Department of Internal Medicine and Rheumatology, Military Institute of Medicine, Warsaw
Head of Department: Professor Witold Tłustochowicz, MD, PhD
Rheumatoid arthritis (RA) is a chronic autoimmune systemic disease characterized predominantly by synovial inflammation, leading to joint destruction. RA affects up to 1% of the population in the world and is associated with reduced life expectancy (1). The synovium in RA transforms into inflammatory tissue, called pannus, which produces several proinflammatory mediators and invades cartilage and bone. Pannus formation is caused by the proliferation of fibroblast-like synovial cells and synoviocytes, angiogenesis, infiltration of macrophages and lymphocytes and migration of polymorphonuclear cells to the synovial tissue (2). Interleukin 1 (IL-1), tumor necrosis factor (TNF-α) and interleukin 6 (IL-6) play a primary role in mediating this process. One of the important mechanisms of RA pathophysiology is the imbalance between Th1 and Th2 response with Th1 predominance (interleukin 2 and interferon γ excretion). The other significant inflammatory pathway is associated with Th17 cells and characterized by production of IL-17A, IL-17F, TNF and IL-6 (3). The risk factors for RA development involve the combination of genetic and environmental components. The most important genetic factor is associated with the major histocompatibility complex antigen HLA-DRB1 and shared epitope, which is closely related to serum presence of rheumatoid factor (RF) or anti-citrullinated peptide antibodies (a-CCP) (4, 5). Of the environmental stimuli that contribute, the best defined is smoking, which can interact with genes to increase disease susceptibility (4). One of the other possible environmental factors is vitamin D. Despite being a crucial element of calcium homeostasis and bone mineralization, vitamin D also plays an important role in immune system. The expression of vitamin D receptor (VDR) was discovered on antigen-presenting cells, dendritic cells and lymphocytes. VDR has been demonstrated in the rheumatoid synovium and macrophages derived from RA patients are capable to vitamin D synthesis (6). Active metabolite of vitamin D, calcitriol (1,25-dihydroxyvitamin D) can inhibit the macrophage synthesis of interleukines 1, 6, 12 and TNF-α, suppress the interleukin 2 secretion by Th1 lymphocytes and decrease antigen-presenting activity of macrophages – therefore restoring balance between Th1, Th17 and Th2 cells (7). Furthermore, calcitriol inhibits plasma-cell differentiation and B-cell proliferation (8). Vitamin D deficiency is more common in autoimmunological diseases than in general population (9). These observations were the reason for numerous studies on the role of vitamin D deficiency in the occurrence, activity and severity of RA.
1. Alamanos Y, Drosos AA: Epidemiology of adult rheumatoid arthritis. Autoimmunity Reviews 2005; (4)3: 130-136.
2. Dayer JM: The pivotal role of interleukin-1 in the clinical manifestations of rheumatoid arthritis. Rheumatology 2003; 42(suppl. 2): 3-10. DOI: 10.1093/rheumatology/keg326.
3. Furst DE, Emery P: Rheumatoid arthritis pathophysiology: update on emerging cytokine and cytokine-associated cell targets. Rheumatology 2014 Sep; 53(9): 1560-1569. DOI: 10.1093/rheumatology/ket4.
4. Lundström E, Källberg H, Alfredsson L et al.: Gene-environment interaction between the DRB1 shared epitope and smoking in the risk of anti-citrullinated protein antibody-positive rheumatoid arthritis: all alleles are important. Arthritis Rheum 2009; 60(6): 1597-1603.
5. Boissier M-C, Semerano L, Challal S et al.: Rheumatoid arthritis: From autoimmunity to synovitis and joint destruction. Journal of Autoimmunity 2012; 39: 222-228.
6. Ranganathan P: Genetics of bone loss in rheumatoid arthritis – role of vitamin D receptor polymorphism. Rheumatology (Oxford) 2009; 48(4): 342-346.
7. Braun-Moscovici Y, Toledan K, Markovits O et al.: Vitamin D: is it related to disease activity in inflammatory joint disease? Rheumatol Int 2011; 31: 493-499.
8. Van Belle TL, Gysemans CG, Mathieu C: Vitamin D in autoimmune, infectious and allergic diseases: a vital player? Best Practice & Research Clinical Endocrinology & Metabolism 2011; 25: 617-632.
9. Gatenby P, Lucas R, Swaminathan A: Vitamin D deficiency and risk for rheumatic diseases: an update. Curr Opin Rheumatol 2013; 25(2): 184-191.
10. Rass P, Pákozdi A, Lakatos P et al.: Vitamin D receptor gene polymorphism in rheumatoid arthritis and associated osteoporosis. Rheumatology International 2006; 26(11): 964-971.
11. Gómez-Vaquero C, Fiter J, Enjuanes A et al.: Influence of the BsmI polymorphism of the vitamin D receptor gene on rheumatoid arthritis clinical activity. Journal of Rheumatology 2007; 34(9): 1823-1826.
12. Garcia-Lozano JR, Gonzalez-Escribano MF, Valenzuela A et al.: Association of vitamin D receptor with early onset rheumatoid arthritis. European Journal of Immunogenetics 2001; 28: 89-93.
13. El-Barbary AM, Hussein MS, Rageh EM et al.: Vitamin D receptor gene polymorphism in rheumatoid arthritis and its association with atherosclerosis. Egyptian Rheumatology & Rehabilitation 2015; 42: 145-152.
14. Maalej A, Petit-Teixeira E, Michou L et al.: Association study of VDR gene with rheumatoid arthritis in the French population. Genes and Immunity 2005; 6: 707-711.
