done to reach a target serum 25(OH)D > 100 nmol/L.

• Follow-up (12 ± 3 months ): The mean 25(OH)D concentration for hypertensive

participants increased from 33 ± 16 ng/mL to 45 ± 14 ng/mL.
• 71% of them were no longer hypertensive.
• Significant negative association between BP and serum 25(OH)D level

Improvement in serum 25(OH)D concentrations > 100 nmol/L in hypertensive

levels were associated with improved control of SBP and DBP.

Mirhosseini N, Vatanparast H, Kimball SM. The association between serum 25 (OH) D status and blood pressure in participants of a community-
Proprietary and confidential — do not distribute based program taking vitamin D supplements. Nutrients. 2017 Nov 14;9(11):1244. | 04/09/202 | 49
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Association Of Vitamin D
& Comorbidities
3. Immunity

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Vitamin D deficiency and Immunity
Consistent associations: Low serum concentrations of Vitamin D and
susceptibility to acute respiratory tract infections (RTIs)1

Observation that there is an increased incidence of respiratory infections

during winter (when Vitamin D levels are low) 1

Vitamin D: Mechanisms to reduce Bacterial / viral infections 2

Increased Direct microbial
cathelicidins toxicity
Cellular Immunity
Suppression of
Vitamin D cytokine storm

Suppression of
Adaptive immunity inflammatory
cytokines

Proprietary and confidential — do not distribute 1. Martineau AR, et al. BMJ. 2017 Feb 15;356:i6583. 2. Azrielant S, Shoenfeld Y. IMAJ 2017; 19: 510–511 | 04/09/202 | 51
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Net effect of boosting mucosal defenses &
suppressing excessive inflammation
Blocking production
of pro-inflammatory
mediators
Anti-inflammatory
effect
Macrophages / inhibition of COX-2
Monocytes Anti – inflammatory
enzyme
Anti-oxidative effect effects
Vitamin D

by upregulating
glutathione oxidase

Dendritic cells Reduce maturation

Increased production
Natural Killer Cells Anti – microbial effects
of cathelicidins and α,
and Neutrophils
β defensins

Cathelicidins and Defensins are the body’s first-line defense

against invading pathogens

Proprietary and confidential — do not distribute Martens PJ et al. Vitamin D’s Effect on Immune Function. Nutrients. 2020 May; 12(5): 1248 | 04/09/202 | 52
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Net Effect of Vitamin D on Immunity

Epidemiological data link vitamin D deficiency to a defective functioning of

the immune system with an increased risk of infections and a
predisposition to autoimmune disease

Proprietary and confidential — do not distribute Martens PJ et al. Vitamin D’s Effect on Immune Function. Nutrients. 2020 May; 12(5): 1248 | 04/09/202 | 53
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 Vitamin D – effect on Adaptive Immunity
Net effect: Reduces chances of developing autoimmune disorders
(destruction of normal cells and tissues by the body’s own immune system)

Modulation of T- Reduced activation of T- Stimulation of

lymphocyte response lymphocytes by B- programmed cell death of
lymphocytes autoimmune T-
lymphocytes and B-
lymphocytes

Proprietary and confidential — do not distribute Martens PJ et al. Vitamin D’s Effect on Immune Function. Nutrients. 2020 May; 12(5): 1248 | 04/09/202 | 54
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Vitamin D – Role in Infections and Immunity
Recommendations for Vit D Supplementation

• Vitamin D3 supplementation should be started or increased several months before

winter in order to raise 25(OH)D concentrations to the range necessary to prevent acute RTIs.

• The optimal level of 25(OH)D appears to be in the range of 40–60 ng/mL

(100–150 nmol/L).

• Vitamin D 10,000 IU/d for a month has been indicated to be effective in rapidly increasing
circulating levels of 25(OH)D in the preferred range of 40–60 ng/mL.

• To maintain 25(OH)D levels after that first month, the dose can be decreased to 5000 IU/d.

