JURNAL STASE PARU

Effects of vitamin D supplementation on

the outcomes of patients with pulmonary
tuberculosis: a systematic review and metaanalysis

Dandy Firmansyah Pembimbing :

PPDS Ilmu Penyakit Dalam
dr. Eko Budiono SpPD KP
Periode Juli 2017
 BACKGROUND
Tuberculosis (TB) is a major health problem
(WHO, 2017)

Variations in serum vitamin D concentration

were strongly related to the incidence of TB
( Martineu, 2011 & Maclachlan, 2002)
 OBJECTIVES

To measure effects of vitamin D

supplementation on patients with
pulmonary tuberculosis consisted of
efficacy assessment and safety evaluation
CRITERIA FOR CONSIDERING STUDI

• Randomized control trials, irrespective of

Types of study language

• RCTs, newly diagnosed with PTB who

Inclusion were on initial anti-tuberculosis
treatment, aged > 16 years, and receiving
criteria vitamin D3 or vitamin D2 as an
interventional treatment

• Patients had taken oral corticosteroid or

other immunosuppressant therapy, or
Exclusion citeria drugs known to interfere with vitamin D
levels
• Pregnant women
Outcome Measures

Primary • Proportion of sputum smear or culture conversion

outcomes • Time to sputum smear or culture conversion

• serum 25-hydroxy vitamin D(25(OH)D) concentration

serum, calcium concentration, TB score, chest imaging,
Secondary body mass index (BMI), weight gain, mean mid-upper
arm circumference, C-reactive protein (CRP),
outcomes erythrocyte sedimentation rate (ESR), blood indexes
(total white cell, neutrophil, monocyte, lymphocyte,
and hemoglobin), adverse effects, and mortality
 SEARCH STRATEGY

We searched Medline, Embase, Cochrane

Central Register of Controlled Trials, Web of
Science (Until Nov 26, 2017)

This study limitations in the publication type

of RCTs but not in the publication language
 METHODS
Data collection
• Two investigators independently assessed trial
eligibility and quality, and extracted data.
• For any missing information, corresponding authors
were contacted by email
• A third investigator was consulted to solve any
disagreement on study selection, data extraction,
or quality assessment
Quality Assesment
• Five GRADE considerations & the Cochrane risk of
bias tool
Data analysis
• Data were analysed using Review Manager 5.3
RESULT
 MAIN RESULTS
Vitamin D supplementation increased the proportion of sputum
smear and culture conversions but did not improve the time to
sputum smear and culture conversions

Vitamin D improved serum 25(OH)D, plasma calcium concentration,

lymphocyte count, and chest radiograph but had no impact on
adverse events, mortality and other indicators (TB score, BMI, mean
mid-upper arm circumference, weight gain, CRP, ESR, and other blood
cells)
DISCUSSION
 DISCUSSION

Need more rigorous and

larger scale RCTs to verify
effects of vitamin D are there potential effect of
supplementation on the
vitamin D supplementation immune modulatory effect of
outcomes of patients with
on accelerating resolution of vitamin D might have a
pulmonary tuberculosis
Inflammatory responses preventing role on TB
because the results of this
metaanalysis are inconsistent during tuberculosis therapy ?
with those of previous meta-
analyses
 Limitations

The administration doses of

For small number of vitamin D receptor
vitamin D, duration of
published RCTs, power of polymorphisms do not
treatment, and follow-up
some analyses was limited analized
time were different
AUTHORS’CONCLUSIONS

Vitamin D supplementation can safely and effectively

increase the proportion of sputum smear and culture
conversion, but it may not have enough beneficial effects
on time to sputum conversion

Vitamin D supplementation considered a cost-effective

strategy in treating patients with PTB
Critical Appraisal
DOES THIS REVIEW ADDRESS A CLEAR QUESTION?

YES CAN’T NO
TELL
1. Did the review address a clearly focussed issue? YES
Was there enough information on:
• The population studied
• The intervention given
• The outcomes considered
2. Did the authors look for the appropriate sort of papers? YES
The ‘best sort of studies’ would
• Address the review’s question
• Have an appropriate study design
 ARE THE RESULTS OF THIS REVIEW VALID ?

YES CAN’T NO
TELL
3. Do you think the important, relevant studies were included? YES
Look for
• Which bibliographic databases were used
• Follow up from reference lists
• Personal contact with experts
• Search for unpublished as well as published studies
• Search for non-English language studies
4. Did the review’s authors do enough to assess the quality of the included studies? YES
The authors need to consider the rigour of the studies they have identified.
Lack of rigour may affect the studies results.
5. If the results of the review have been combined, was it reasonable to do so? YES
Consider whether
• The results were similar from study to study
• The results of all the included studies are clearly displayed
• The results of the different studies are similar
• The reasons for any variations are discussed
 WHAT ARE THE RESULTS?

YES CAN’T NO
TELL

6. What is the overall result of the review? YES

Consider
• If you are clear about the reviews ‘bottom line’ results
• What these are (numerically if appropriate)
• How were the results expressed (NNT, odds ratio, etc)

7. How precise are the results? YES

Are the results presented with confidence intervals?
 WILL THE RESULTS HELP LOCALLY ?

YES CAN’T NO
TELL
8. Can the results be applied to the local population? YES
Consider whether
• The patients covered by the review could be sufficiently different
from your population to cause concern
• Your local setting is likely to differ much from that of the review

9. Were all important outcomes considered? YES

10. Are the benefits worth the harms and costs? YES
Even if this is not addressed by the review, what do you think
Thank you