15. Hitchon C, Sun Y, Robinson DB et al.: Vitamin D Receptor Polymorphism rs2228570 (Fok1) Is Associated with Rheumatoid Arthritis in North American Natives. The Journal of Rheumatology 2012; 39(9): 1792-1797. DOI: 10.3899/jrheum.120387.
16. Mostafa Hussien YM, Shehata A, Karam RA et al.: Polymorphism in vitamin D receptor and osteoprotegerin genes in Egyptian rheumatoid arthritis patients with and without osteoporosis. Molecular Biology Reports 2013; 40(5): 3675-3680.
17. Cantorna MT, Hayes CE, DeLuca HF: 1,25-Dihydroxychoecalciferol inhibits the progression of arthritis in murine models of human arthritis. J Nutr 1998; 128(1): 68-72.
18. Laragione T, Shah A, Gulko PS: The vitamin D receptor regulates rheumatoid arthritis fibroblast invasion and morphology. Mol Med 2012; 18: 194-200.
19. Zwerina K, Baum W, Axman R et al.: Vitamin D receptor regulates TNF-mediated arthritis. Ann Rheum Dis 2011; 70: 1122-1129.
20. Van Hamburg JP, Asmavidjaja PS, Davelaar N et al.: TNF blockade requires 1,25(OH)D3 to control human Th17-mediated synovial inflammation. Ann Rheum Dis 2012; 71: 606-612.
21. Cutolo M: Further emergent evidence for the vitamin D endocrine system involvement in autoimmune rheumatis disease risk and prognosis. Ann Rheum Dis 2013; 72(4): 473-475.
22. Costenbader KH, Feskanich D, Holmes M et al.: Vitamin D intake and risk of systemic lupus erythematosus and rheumatoid arthritis. Ann Rheum Dis 2008; 67: 530-535.
23. Merlino MA, Curtis J, Mikuls TR et al.: Vitamin D intake is inversely associated with rheumatoid arthritis. Arthritis & Rheumatism 2004; 50(1): 72-77.
24. Song GG, Bae S-C, Lee YH: Association between vitamin D intake and the risk of rheumatoid arthritis: a meta-analysis. Clin Rheumatol 2012; 31: 1733-1739.
25. Mouterde G, Lucas C, Logeart I et al.: Predictors of radiographic progression in the ESPOIR cohort: the season of first symptoms may influence the short-term outcome in early arthritis. Ann Rheum Dis 2011; 70: 1251-1256.
26. Kriegel M, Manson JE, Costenblader KH: Does vitamin D affect risk of developing autoimmune disease? A systematic review. Semin Arthritis Rheum 2011; 40(6): 512-531.
27. Antico A, Tampoia M, Tozzoli R, Bizzaro N: Can supplementation with vitamin D reduce the risk or modify the course of autoimmune diseases? A systematic review of the literature. Autoimmunity Reviews 2012; 12: 127-136.
28. Rossini M, Bongi SM, La Montagna G et al.: Vitamin D deficiency in rheumatoid arthritis: prevalence, determinants and associations with disease activity and disability. Arthritis Research & Therapy 2010; 12: R216.
29. Raczkiewicz A, Kisiel B, Kulig M, Tłustochowicz W: Vitamin D status and its association with quality of life, physical activity, and disease activity in rheumatoid arthritis patients. JCR 2015; 21(3): 126-130.
30. Gatenby P, Lucas R, Swaminathan A: Vitamin D deficiency and risk for rheumatic diseases: an update. Curr Opin Rheumatol 2013; 25: 184-191.
31. Yazmal L, Ediz L, Alpayaci M et al.: Seasonal disease activity and serum vitamin D levels in rheumatoid arthritis, ankylosing spondylitis and osteoarthritis. African Health Science 2013; 13(1): 47-54.
32. Hong Q, Xu J, Xu S et al.: Association between serum 25-hydroxyvitamin D and disease activity, inflammatory cytokines and bone loss in patients with rheumatoid arthritis. Rheumatology 2014; 53: 1994-2001.
33. Haque UJ, Bartlett SJ: Relationship among vitamin D, disease activity, pain and disability in rheumatoid arthritis. Clinical and experimental rheumatology 2010; 28: 745-747.
34. Kostoglou-Athanassiou I, Athanassiou P, Lyraki A et al.: Vitamin D and rheumatoid arthritis. Ther Adv Endocrinol Metab 2012; 3(6): 181-187.
35. Higgins MJ, Mackie SL, Thalayasingam N et al.: The effect of vitamin D levels on the assessment of disease activity in rheumatoid arthritis. Clinical Rheumatology 2013; 32(6): 863-867.
36. Haga HJ, Schmedes A, Naderi Y et al.: Severe deficiency of 25-hydroxyvitamin D3 (25-OH-D3) is associated with high disease activity of rheumatoid arthritis. Clin Rheumatol 2013; 32(5): 629-633.
37. Baker JF, Baker DG, Toedter G et al.: Association between vitamin D, disease activity, and clinical response to therapy in rheumatoid arthritis. Clin Exp Rheumatol 2012; 30(5): 658-664.
38. Hasan E, Olusi S, Al-Awadhi A et al.: Effects of rituximab treatment on the serum concentrations of vitamin D and interleukins 2, 6, 7, and 10 in patients with rheumatoid arthritis. Biologics 2012; 6: 31-35.
39. Haga HJ: Vitamin D in rheumatoid arthritis. Expert review of clinical immunology 2013; 9(7): 591-593.