Shon E. Meek, M.D., Ph.D. Assistant Professor of Medicine
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1 Shon E. Meek, M.D., Ph.D. Assistant Professor of Medicine 2016 MFMER
2 Update on Vitamin D Shon Meek MD, PhD 20 th Annual Endocrine Update January 30-Feb 3, 2017
3 Disclosure Relevant Financial Relationship none Off Label Usage none
4 Objectives 1. Learn the natural sources of vitamin D 2. Understand how vitamin D may improve bone health 3. Identify the factors which influence vitamin D metabolism.
5
6 What is the Richest Dietary Source of Vitamin D 1. Milk 2. Chicken 3. Egg yolk 4. Tuna 5. Salmon
7 Vitamin D Content IU Salmon, wild ug/kg Tuna ug/kg Mackerel ug/kg Trout, rainbow 150 ug/kg Cod ug/kg Beef ug/kg Pork ug/kg Chicken 2-3 ug/kg Egg yolk, Chicken 5-58 ug/kg Milk, raw ug/l 1 ug = 40 units Adv Nutr (4)453
8 Case 1 45 year old female referred for low vitamin D Past history gastric bypass for obesity Medicines calcium plus D 600 mg three times daily multivitamin plus iron vitamin B12 injections monthly
9 Case 1 Physical exam blood pressure 130/80 weight 108 kg healed abdominal scars Lab CBC normal calcium 8.9 mg/dl (normal ) phosphorus 3.5 creatinine 0.8 alkaline phophatase 115 magnesium normal 25 hydroxyvitamin D 19 ng/ml PTH 65 pg/ml (normal 15-50) 24 hour urine calcium 40 mg (normal )
10 Next Best Step 1. Recommend parathyroid scan and surgical referral 2. Recommend vitamin D 600 units daily 3. Recommend vitamin D 50,000 units once weekly for 8 weeks, followed by 2000 units daily 4. Recommend calcitriol 0.25 mcg twice daily 5. Recommend vitamin D 2000 units daily
11 Vitamin D Replacement Post Gastric Bypass 134 patient treated with gastric bypass Vitamin D 50,000 u/week x 8 weeks if vitamin D <30ng/ml, followed by 2000 u/d, 2000 units daily if D>30 ng/dl Vitamin D deficiency decreased from 64% to 28% at 1 year Obes Surg :2321
12 Vitamin D Post Gastric Bypass 50 patients undergoing gastric bypass randomized Vitamin D 100,000 q 2 weeks x 3 then 3420 units/d Control 3420 units/d Obes Surg 2016 online
13 Secondary Hyperparathyroidism Post Gastric Bypass 50 patients undergoing gastric bypass randomized Vitamin D 100,000 q 2 weeks x 3, then 3420 units/d Control 3420 units/d Obes Surg 2016 Online
14 Case 2 72 year old female with: Diabetes Hypertension, Chronic Kidney Disease Medicines lisinopril furosemide amlodipine metoprolol calcium plus D 600 mg three times daily with meals detemir insulin aspart insulin with meals
15 Case 2 Physical exam Blood pressure 140/85, pulse 56 decreased sensation on feet Labs calcium 8.9 mg/dl (normal ) albumin 4.0 mg/dl phosphorus 4.2 mg/dl (normal ) creatinine 2.5 mg/dl (normal ) Estimated GFR 30 PTH 120 pg/ml (normal 15-50) 25 hydroxyvitamin D 28 ng/ml glycosylated hemoglobin A1C 7.2 chemistries otherwise normal Bone density spine T- 2.6, hip T - 2.5
16 Next Best Step 1. Recommend parathyroid scan and surgical referral 2. Recommend paricalcitol 3. Recommend vitamin D 50,000 units weekly 4. Recommend vitamin D 600 units daily 5. Recommend an oral bisphosphonate
17 Paricalcitol vs Ergocalciferol for Secondary Hyperparathyroidism 80 patients CKD stage 3-4, 25 OH Vitamin D <30ng/dl Vitamin D units titrated to vitamin D > 30ng/dl Paricalcitol 1 ug/day Am J Kidney Dis (1):58
18 Vitamin D and Falls Meta-analysis 26 trials vitamin D reduced risk of fall OR.86 Effect more pronounced when vitamin D deficient and calcium supplemented studies JCEM :2997
19 Yearly Very High Dose Vitamin D Supplement Increases Falls and Fractures 2256 women >70, 500,000 u vitamin D yearly vs placebo for 3-5 yrs. Vitamin D group had 15% more falls, 26% more fractures Highest risk in first 3 months after vitamin D dose JAMA (18):1815
20 Higher Dose Vitamin D and Falls 200 patient >70 years, double blind randomized control No benefit on lower extremity function Increase falls in higher dose vitamin D compared to 24000/m JAMA Intern Med (2):175
21 Vitamin D without Calcium Fails to Reduce Fractures Ann Intern Med :827
22 Vitamin D with Calcium Reduces Fractures Ann Intern Med :827
23 Vitamin D and Bisphosphonate Response 210 patients treated with bisphosphonates at least 2 years. Bisphosphonate nonresponder: persistent T <-3, >3% decline in BMD, incident fracture Vitamin D> 33ng/ml had 4.5 fold greater odds of favorable response (p<0.0001) Osteoporosis Int 2012 Jan 12 online
24 Optimal Vitamin D Level Bone Density, ages > subjects age > 50 in NHANES III nmol/l = ng/ml vitamin D Whites, Mexican Americans, Blacks Am J Med :634
25 Optimal Vitamin D Levels PTH Suppression 209 women, 182 men age> nmol/l = ng/ml vitamin D Am J Clin Nutrition :67
26 Optimum Vitamin D Levels Increase in 1,25 Dihydroxyvitamin D 17 children with nutritional rickets treated with Vitamin D2 or D3 JCEM :3314
27 Vitamin D Level and Mortality 15,099 participants >20 years of age, 15 year follow up 3784 deaths JCEM :3001
28 Vitamin D3 versus D2 64 adults age >64years 1600 u daily vs u monthly of D2 or D3 JCEM (4):981
29 Estrogen Containing Contraceptives Increases Vitamin D Levels 1662 African American women aged mcg ethinyl estradiol used JCEM :3370
30 Vitamin D Supplementation in Pregnancy 829 patients 1000 u vitamin D daily vs placebo 83% vitamin D group achieved >50nmol/l at 34 weeks 36% placebo group achieved >50nmol/l at 34 weeks JCEM
31 Vitamin D Dose Attenuated in Obese 13 controls BMI obese BMI 38 Treated with single dose of vitamin D2 50,000 units Am J Clin Nutr :690
32 Vitamin D Level and Dose Frequency 48 women with hip fracture treated with either: 1500 units vitamin D3 daily 10,500 units vitamin D3 weekly 45,000 units vitamin D3 monthly J CEM :3430
33 Vitamin D Summary Vitamin D is obtained naturally from fish, fortified dairy, mushrooms, egg yolks, and sunlight 25 hydroxyvitamin D is the best measure of vitamin D sufficiency Vitamin D is important in bone health and fall risk Vitamin D levels are affected by medical conditions, drugs, obesity, pregnancy and type of vitamin D
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