Is Treatment of Vitamin D Deficiency Associated With Resolution of Statin-Induced Muscular Symptoms

Statins are a class of drugs that are highly effective at lowering cholesterol levels. However, compliance is often limited by symptoms of muscle pain. The investigators would like to study Vitamin-D deficient individuals who also have muscle pain due to statin use. About 1 billion people are estimated to have low or insufficient levels of vitamin D worldwide. Patients with low or insufficient levels of vitamin D may develop muscle disease. The purpose of this study is to identify if these symptoms are associated with vitamin D deficiency, and most importantly, if treatment of vitamin D deficiency can reduce muscle pain that is caused by statin treatment.

Study Overview

• Status: Completed
• Conditions: Myopathic Symptoms
• Intervention / Treatment: Drug: Ergocalciferol; Drug: Placebo

Detailed Description

Vitamin D2 (Ergocalciferol) is approved by the FDA to treat Vitamin D deficiency and will be given according to approved labeling. This drug has not been systematically studied to test the potential benefits of Vitamin D in patients who suffer from statin-induced muscle pain. Vitamin D2 is the current standard of care for treating vitamin D deficiency. Since the investigators are using Vitamin D2 therapy to treat vitamin D deficiency, and because our trial is a pilot study, the data will not be submitted to the FDA for consideration of changing the labeled indications for Vitamin D2 therapy.

This is a randomized, double-blinded, and placebo-controlled pilot study that will only be performed at CSMC. 40 females with moderate to severe myopathic pain while on Simvastatin will be enrolled in this study and will be randomized at a 1:1 ratio. Patients who will be approached are considering an alternative statin medication as part of their clinical care to address their muscle pain.

Participants will be recruited from the investigators' clinic patients. The study will be discussed with a patient during clinical visit by the treating doctor. Interested individuals will be provided with a copy of the consent form to take home for review with friends, family, and other physicians. The patient may then call the study staff to set a study appointment or enroll in the study during the clinical visit. A study investigator will discuss the study with the patient and ask the patient to read through the consent. The investigator will encourage the patient to ask any questions or discuss any concerns she might have.

If the consenting investigator is also the patient's treating doctor, the consenting investigator will request that the study coordinator approach the patient to determine the patient's interest in the study in order to avoid a conflict of interest. The coordinator will explicitly tell the patient that the patient's participation in the study is completely voluntary and that the patient's medical care will not be affected should she choose not to participate.

Participation in this study will be approximately 8 weeks. 20 participants will be randomized to the treatment group and 20 to the placebo group. The treatment group will receive Vitamin D2 therapy at 50,000 IU for 8 weeks (once per week) while the placebo group will receive a placebo pill (once per week) that is identical in nature. Participants have 2 study visits respectively at Week 0 and Week 8, and 1 phone follow-up visit at Week 1. In addition to the administration of Vitamin D2 or placebo mentioned above, other study procedures include informed consent, physical exam, questionnaires (brief pain assessment, and SF-12 to assess limitations on physical activity), review of medical records, medication and supplement review, blood draw, and phone followup. Subjects will be asked to stop any supplemental Vitamin D therapy to maintain an equal dose within patients in the Vitamin D2 and placebo group.

Prior to randomization, statin medication will be changed from Simvastatin to Atorvastatin and patients will be followed up by telephone at Week 1 for tolerability of the new statin medication. When a patient is intolerant to a particular statin, it is the standard of care to attempt another statin medication. Typically, many choose atorvastatin since a lower dose of the drug can be used to obtain the same target LDL/HDL, and lower doses reduce the risk of toxicity. This change in medication would be preformed regardless of the research protocol. Since the statin will be switched to a lower dose, it is possible that it will be a confounding factor, however, even the placebo group will be switched to the same alternate statin, reducing the differences between the two groups. In addition, Atorvastatin is also metabolized by the CYP3A4 enzyme, and because the presumed mechanism of association between vitamin D deficiency and statin-induced myopathic pain pivots on this enzyme, the investigators wanted to choose a statin that continues to utilize this enzyme. But, for reasons stated above, Atorvastatin has less myopathic symptoms due to lower doses used.

At the conclusion of the study, those in the treatment group whose serum 25 OH D levels have reached > 30ng/mL (therapeutic) may continue on maintenance doses on ergocalciferol (1,000 Units/day) if they are receiving clinical benefit. For those whose 25 OH D levels are < 30ng/mL, regardless of whether they received clinical benefit or not from the treatment arm, they will be offered a repeated 8 week course of Ergocalciferol therapy at 50,000 Units/week under standard of care. It will be up to the patient to accept or decline the therapy.