1. Martineau AR, et al. BMJ. 2017 Feb 15;356:i6583.

2. Heaney RP, et al. Am J Clin Nutr. 2003 Jan;77(1):204-10
3. Ekwaru JP, et al. PLoS One. 2014 Nov 5;9(11): e111265.
Proprietary and confidential — do not distribute 4. | 04/09/202
Shirvani A, et al. Sci Rep. 2019 Nov 27;9(1):17685. | 55
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DeScribing
Management of Vitamin D
deficiency

Proprietary and confidential — do not distribute Special Use Cases | 04/09/202 | 56

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Vitamin D Treatment Recommendations
Option 1: Weekly dose followed by Option 2: Continuous monthly therapy
Maintenance 60,000 – 120,000 IU/month
60,000 IU weekly dose of vitamin D3 for 8 weeks
Followed by maintenance therapy of 60,000 IU
once a month OR 1500-2000 IU/day

Option 3: Daily continuous therapy Option 4: Parenteral mega dose of

3,00,000 – 6,00,000 IU
Daily supplementation of 1000-2000 IU
Measure serum 25 (OH) D level after 3-4 months
If levels are not adequate then repeat the dose
after 6 months

Toxicity has not been reported up to intake of 10,000 IU/day

1. Kennel KA, Drake MT, Hurley DL. Vitamin D Deficiency in Adults: When to Test and How to Treat. Mayo Clin Proc. 2010;85(8):752-758
2. Hollick MF et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. The
Proprietary and confidential — do not distribute Journal of Clinical Endocrinology & Metabolism. July 2011; 96(7): 1911–1930 | 04/09/202 | 57
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 Common oversight in management → to stop
treatment once sufficient levels of Vitamin D is
attained1

Need to continue maintenance therapy, especially in

high risk group, to ensure optimal levels of Vitamin D1,2

Maintenance therapy of 1500 – 2000 IU/d or

60000 IU/month in adults > 18 years
recommended by following guidelines:

1. Kennel KA, Drake MT, Hurley DL. Vitamin D Deficiency in Adults: When to Test and How to Treat. Mayo Clin Proc. 2010;85(8):752-758
2. Hollick MF et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. The Journal of
Clinical Endocrinology & Metabolism. July 2011; 96(7): 1911–1930
3. Cesareo R et al. Italian Association of Clinical Endocrinologists (AME) and Italian Chapter of the American Association of Clinical Endocrinologists
Proprietary and confidential — do not distribute (AACE) Position Statement: Clinical Management of Vitamin D Deficiency in Adults. Nutrients. 2018 May; 10(5): 546 | 04/09/202 | 58
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DeLineate
Nanotechnology &
Vitamin D

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Defining Nanoparticles & Nanotechnology
Nanoparticles: Colloidal particles that range in size from 10 to 1000 nm in diameter

Vitamin D encapsulated in lipid nanoparticle

with hydrophilic surface
A “First time in India” - Novel Drug Delivery
System

Comprises of nanoparticles < 150nm in diameter

Stable even in harsh GI conditions

“Ready to Absorb” formulation – absorption

does not depend on lipids or bile salts. Promotes
absorption of Vitamin D across entire
small intestine

Bothiraja C, Pawar A & Deshpande G. Ex vivo absorption study of a nanoparticle based novel drug delivery system of vitamin
D3(Arachitol Nano™)
using everted intestinal sac technique. J Pharma Investig. 2016;46(5):425-432.
Proprietary and confidential — do not distribute NDDS: Novel Drug Delivery System | 04/09/202 | 60
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Vitamin D Nanoparticle : A ‘Ready to Absorb’ NDDS

• No need for disintegration / dissolution

• Absorption not dependent on lipids
• Not dependent on bile salts for ‘Micelle’
formation
• Promotes absorption of Vitamin D
across entire small intestine
• Promotes intestinal absorption through
multiple pathways

Proprietary and confidential — do not distribute | 04/09/202

Data on file | 61
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Nanoparticle based vitamin D: Ex vivo study for
absorption profile
Ex-vivo absorption study of a nanoparticle based novel drug delivery system of vitamin D 3using
everted intestinal sac technique

• Vitamin D3 in NDDS: nonspecific absorption through Conclusion:

various segments of rat small intestine, with high flux, Absorption of Vitamin D3 in NDDS
permeability coefficient and percentage of absorption is > 90%, various segment of
(79.21 ± 0.23, 76.55 ± 0.24 and 77.73 ± 0.24 % for Intestine (Duodenum,
duodenum, jejunum and ileum) Jejunum & Ileum)
• Average absorption of Vitamin D3 in NDDS
was 77.83 ± 0.24 % through rat small intestine.
• The predicted human absorption may be more
than 90%.

