A Review of Vitamin D Supplementation in the Adult Patient ACPE UAN: H01-P

A Review of Vitamin D Supplementation in the Adult Patient ACPE UAN: 0171-9999-15-053-H01-P Joshua Hirschhorn, PharmD Candidate, Class of 2015. South Carolina College of Pharmacy, MUSC Campus. Kristy L. Brittain, PharmD, BCPS, CDE. Assistant Professor Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, MUSC Campus. Objective: At the conclusion of this knowledge-based activity, the pharmacist will be able to: 1) Review the physiological role of vitamin D and identify potential consequences of deficiency or toxicity. 2) Identify guiding organizations and interpret their specific recommendations on vitamin D supplementation. 3) Identify available preparations of vitamin D and characteristics to guide selection of a product for a patient. 4) Given a patient case or scenario, recommend a course of vitamin D therapy. Abstract Summary: Sales of vitamin D supplements have increased by an order of magnitude over the past decade, and patients may present to their community pharmacy with questions of what and how much to take. This article will review the physiological impact of vitamin D and its clinical use in practice. Multiple organizations provide guidance on appropriate dosing and target serum concentrations of vitamin D. Specific guidelines from the Institute of Medicine (IOM), National Osteoporosis Foundation (NOF), American Geriatric Society (AGS), and Endocrine Society publications are addressed. Vitamin D supplements are available as vitamin D3 (cholecalciferol), vitamin D2 (ergocalciferol), and calcitriol in multiple dosage forms and a range of strengths, a potentially daunting choice for the patient and an opportunity for the pharmacist to help. Conclusion: Pharmacists may increasingly expect to receive questions about vitamin D, its potential health benefits, and selection of an appropriate product and dosing regimen. Benefits for bone health and fall prevention are established, and extraskeletal benefits such as cardiovascular mortality have shown correlation. Prospective trials examining extraskeletal health benefits are underway. Guidance from IOM, NOF, AGS, and Endocrine Society provide suggestions of 600 to 4,000 IU per day depending on age. Patients concerned for deficiency requiring a corrective regimen may be referred to a physician for laboratory diagnosis. Keywords: vitamin D, cholecalciferol, ergocalciferol, osteoporosis, geriatric, dietary supplement Introduction Vitamin D has received increased attention in recent years, both for its known role in skeletal health as well as potential involvement in other physiological systems. Sales of vitamin D supplements have increased over 10-fold in the United States, from $50 million to $600 million per year, between 2005 and 2011. 1 The most recent United States National Health and Nutrition Examination Survey (NHANES III), conducted in 2006, found 41.6% of adult participants had serum vitamin D concentrations under 20 ng/ml, a threshold considered inadequate for optimal health by several published guidelines. 2-6 Vitamin D has a recognized role in calcium homeostasis and bone metabolism; it increases serum calcium by increasing absorption of calcium, and to a lesser extent, phosphate from the small intestine. Vitamin D, along with parathyroid hormone, additionally acts to increase serum calcium concentrations via bone resorption. These actions are balanced by the serum-calcium-lowering activity of calcitonin. 7 Palmetto Pharmacist Volume 55, Number 5 19

The majority of vitamin D in the body is produced as cholecalciferol (vitamin D3) by the skin in response to ultraviolet-b rays in sunlight. Very few foods, such as fatty fish, naturally contain vitamin D although others, such as breakfast cereals and milk, are fortified. 2,8 Dietary sources may contain cholecalciferol or ergocalciferol (vitamin D2, of plant origin). 7 Average American adults consume approximately 150 to 225 international units (IU) per day from food. 5 Dietary or endogenous vitamin D is converted to calcidiol (25-hydroxyvitamin D) in the liver and then to the active form, calcitriol (1,25-dihydroxyvitamin D), in the kidney. 7,9 This process provides a number of potential causes for deficiency of the active form, including lack of sun exposure, decreased production by the skin, deficiency in dietary intake, or liver or kidney dysfunction. 8,10 All of these etiologies may increase in prevalence as patients age. Complications of hyper- and hypovitaminosis D Skeletal benefits have been established outcomes in vitamin D trials. Low bone mineral density and risk of hip and nonvertebral fractures correlate inversely with vitamin D in older individuals (age 65 years), as does risk of fall events. 5,11,12 However, the vitamin D receptor has been found to be expressed in a multitude of cell types in the human body including bone, skeletal muscle, immune, colon, pituitary, ovarian, and parathyroid cells and thus extraskeletal benefits are also beginning to draw research. 