• Study Type: Interventional
• Enrollment (Actual): 11
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • California
    • Los Angeles, California, United States, 90048
      • Cedars-Sinai Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

1. Female gender (refer to section 4)
2. Age > 18, using an effective form of contraception (refer to section 4)
3. An indication to be on statin therapy
4. Moderate to severe myopathic pain while on Simvastatin
5. Serum CK level < 10 x ULN
6. Vitamin 25 OH D level < 30 ng/mL (as secondary hyperparathyroidism is triggered below this level)1
7. English speaking patients only
8. Myopathic pain that cannot be attributed to other medical conditions
9. Continue a statin within the CYP3A4 family
10. Competent to give informed consent

Exclusion Criteria:

1. Clinical diagnosis of overt vitamin D deficiency: osteomalacia, rickets, hypocalcemia, hypophosphatemia
2. Already taking Vitamin D supplements > 1000 IU/day
3. Serum creatinine > 2.2 mg/dL within last 6 months
4. AST/ALT > 3 x ULN of the local reference range
5. Serum CK level > 10 x ULN
6. Systolic blood pressure < 100 mmHg
7. Albumin adjusted calcium > 2.55 mmol/L or < 2.20 mmol/L
8. Renal osteodystrophy
9. Malabsorption syndrome
10. Metastatic malignancy
11. Transplant recipients
12. A co-existent diagnosis of renal calculi within the previous 6 months
13. A co-existent diagnosis of primary hyperparathyroidism within the previous 6 months
14. Recent therapy with corticosteroids within the previous 6 months
15. Currently consuming Digoxin, as usage increases risk of hypercalcemia
16. Lactating women

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Vitamin D Treatment; Vitamin D Treatment Group	Drug: Ergocalciferol; Ergocalciferol therapy at 50,000IU for 8 weeks
Placebo Comparator: Placebo Group; Placebo at 50,000IU for 8 weeks	Drug: Placebo; placebo at 50,000IU for 8 weeks

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants With Reduction in Myopathic Pain	To investigate if Vitamin D therapy reduces myopathic pain in subjects on statin medication who have low vitamin D levels and experience myopathic pain.	8 weeks
Brief Pain Inventory (BPI) Severity at Exit	Brief Pain Inventory (BPI) severity and interference questionnaires. BPI Severity Scale from 0 (Low Pain) to 10 (High Pain).	8 weeks
Vitamin 25 OH D Levels	Assessed with serum measurements	8 weeks
Brief Pain Inventory (BPI) Interference at Exit	Brief Pain Inventory (BPI) severity and interference questionnaires. BPI Severity on a scale from 1 (Low Interference) to 10 (High Interference).	8 weeks

Secondary Outcome Measures

Outcome Measure	Time Frame
Lipid Profile - Total Cholesterol Levels	8 weeks
Lipid Profile - LDL Cholesterol Levels	8 weeks
Lipid Profile - HDL Cholesterol Levels	8 weeks
Lipid Profile - Triglycerides Levels	8 weeks

Collaborators and Investigators

• Sponsor: Cedars-Sinai Medical Center
• Investigators: Principal Investigator: Margo B. Minissian, PhD, Cedars-Sinai Medical Center

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2012
• Primary Completion (Actual): June 1, 2019
• Study Completion (Actual): June 1, 2019

Study Registration Dates

• First Submitted: March 29, 2012
• First Submitted That Met QC Criteria: March 30, 2012
• First Posted (Estimate): April 2, 2012

Study Record Updates

• Last Update Posted (Actual): June 10, 2021
• Last Update Submitted That Met QC Criteria: May 17, 2021
• Last Verified: May 1, 2021

More Information

Terms related to this study

• Keywords: myopathic symptoms
• Additional Relevant MeSH Terms: Nutrition Disorders; Avitaminosis; Deficiency Diseases; Malnutrition; Vitamin D Deficiency; Physiological Effects of Drugs; Micronutrients; Vitamins; Bone Density Conservation Agents; Calcium-Regulating Hormones and Agents; Vitamin D; Ergocalciferols
• Other Study ID Numbers: 23187

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: The data was presented by poster presentation internally at Cedars-Sinai Medical Center. The plan is to publish the manuscript.
• IPD Sharing Time Frame: The data is currently available
• IPD Sharing Access Criteria: We plan to submit manuscript for peer review.
• IPD Sharing Supporting Information Type: Study Protocol; Informed Consent Form (ICF)