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Renal Diseases
Published in Stephan Strobel, Lewis Spitz, Stephen D. Marks, Great Ormond Street Handbook of Paediatrics, 2019
The principles of management of renal osteodystrophy are: Correction of acidosis using sodium bicarbonate.Phosphate restriction by control of dietary intake and the use of a phosphate binder (e.g. calcium carbonate to maintain plasma phosphate within the normal range for age).Supplements of oral 1-α-hydroxycholecalciferol or 1,25 dihydroxycholecalciferol to maintain the PTH within normal range, if not achieved by control of plasma phosphate. This may require the total calcium to be maintained at the upper end of the normal range. Total calcium is a measurement of bound, ionised and complexed calcium. The proportion may increase in CKD, reflected by total hypercalcaemia. However, if the ionised calcium is within the normal range, treatment with vitamin D analogues may continue.
Answers
Published in John D Firth, Professor Ian Gilmore, MRCP Part 2 Self-Assessment, 2018
John D Firth, Professor Ian Gilmore
The calcium x phosphate product is high, putting the patient at risk of metastatic calcification. Lowering the phosphate (rather than the calcium) is the most important measure as the elevated phosphate stimulates parathyroid proliferation and PTH secretion. This is best done by reinforcing dietary restriction and ensuring that the patient is receiving adequate dialysis. The vitamin D analogue will be increasing absorption of calcium and phosphate, so this should be reduced or stopped; ideally the patient will remain on a small dose as this helps to stop parathyroid proliferation. If these changes do not return the calcium and phosphate to satisfactory values, the patient should be changed to a phosphate binder that does not contain calcium. Aluminium based compounds are best avoided because of the risk of toxicity, hence sevelamer would be an appropriate (but expensive) choice.
Topical Therapies for Psoriasis
Published in Siba P. Raychaudhuri, Smriti K. Raychaudhuri, Debasis Bagchi, Psoriasis and Psoriatic Arthritis, 2017
Synthetic topical vitamin D analogues were introduced into clinical use for psoriasis in 1988 [62,63]. Apart from their immunomodulatory capacity, the modulation of receptor-mediated keratinocyte proliferation and differentiation is regarded as a major mode of action. The compounds bind to intracellular vitamin D receptors, which after translocation to the nucleus bind to vitamin D response elements and regulate genes directly involved in keratinocyte proliferation and keratinization, as well as epidermal inflammation. Calcipotriol (Europe and Canada; calcipotriene in the United States) is probably one of the best-studied topical agents by GCP criteria (good clinical practice) [64,65]. Monotherapy resulted in a 59% reduction of PASI 75 after 8 weeks of treatment. In head-to-head studies, calcipotriol proved superior to tar and anthralin and comparable to class II corticosteroids. In early studies, a 59% reduction of PASI 75 could be achieved after 8 weeks of treatment [12–15,66]. Vitamin D analogues are cosmetically well appreciated; however, they may cause skin irritations at locations like the face and skinfolds and result in discontinuation of treatment in 5%–10% of cases. Contact sensitization has been described in a few cases, whereas cancerogenic properties are absent. The three different agents, calcipotriol, tacalcitol [67,68], and calcitriol, are available as solution, cream, and ointment. Calcitriol at 3 μg/g ointment was shown to be equally effective as the other synthetic analogues; however, it had less irritability, especially at sensitive sites like the face and skinfolds [69,70]. Clearing or almost clearing could be seen in 34% of patients compared with the vehicle control of 12%–22%. Vitamin D analogues should only be used on less than 30% of the body surface for 8 weeks maximum because of systemic resorption with hypercalcemia and hypercalcuria (Table 15.3), and they can successfully be combined with UV light [71,72]. Long-term treatment is possible with a fixed combination of calcipotriol and betamethasone dipropionate (see the next section). As vitamin D analogues destabilize in the presence of lactic and salicylic acid, they should not be used at the same time.
A critical review of halobetasol propionate foam (0.05%) as a treatment option for adolescent plaque psoriasis
Published in Expert Review of Clinical Immunology, 2022
Mimi Chung, Samuel Yeroushalmi, Marwa Hakimi, Erin Bartholomew, Wilson Liao, Tina Bhutani
Many different types of topical treatments exist for the treatment of psoriasis. Other topical steroids vary in potency from low strength to super-potent, with formulations, such as ointments, creams, lotion, gels, tape, and foams. Vitamin D analogues such as calcipotriene and calcitriol and retinoids like tazarotene can be used both as a monotherapy or in combination with other topical agents, generally corticosteroids. These combination treatments can be found as ointments, gels, and foams, with foam formulation showing improved efficacy and patient adherence [12]. Topical calcineurin inhibitors like pimecrolimus and tacrolimus are second-line therapy often prescribed as steroid-sparing agents for the face or other sensitive areas; however, they are not FDA approved for the treatment of psoriasis. These treatments have been a cornerstone for the topical treatment of psoriasis over the past two decades, with innovations in vehicles and the development of combination treatments as major changes. Tapinarof, which targets the aryl hydrocarbon receptor (AhR), has shown efficacy in Phase III trials compared to the vehicle and was approved for psoriasis on 24 May 2022 [13].
Systematic literature review of long-term efficacy data for topical psoriasis treatments
Published in Journal of Dermatological Treatment, 2022
Claire Bark, Chloe Brown, Per Svangren
Topical therapy is the standard of care for treatment of the majority of patients with mild to moderate disease (∼88% of all patients with psoriasis, (5)), whilst patients with more severe disease may use topical therapies in conjunction with conventional systemic treatments and biologics (6,7). Effective management with topical therapies offers several advantages over conventional systemic and biologic treatment including a more favorable side effect profile, significantly lower cost and the possibility for patients to manage their psoriasis without the need for specialist treatment (4,8). Vitamin D analogues (such as calcipotriol) and corticosteroids (such as betamethasone dipropionate and clobetasol propionate) are commonly used topical treatments and are often prescribed in combination.
Prescribing patterns of vitamin D and analogues in a private healthcare patient population in South Africa
Published in South African Journal of Clinical Nutrition, 2022
Angela Ann Morris-Paxton, Ilse Truter
A retrospective, cross-sectional drug utilisation study was conducted on a South African medical insurance administrator database for accepted and paid claims for the year 2018. The administrator oversees the claims for several medical insurance schemes. The database contained 4 191 138 records for medicine, medical devices and procedures. The ATC,45 Monthly Index of Medical Specialities (MIMS)46 and the South African Medicines Formulary47 were used to classify medicines. Products in ATC subgroup A11CC (vitamin D and analogues) were extracted and analysed. As this study relates only to prescribed medications and the diagnoses of the individual patients were not disclosed the authors assumed that the prescriptions were given due to there being a clinical indication for their use. It must also be noted that the study did not include the numerous multivitamin products containing low-dose vitamin D that are available over the counter (OTC) from pharmacies, health shops and other distributors in South Africa. The focus of this study was specifically to determine which products containing vitamin D or a vitamin D analogue were prescribed to patients and paid for by the medical insurance schemes.