Oral versus intramuscular administration of vitamin B12 for the treatment of patients with vitamin B12 deficiency: a pragmatic, randomised, multicentre, non-inferiority clinical trial undertaken in the primary healthcare setting (Project OB12).

BACKGROUND: The oral administration of vitamin B12 offers a potentially simpler and cheaper alternative to parenteral administration, but its effectiveness has not been definitively demonstrated. The following protocol was designed to compare the effectiveness of orally and intramuscularly administered vitamin B12 in the treatment of patients ≥65 years of age with vitamin B12 deficiency. METHODS/DESIGN: The proposed study involves a controlled, randomised, multicentre, parallel, non-inferiority clinical trial lasting one year, involving 23 primary healthcare centres in the Madrid region (Spain), and patients ≥65 years of age. The minimum number of patients required for the study was calculated as 320 (160 in each arm). Bearing in mind an estimated 8-10% prevalence of vitamin B12 deficiency among the population of this age group, an initial sample of 3556 patients will need to be recruited. Eligible patients will be randomly assigned to one of the two treatment arms. In the intramuscular treatment arm, vitamin B12 will be administered as follows: 1 mg on alternate days in weeks 1 and 2, 1 mg/week in weeks 3-8,and 1 mg/month in weeks 9-52. In the oral arm, the vitamin will be administered as: 1 mg/day in weeks 1-8 and 1 mg/week in weeks 9-52. The main outcome variable to be monitored in both treatment arms is the normalisation of the serum vitamin B12 concentration at weeks 8, 26 and 52; the secondary outcome variables include the serum concentration of vitamin B12 (in pg/ml), adherence to treatment, quality of life (EuroQoL-5D questionnaire), patient 3satisfaction and patient preferences. All statistical tests will be performed with intention to treat and per protocol. Logistic regression with random effects will be used to adjust for prognostic factors. Confounding factors or factors that might alter the effect recorded will be taken into account in analyses. DISCUSSION: The results of this study should help establish, taking quality of life into account, whether the oral administration of vitamin B12 is an effective alternative to its intramuscular administration. If this administration route is effective, it should provide a cheaper means of treating vitamin B12 deficiency while inducing fewer adverse effects. Having such an alternative would also allow patient preferences to be taken into consideration at the time of prescribing treatment. TRIAL REGISTRATION: This trial has been registered with ClinicalTrials.gov, number NCT 01476007, and under EUDRACT number 2010-024129-20.

[Protocol for prevention and treatment of osteoporosis in patients with cystic fibrosis]. / Efectividad en la aplicación de tres protocolos de prevención y tratamiento de la osteoporosis en pacientes adultos con fibrosis quística.

BACKGROUND AND OBJECTIVE: Reduction of bone mineral density (BMD) is a complication of cystic fibrosis (CF) which is observed in parallel to the increment of life expectancy in these patients. The aim of this study was to analyze the evolution of BMD following the application of a protocol for the prevention and treatment of osteoporosis. PATIENTS AND METHOD: We performed a multidisciplinary prospective study in 21 adult patients with CF with a mean age of 24.3 (r: 19-44) years. We evaluated BMD results depending on the treatment schedule, and the annual relative change of BMD percentage was correlated with changes observed in respiratory function, corporal mass index (CMI), Brasfield radiologic score and Shwachman clinical score for a 3 years follow up period. Three regimens of treatment were applied: general measurements, supplementation of calcium and vitamin D, and 10 daily mg of alendronate plus calcium and vitamin D supplements. RESULTS: Basal assessment showed that 14.2% of CF patients had a marked diminution of bone mass with respect to an age and sex matched control population, with a Z score of < -2 DE in lumbar vertebral and/or total femur. Another 38% showed a lessening of Z score between -1 and -2.5 DE. We observed a progressive annual reduction of BMD in all the anatomic areas analyzed: -0.52% (1.87) in lumbar spine, -1.17% (1.91) in total femur and -2.16% (2.65) in neck femur. The hip BMD annual decrement was related to that observed in FEV1. Only patients treated with alendronate did not suffer progressive BMD lose. Treatment with a combination of calcium, vitamin D and alendronate was more efficient in hip BMD than calcium plus vitamin D alone (p < 0.05). Also, this combination was better than no treatment at hip and femoral neck levels (p < 0.05). CONCLUSIONS: Our work confirms that Spanish young adults patients with CF show low control matched BMD, and that it even worsens at follow-up. This decrement is not adequately halted with preventive treatment with supplements of calcium and vitamin D, and only patients treated with alendronate show increments of their BMD.

