1. Rod Hughes Rheumatology ASPH 6th Oct 2011
Vitamin D for the GP
Rod Hughes
Rheumatology ASPH
6th Oct 2011

2. Surrey data 50% of the population is Vitamin D deficient
150,000 ‘potential’ cases
Exponential rise in ordering of Vitamin D testing
Cost per test - £2.90 ASPH

3. Vitamin D NHS Surrey

4. The size of the problem No-one is sure how to treat
No-one is sure when to treat
No-one is sure who to treat
No-one is sure how long you treat for

5. Vitamin D – clinical issues
Should we be restricting access to testing?
Should we be testing everyone?
When to test
What time of year
When to treat
What with and for how long
How to reassure the worried well

6. Vitamin D deficiency – an epidemic

7. Sources of Vitamin D
Vitamin D2 – ergocalciferol – synthesised by plants
Vitamin D3 – cholecalciferol the analyte – colecalciferol the drug – from UVB effect on skin of invertebrates – naturally in fish
Vitamin D measurement = 25 hydroxy Vit D – raised by both Vit D2 and D3

8. Sources of Vitamin D
2-3 exposures of mins sunlight per week should provide enough Vit D for adults in the UK
Sun exposure due to latitude in the UK insufficient to provide needs Oct through to April
Diet – oily fish, egg yolks, light exposed mushrooms and liver + fortified products

9. Vitamin D – the media

10. Some facts Half the world’s population is Vit D deficient
Holick MF. Vitamin D deficiency. N Engl J Med. 2007; 357:266-81
The Institute of Medicine (IOM)Nov 2010 recommends increasing the daily vitamin D intake for children and adults to 600 IU per day for people ages 1 to 70, and 800 IU for people over age 70.
A combined analysis of multiple studies found that taking 700 to 1,000 IU of vitamin D per day lowered the risk of falls by 19 percent, but taking 200 to 600 IU per day did not offer any such protection.
Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009; 339:b3692.
Low vitamin D levels might somehow increase colon cancer risk
Garland CF, Garland FC. Do sunlight and vitamin D reduce the likelihood of colon cancer? Int J Epidemiol. 1980; 9:

11. Osteomalacia Impaired mineralisation phase of remodelling
Spinal bone pain
Pelvic pain
Leg pain
Muscle weakness
Hypocalaemia
Pelvic flattening
Low trauma fractures
Bone softening and bending of bones

12. Clinical presentation
Insidious onset
Lumbar pain
Lordosis and pelvic flattening
Waddling gait
Low trauma fractures
Bone sensitivity on pressure
Easy fatiguability

13. Osteomalacia images

15. Assays
Assay of serum 25-hydroxy Vit D by measuring 25-hydroxy D3 or total 25 hydroxy D2 and D3
<25 nmol/L – severely deficient – below this level PTH starts to rise and bone turnover increases
25-50 nmol/L – insufficient
50-75 nmol/L - adequate
>75 nmol/L – normal and replete
Highest levels at the end of summer and lowest in the early Spring

16. Case 1 34 year old doctor 28 weeks pregnant 1st pregnancy
Tired – aching – feels unwell
Sees her GP and asks for Vitamin D levels
Measured nmol/L
Wants to be treated as she feels that her risks for foetal abnormality are increased

17. Case 1 Management advice
What would you tell her?
What treatment would you give?
What follow up would you give?

18. Case 2
47 year old asian lady presents with proximal myalgia and leg pain
Vitamin D levels June 2011 – 6 nmol/L
No clear cause for deficiency
X rays suggest Looser’s zones tibia bilaterally
Seen at the request of the GP in Rheumatology

19. Case 2 – Management advice
What would you treat her with?
Specific product
Dose
Duration
What follow up instructions would you give