8,13 Deficiency of vitamin D may be subclinical; symptoms of bone pain and muscle weakness may be subtle or unnoticed. Chronic deficiency can result in bone demineralization and manifest as osteomalacia in adults or rickets in children. 8,10 Vitamin D toxicity is rare in the absence of supplementation because prolonged sun exposure degrades vitamin D3 as it forms. 7,8 Serum concentrations required to elicit toxicity differ by reference, with values greater than 200 ng/ml or as low as 60 ng/ml suggested. 5,8 A toxicity threshold for daily oral intake is suggested between 10,000 and 40,000 IU per day. This intake is well above maintenance dosages suggested by guidance from the organizations detailed below. Hypervitaminosis D may raise serum calcium levels, which can result in vascular and tissue calcification, damaging the heart, blood vessels, and kidneys. Excessive long-term intake of vitamin D is also associated with increases in mortality, some cancers, and fracture risk. Symptoms of toxicity may be non-specific, including anorexia, weight loss, polyuria, and arrhythmias. 8,9 Potential extraskeletal benefits of vitamin D supplementation have thus far been examined only in observational studies. A 2014 meta-analysis examined correlation between vitamin D serum concentrations and the outcomes of all-cause mortality, cardiovascular mortality, and cancer mortality. The investigators incorporated data from NHANES III along with 7 studies across 16 European nations. All were prospective cohort studies. The authors analyzed differences in outcomes between the patients with serum vitamin D concentrations in the bottom versus top 20% from each included study and pooled the results. Cut-offs for the bottom quintile of serum vitamin D concentrations ranged from less than 6.6 ng/ml in a Czech Republic study (HAPIEE CZ), to less than 16.8 ng/ml in NHANES III. Top quintile cut-offs ranged from 17.5 ng/ ml or greater in HAPIEE CZ to 34.24 ng/ml or greater in NHANES III. The analysis included 26,018 men and women ages 50 through 79, with trial follow-up periods ranging from 4.2 to 15.9 years. 2 Relative risk (RR) of all-cause mortality was 57% higher in the bottom quintile of subjects, as compared with the top quintile. Cardiovascular mortality was higher in the lowest quintile, both in patients with preexisting cardiovascular disease (RR 1.65) and those without (RR 1.41). Patients in the bottom quintile of serum vitamin D concentrations and a history of cancer had a 70% increase in relative risk of death from cancer compared with the top quintile. These 4 mortality outcomes were statistically significant; however, no significant difference in cancer mortality was seen among patients without a history of cancer. 2 While these results show only correlation and not causation with respect to vitamin D and mortality, the relationship warrants further study to determine whether low vitamin D is a marker of bad health or a cause of it. Multiple placebocontrolled trials are underway with tens of thousands of participants, but the first results are not expected until 2017. 1,2 Measurement of serum concentrations Given the potential benefits of appropriate concentrations of vitamin D, patients suspected of deficiency, or at risk for such deficiency, may have their serum concentration measured. Laboratories assess 25-hydroxyvitamin D, the metabolite formed between 20 Palmetto Pharmacist Volume 55 Number 5

hydroxylation steps in the liver and kidney, as it fluctuates less than calcitriol and has a much longer half-life (weeks for calcidiol versus hours for calcitriol). Serum calcidiol concentrations should be measured in patients at risk for deficiency; qualifying conditions may include malabsorption, obesity, limited sun exposure or very dark skin, chronic renal or hepatic disease, osteoporosis, older patients with a history of falls, or those on certain medications including glucocorticoids and some anti-seizure drugs. 4,6 The subsequently mentioned organizations publishing guidance on vitamin D do not consider screening or monitoring necessary for the general public. 5,6,14 Summary of guideline recommendations Several United States organizations have produced publications on the management of vitamin D. These include the Institute of Medicine (IOM), National Osteoporosis Foundation (NOF), American Geriatrics Society (AGS), and the Endocrine Society. These organizations differ in how they describe goal serum concentrations of vitamin D, although all consider values below 20 ng/ml suboptimal for skeletal health. Recommendations for daily supplementation also differ, and it is important to note the portion of the population to which each guidance is targeted. Table 1 contains an overview of goal serum concentrations, and the following sections will briefly describe specifics to each organization s published guidance. Institute of Medicine recommendations The IOM was tasked by the United States and Canadian governments to assess current data on calcium and vitamin D, resulting in a 2010 brief. The Recommended Daily Allowances (RDA) are the basis for information within nutrition labels on commercial food products. IOM recommends 600 IU of vitamin D per day from dietary sources for all individuals age 1 to 70, and 800 IU of vitamin D daily for those greater than 70 years of age. IOM also sets an upper limit of 4,000 IU of vitamin D per day, beyond which the risk for harm begins to increase. The IOM committee found blood concentrations greater than 20 ng/ml to be the level that is needed for good bone health for practically all individuals. 