Efectividad en la aplicación de tres protocolos de prevención y tratamiento de la osteoporosis en pacientes adultos con fibrosis quística / Protocol for prevention and treatment of osteoporosis in patients with cystic fibrosis

Fundamento y objetivo: La disminución de la densidad mineral ósea (DMO) es una complicación de la fibrosis quística (FQ) que se observa al aumentar la esperanza de vida de estos pacientes. El objetivo del presente estudio ha sido valorar la evolución de la DMO tras la instauración de un protocolo de prevención y tratamiento de la osteoporosis. Pacientes y método: Realizamos un estudio prospectivo en 21 pacientes adultos (10 mujeres y 11 varones) con FQ de una unidad multidisciplinaria, con una edad media de 24,3 años (extremos, 19-44). Se evaluaron los resultados de la DMO según los diferentes tratamientos administrados y se relacionó el cambio relativo anual en el porcentaje de la DMO con los observados en la función pulmonar, índice de masa corporal y puntuaciones radiológica de Brasfield y clínica de Shwachman, durante un período de seguimiento medio de 3 años. Las 3 pautas de tratamiento instauradas fueron: medidas preventivas generales, suplementos de calcio y vitamina D, y alendronato a dosis de 10 mg diarios con suplementos de calcio y vitamina D. Resultados: Inicialmente se observó que el 14,2% de los pacientes con FQ presentaban una disminución acusada de la masa ósea respecto a la población control de su misma edad y sexo, con una puntuación Z inferior a ­2 desviaciones estándar en columna lumbar y/o fémur total. Otro 38% presentaban descensos de la puntuación Z entre ­1 y ­2 desviaciones estándar. La disminución anual progresiva de la DMO durante los 3 años fue generalizada en todas las áreas anatómicas analizadas: ­0,52% (1,87) en columna lumbar, ­1,17% (1,91) en fémur total y ­2,16% (2,65) en cuello de fémur. En fémur el porcentaje de cambio relativo anual de DMO se relacionó con el observado en el volumen espiratorio forzado en el primer segundo (p < 0,05). Sólo los pacientes tratados con alendronato no sufrieron pérdida progresiva de masa ósea. El tratamiento con calcio, vitamina D y alendronato fue más eficaz para prevenir la disminución de la DMO en fémur total y cuello femoral que las medidas preventivas generales (p < 0,05) y en fémur total fue más eficaz que los suplementos de calcio con vitamina D (p < 0,05). Conclusiones: Nuestro trabajo confirma que los pacientes adultos jóvenes españoles con FQ tienen una disminución de la DMO respecto a la población control y que, a lo largo de la enfermedad, esta disminución es progresiva. Esta pérdida de masa ósea no se previene con medidas generales ni con suplementos de calcio y vitamina D, y únicamente en los pacientes tratados con alendronato se produce un aumento de la DMO

Background and objective: Reduction of bone mineral density (BMD) is a complication of cystic fibrosis (CF) which is observed in parallel to the increment of life expectancy in these patients. The aim of this study was to analyze the evolution of BMD following the application of a protocol for the prevention and treatment of osteoporosis. Patients and method: We performed a multidisciplinary prospective study in 21 adult patients with CF with a mean age of 24.3 (r: 19-44) years. We evaluated BMD results depending on the treatment schedule, and the annual relative change of BMD percentage was correlated with changes observed in respiratory function, corporal mass index (CMI), Brasfield radiologic score and Shwachman clinical score for a 3 years follow up period. Three regimens of treatment were applied: general measurements, supplementation of calcium and vitamin D, and 10 daily mg of alendronate plus calcium and vitamin D supplements. Results: Basal assessment showed that 14.2% of CF patients had a marked diminution of bone mass with respect to an age and sex matched control population, with a Z score of < ­2 DE in lumbar vertebral and/or total femur. Another 38% showed a lessening of Z score between ­1 and ­2.5 DE. We observed a progressive annual reduction of BMD in all the anatomic areas analyzed: ­0.52% (1.87) in lumbar spine, ­1.17% (1.91) in total femur and ­2.16% (2.65) in neck femur. The hip BMD annual decrement was related to that observed in FEV1. Only patients treated with alendronate did not suffer progressive BMD lose. Treatment with a combination of calcium, vitamin D and alendronate was more efficient in hip BMD than calcium plus vitamin D alone (p < 0.05). Also, this combination was better than no treatment at hip and femoral neck levels (p < 0.05). Conclusions: Our work confirms that Spanish young adults patients with CF show low control matched BMD, and that it even worsens at follow-up. This decrement is not adequately halted with preventive treatment with supplements of calcium and vitamin D, and only patients treated with alendronate show increments of their BMD