PREVENTION OF BENIGN PAROXYSMAL POSITIONAL

VERTIGO WITH VITAMIN D SUPPLEMENTATION

A RANDOMIZED TRIAL

Seong-Hae Jeong,MD,PHD, Ji-Soo Kim, MD, PhD, Hyo-Jung Kim, PhD, Jeong-Yoon choi, MD, PhD,
Ja-Won Koo, MD, PhD, Kwang-Dong Choi, MD, PhD, Ji-Yun Park ,MD, PhD,Seung-Han Lee,MD,
PhD, Seo-Young Choi, MD,PhD, Sun-Young Oh, Md, PhD, Tae-Ho Yang, MD, Jae han Park,MD,
Ileok Jung,MD, Soyeon Ahn,PhD, and Sooyeon Kim, MS.
Journal of The American Academy of Neurology 95 (2020) e1117- e1125

Presented by Disa Almira, MD

Jakarta November 17th 2021
BACKGROUND
Otoconia (otolith) dislodge to
semicircular canal induced by
change in head position

1 - 10 year recurrence rate of

15 - 56%. Multicenter, pragmatic,
Objective:
randomized , controlled trial to
BPPV ↑ cost to diagnosis and
to determine themanagement
efficacy ofofBPPV vitamin D 400 IU and
assess500 mg ofofvitamin
the effect calcium
D and
calcium supplementation in
carbonate twice a day for one year in reducing recurrences
preventing
of BPPVof using
recurrences BPPV
No established ways to
a randomized controlled trialattacks
prevent further

Higher prevalence of vit D

deficiency or insufficiency with
decreased bone mineral
density in BPPV Patients
METHODS (1) INTERVENTION
Primary Outcome
• Total Number of BPPV
1 YEAR OF
•Randomized Controlled Trial 400 IU VIT D , recurrences per patient ( annual
500 mg CaCO3 recurrence rate of BPPV per one-
BPPV
•8 university 445
PATIENTS hospitals in South Korea person year)
VIT D SERUM
LEVEL <20
NG/ML, 2 & 12
December
CANALITH 2013 MONTHS
May 2017
REPOSITION SIMPLE
MANUEVERS 1050
RANDOMIZATION
Secondary Outcome
(1491) 1:1 Ratio
Proportion of BPPV recurrence,
Inclusion Criteria OBSERVATION
Exclusion Criteria Change in serum vitamin D,
• > INCLUSION,
18 years of age • Planned use of vitamin Dannual
(FOLLOW UPS) fall therapy.
or calcium rate, annual fracture
• Confirmed 512
EXCLUSIONand treated BPPV • Pregnancy rate using UCLA - DQ
VIT D SERUM
• History
CRITERIA of an allergic reaction/ significant adverse
LEVEL IS NOT
reaction to the investigational product
EVALUATED
RESULT

Group Relative Absolute

P value

Intervention Observation
(N=445) (N=512) difference difference

Primary Outcome

Annual recurrence rate (95% 0.83 (0.74 to 1.10 (1.00 to 0.76 (0.66 -0.27 (-0.40 to
CI)a 0.92) 1.19) to 0.87) -0.14) < 0.001

Secondary Outcome

Proportion of BPPV 37.8% (33.3 to 46.7% (42.4 to 0.81 (0.70 -8.9% (-15.2
recurrence (95% CI) 42.3) 51.0) to 0.94) to -2.7) 0.05

Changes in serum vitamin D 13.3 (3.9) to 24.2 10.9 (10.0 to

(ng/ml)b (8.4) NA NA 11.9) <0.001

0.22 (0.17 to 0.18 (0.14 to 1.25 (0.93 0.04 (-0.02 to

Annual fall rate (95% CI)a 0.27) 0.21) to 1.69) 0.10) 0.14

Annual fracture rate (95% 0.03 (0.01 to 0.03 (0.02 to 0.93 (0.44 -0.002 (-0.03
CI)a 0.05) 0.05) to 1.96) to 0.02) 0.84
RESULTS (2)
Comparison of annual recurrence rate according to serum vitamin D level in the intervention group
Adverse events Intervention group Control group
(N=445) (N=512)
Outcome Group Relative difference Absolute difference P value
≥ 1 Adverse events 26 3
Normal (N=146) Decreased (N=299)
Withdrawals due to adverse
events
0.95 (0.79 to 1.11) ) 0.76 (0.65 to 0.87 1.24 (1.00 to 1.56) 0.19 (0.01 to 0.38) 0.05

Related to the study drug 8

Normal(N=146) 8 (N=512)
Observation
0.95 (0.79 to 1.11) 1.10 (1.00 to 1.19) 0.87 (0.72 to 1.05) -0.15 (-0.34 to 0.04) 0.14
Related to other adverse events 2 2

Decreased (N=299)
Death Observation
0 (N=512) 3

Anorexia
0.76 (0.65 to 0.87) 1 to 1.19)
1.10 (1.00 0.70 (0.59 to 0.82) -0.33 (-0.48 to -0.19) <0.001
Annual recurrence rate
(95% CI) dyspepsia 10 (N=228)
Deficient (N=71) Insufficient
0.60 (0.40 to 0.80)
Constipation 0.81 (0.69
5 to 0.94) 0.74 (0.51 to 1.06) -0.21 (-0.45 to 0.02) 0.08

Deficient (N=71)
Edema Observation
3 (N=512)

0.60sense
Itching (0.40 to 0.80) 1.10 (1.02 to 1.19) 0.55 (0.39 to 0.77) -0.50 (-0.72 to -0.28) <0.001

Insufficient (N=228)
Urticaria Observation
1 (N=512)

0.81 (0.69 to 0.94)

Hypercalcemia 1.10 (1.02 to 1.19) 0.86 (0.79 to 0.94) -0.28 (-0.44 to -0.13) <0.001
aEach group was classified with the following criteria of serum 25(OH) vitamin D; normal, ≥ 20 ng/ml; insufficient, 10 ng/ml ≤ & < 20 ng/ml;
Loose stool 2
deficient, < 10 ng/ml. The decreased group included both insufficient and deficient groups (< 20 ng/ml). CI = confidence interval
DISCUSSION
Daily oral Vit D and Calcium Carbonate significantly
reduced recurrences of BPPV

Canalith repositioning maneuvers has been the only verified

treatments of BPPV

Vit D help to regulate some Ca2+ binding proteins in Ca2+

channel transport system

Calcium is required to mineralize the otoconia for

maintenance of turnover
CONCLUSION :
THIS STUDY PROVIDES CLAS III EVIDENCE: FOR PATIENTS WITH BPPV,
VIT D AND CALCIUM SUPPLEMENTATION REDUCE RECURRENCES OF
BPPV, ESPECIALLY WHEN SERUM VITAMIN D IS SUBNORMAL

Limitation :
• absence of placebo control
• potential for misclassification of
vertigo by questionnaire
• Ethnicity Bias
Thank You