Vitamin D. Pat Ahlquist
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1 Vitamin D Pat Ahlquist
2 Aim What is it? What does it do? How do we get it? Why is this important to us? Why is this important to our patients?
3 Vitamin D Cholecalciferol (D 3 ) Ergocalciferol (D 2 ) Important for bone health Also immune system, nervous system, cardiovascular system
4 How do we get Vitamin D? oily fish such as salmon, sardines and mackerel eggs fortified fat spreads fortified breakfast cereals some powdered milks Not milk in UK
5
6 Immune system Vitamin D Induction of antimicrobial peptides (AMPs) at mucosal surfaces and in immune cells Down regulates proinflammatory cytokines Low levels associated with increased risk of TB and Resp Tract Infections Levels below 50nmol/l have x2 increased risk of developing MS
7 Cancer Link with colon cancer. Inconsistent evidence for prostate and breast cancer. Macrophages kill B-cell lymphoma cells by releasing AMPs in a vit D dependant fashion Rituximab-mediated macrophage cytotoxicity improved with vit D
8 How much do we need? No real consensus for insufficiency Institute of Medicine (USA) <50nmol/l Consensus for deficiency < 25nmol/l Toxicity >220nmol/l
9 Sun exposure
10 How much do we need? DOH recommends 400 units daily if Cover skin for cultural reasons >65 yrs age Housebound 800 units daily if mild deficiency
11 Palliative care relevance Bisphosphonates High incidence of deficiency in palliative care population Other symptoms that may be related to Vitamin D deficiency fatigue, pain.
12 Bisphosphonate prophylaxis for SRE Patients with vitamin D deficiency more likely to experience more severe and prolonged hypocalcaemia should be assessed before treatment (BMJ 2015 Sept Clinical review of bisphosphonates for prevention and treatment of osteoporosis) PCF 5 Caution increased risk of hypocalcaemia in Vitamin D deficiency (from a case report 2005 Am Journal hospice and PC)
13 Bisphosphonate prophylaxis for SRE Study showed significant higher rates of acute phase response symptoms in women with lower vitamin D levels (J Bone Mineral Research 2010)
14 Deficiency in palliative care population High levels in general uk population (50% insufficiency and 16% severe in winter/spring) Prevalence between 33 and 88% in cancer population Reasons for increase in palliative care population decreased sun exposure, food intake, malabsorption, liver and renal disease, steroids, anticonvulsants
15 Falls Prevention Vit D supplements ( u daily) Several meta-analyses Relative risk reduction up to 20% Vit D high intermittent high dose Increase risk of falls and fracture Combine with calcium and exercise
16 Symptom control issues Fatigue/qol study (Palliative Medicine Jan 2016) 30 patients 90% deficiency Fatigue ranked high in self assessmentsignificantly correlated with vit D levelscorrelated with PS Significant positive correlation of vitamin D with PS (Brisbane)
17 Pain Significant association with low vit D and higher opioid dose (100 Pall patients) If vit D <50 4x more likely to get muscle pain starting statins, and can also have abnormal nerve conduction Animal studies suggest connection with remyelination after nerve damage Björkhem-Bergman, Bergman bjspcare
18 Pain UVB exposure may increase endogenous opiates Case report GI cancer, liver and bone mets, Fentanyl 75 Unmeasurable vitamin D, given 2000u daily After 3 months level 56nmol/l, ESAS 9 2, albumin After 4 months, off Fentanyl, on chemo again Björkhem-Bergman, Bergman bjspcare
19 Colecalciferol InVita D3 (Consilient) Oral solution, colecalciferol 625 micrograms ( units)/ml, net price 3 1-mL unit amp = Fultium-D3 Fultium-D3 (Internis) Capsules, colecalciferol 20 micrograms (800 units) (blue), net price 30-cap pack = 3.60, 90-cap pack = 10.80; 80 micrograms (3200 units) (green), 30-cap pack = 13.32, 90-cap pack = 39.96; 500 micrograms (20000 units) (yellow), 15-cap pack = 17.04, 30-cap pack =
20 Colecalciferol Adcal-D3 Tablets (chewable) (lemon or tutti-frutti flavour), calcium carbonate 1.5 g (calcium 600 mg or Ca2+ 15 mmol), colecalciferol 10 micrograms (400 units), net price 56-tab pack = 3.65, 112-tab pack = Also effervescent and caplets (half strength)
21
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