1. Predictive intestinal absorption of based on an everted sac study data, extrapolated to oral absorption in humans
2. Bothiraja C, Pawar A & Deshpande G. Ex vivo absorption study of a nanoparticle based novel drug delivery system of vitamin D3(™)
Proprietary and confidential — do not distribute using everted intestinal sac technique. J Pharma Investig. 2016;46(5):425-432. | 04/09/202 | 62
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Efficacy of a nanoparticle-based Vitamin D
formulation
Evaluation of efficacy of a nanoparticle-based vitamin D formulation in
correction of vitamin D levels
Mean serum 25 [OH] D (ng/ml)
AIM: A prospective, open label, single arm study to find the at baseline, week 4 and week 8
effectiveness of a nanoparticle-based vitamin D formulation 60
50 41.03
STUDY DESIGN: Subjects planned to receive 60,000 IU 40
of nanoparticle-based vitamin D, once weekly, for 8 weeks 30 31.38
orally. Serum 25(OH) D levels were measured at baseline, 4 20
and 8 week. 10 15.9
0
Baseline 4 weeks 8 weeks
RESULT: Improvement at 4 weeks occured in 84.2% of the
patients. Improvement in the physical component scores
observed in 86.8% patients after 8 week of therapy Vitamin D levels ng/ml

Manek KA. Evaluation of efficacy of a nanoparticle-based vitamin D formulation in correction of vitamin D levels in patients
Proprietary and confidential — do not distribute with documented deficiency or insufficiency of vitamin D. Int J Res Orthop. 2017 May;3(3):486-91. | 04/09/202 | 63
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Denoting bioavailability of a nanoparticle-based
Vitamin D formulation
On comparison of relative bioavailability cholecalciferol (nanoemulsion oral solution,
water-miscible vitamin D3 vs soft gelatin capsules) in healthy participants

Cmax of the nanoemulsion Bioavailability of

significantly higher by 43% nanoemulsion significantly
higher by 36%

Marwaha RK, Verma M, Walekar A, Sonawane R, Trivedi C. An open-label, randomized, crossover study to evaluate the
bioavailability of nanoemulsion versus conventional fat-soluble formulation of cholecalciferol in healthy participants. Journal
Proprietary and confidential — do not distribute of Orthopaedics. 2022 Nov 4. | 04/09/202 | 64
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Efficacy of a nanoparticle-based Vitamin D
formulation
Increase in Vitamin D levels

Open-label pilot study in 180 healthy school 35 31.8 ± 9.1 ng/mL

children. 2 different formulations of

30
Vitamin D3 administered once a month, for
23.7 ± 10.4 ng/mL
6 months 25

• Group A: 60,000 IU fat-soluble Vitamin 20

D3 orally with milk

15
• Group B: 60,000 IU Miscible form
(nanoformulation) of Vitamin D3 10
with water
5
Significantly greater increase in
0
serum 25(OH)D levels in group B as Increase in Vitamin D levels (ng/ml)
compared to group A
Group A Group B

Marwaha et al. Efficacy of micellized vs. fat-soluble vitamin D3 supplementation in healthy school children from Northern
Proprietary and confidential — do not distribute India. J Pediatr Endocrinol Metab 2016; 29(12): 1373–1377 | 04/09/202 | 65
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Key messages

• Diet, increased melanin content of skin, inadequate sun exposure

and lack of fortified foods contribute to the high Vitamin D
deficiency in India

• Vitamin D deficiency has been implicated in development of hypertension,

type 2 diabetes mellitus.

• Recent guidelines recommend maintenance therapy with 1500-2000

IU/d or 60,000 IU/month indefinitely, after treatment of deficiency

• Nano-formulations of Vitamin D provide a “ready-to-absorb” and highly

bioavailable formulation of Vitamin D

Proprietary and confidential — do not distribute | 04/09/202 | 66

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