20. Case 3 54 year old lady with ulcerative colitis
Vitamin D levels via GP 18nmol/L
Feels tired
Joints and muscles ache

21. Case 3 – management advice
What would you treat her with?
Product
Dose
Duration
Route

22. Who should you test? Features of symptomatic deficiency
Insidious-onset widespread bone pain and tenderness
Proximal muscle weakness
Swelling and tenderness at pseudo-fracture sites
Fractures at osteoporotic sites
Myalgia with raised CPK

23. Predisposing features
Black and ethnic minorities with dark skin
Elderly patients in residential care and housebound
Intestinal malabsorption
Wearing of a veil or habitual sunscreen
Vegan/ vegetarian
Liver or renal disease
Anti-convulsants / cholestyramine / rifampicin / steroids / anti- retrovirals

24. Pregnancy Non-evidence based advice
Pregnant women and women with a baby under 1 yr old and children from six months to age 4 are entitled to free vitamins under Healthy Start programme
Treat severe deficiency in pregnancy to avoid foetal risk

25. Assessing Vit D status Serum calcium
PTH (unstable – on site phlebotomy)
Alkaline Phosphatase
Phosphate
Renal function
Liver function
FBC (exclude malabsorption)

26. Treatment Colecalciferol (D3) is the preferred form of treatment
Colecalciferol may raise Vit D levels more effectively than ergocalciferol as it binds better to liver enzymes, plasma Vit D binding protein and vitamin D receptors
Some assays only measure metabolites of colecalciferol

27. What to use? Deficiency – colecalciferol when less than 25nmol/L Drug
Preparation and manufacturer
Distributors and price
6000iu per day for one month
Lamberts Vit D units
Lamberts healthcare or via Alliance Healthcare £7.65 /120
60,000iu orally once per week for 12 weeks
Dekristol 20,000iu capsule
Martindale pharma £ p/p for 50
2 x IM injections of 300,000iu 3 months apart
Colecalciferol 300,000 Streuli Switzerland
Pack of 10 injections £ p/p
150,000iu (50 mls of 3000iu/ml liquid) once daily for 2 days
Special liquid products are not commercially available
Martindale pharma 100mls £71.89

28. What to use? Insufficient
25-50 nmol/L – oral supplementation of units of colecalciferol for 12 weeks
Preferred product is Lambert’s Vit D3 tablets 1000 units
As a fat soluble vitamin D tablets should be taken with food to enhance absorption
Test Vit D after treatment – 3 months later

29. What to use?
Maintenance after treatment 800 – 1000 units daily sometimes for life Adcal D3 (calcium carbonate 1.5g & colecalciferol 400units) one tablet twice daily

30. Vitamin D Surrey

31. Alfacalcidol 1 – alpha hydroxy colecalciferol
With kidney failure or after parathyroidectomy
0.25 microgm or 1 microgm capsules
Dose – initial 1 – 3 microgm daily to achieve calcium normality then maintain at 0.25 – 1 microgm daily
Itching / urticaria / hypercalcaemia / kidney stones

32. Calcitriol (rocaltrol)
1, 25 dihydroxy colecalciferol
Greater chance of inducing hyper calcaemia
Some data in osteoporosis management
Use with dialysis
Start at 0.25 microgm daily and titrate upwards to 0.5 – 1.0 microgm daily

33. Vitamin D NHS Surrey

34. Case 1 Reassure 80% pregnant women have Vit D levels below 75 nmol/L
Suggest supplementation with adcal D3 2 tablets daily
Repeat Vit D 3 months after pregnancy

35. Case 2 Preferred treatment Lamberts Vit D3 600iu daily for 1 month
Repeat Vit D levels
Start maintenance supplementation as adcal D3 for life

36. Case 3 IM Vit D3 300,000iu 2 x 3 months apart Repeat Vit D assay
Repeat treatment?

37. Vitamin D guidelines Guidance on testing and results interpretation
Help with treatment choice and availability
Avoidance of expensive and sub optimal treatments
Standardise replacement and testing across primary and secondary care