3 JOURNAL CE National Osteoporosis Foundation recommendations The NOF published their most recent Guide to Prevention and Treatment of Osteoporosis in 2014. They note the IOM recommendation above, but NOF recommends adults have an intake of 800-1,000 IU per day of vitamin D beginning at age 50 for both bone health and to reduce risk of falls. NOF recommends serum testing of vitamin D concentrations in individuals at risk for deficiency, with supplementation to achieve a level of approximately 30 ng/ml. NOF suggests a dosing regimen for deficient adults of 50,000 IU vitamin D once weekly for 8-12 weeks with maintenance dosing (suggested 1,500 to 2,000 IU per day) to maintain approximately 30 ng/ml. 4 American Geriatrics Society recommendations The AGS provided a 2013 consensus statement on vitamin D supplementation in adults at least 65 years of age, with a stated goal of avoiding falls and fall-related injuries in the primary care setting. Based on their review of the evidence, AGS noted serum concentrations of vitamin D less than 30 ng/ml to be associated with balance problems, muscle weakness, higher fall rates, and lower bone-mineral density. For all older adults, AGS recommends an average of 4,000 IU of vitamin D per day from all sources, including cutaneous production, to achieve a minimum serum vitamin D goal of 30 ng/ml. The guidance publication includes a simple worksheet to estimate an appropriate daily dose of vitamin D, accounting roughly for factors including sun exposure and skin pigmentation, obesity, and input from foods or multivitamins. Separate from the worksheet, AGS notes a recommendation to supplementation with at least 1,000 IU per day, and to also provide calcium. AGS notes 4,000 IU per day of vitamin D is unlikely to result in toxic levels, proposing an upper tolerable level of 10,000 IU per day. 5 Endocrine Society recommendations The Endocrine Society published their most recent guidelines on vitamin D deficiency in 2011. Sufficient serum vitamin D is considered above 30 ng/ml. Endocrine Society suggests adults ages 19 to 70 and adults over age 70 require at least 600 IU and 800 UI of vitamin D per day, respectively, Palmetto Pharmacist Volume 55, Number 5 21

to maximize bone health and muscle function. The guidelines note that achieving serum concentrations above 30 ng/ml may require at least 1,500 to 2,000 IU per day, and consider 10,000 IU per day an upper limit of dosing. For individuals with existing vitamin D deficiency, Endocrine Society guidelines are nearly identical to NOF: 50,000 IU once per week for 8 weeks followed by 1,500 to 2,000 IU per day to maintain serum concentrations above 30 ng/ml. Endocrine Society guidelines suggest significantly higher dosing in patients with obesity, citing sequestration of the fat-soluble vitamin in body fat. The suggestion is at least 6,000 to 10,000 IU of vitamin D per day to treat deficiency followed by maintenance with at least 3,000 to 6,000 IU per day. 6 Sources of vitamin D supplementation Pharmacologic supplementation of vitamin D is available as either vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol). Tablet products may be less expensive than liquid capsules, while the latter contains oil to aid absorption of the vitamin. Chewable cholecalciferol tablets, gummies, and liquid drops are alternatives for patients with difficulty swallowing pills. Patients concurrently taking calcium supplements may choose a combination product. Both vitamin D2 and D3 are effective at raising vitamin D levels, however at higher doses vitamin D3 is more potent. 8,15 Vegan patients may prefer vitamin D2 as it is of plant origin, while D3 is derived from lanolin of sheep. Preparations of 50,000 IU vitamin D2 are available as a prescription product, which a patient s insurance plan may cover. Calcitriol, the active metabolite of vitamin D2 or D3, may be required in patients unable to metabolize those precursors, for example patients with endstage renal disease. Note that calcitriol is dosed in micrograms, unlike the IU dosing of cholecalciferol and ergocalciferol. Outside of special populations, calcitriol is more expensive, prescription-only, and otherwise not the first-line choice. Regardless of pharmacological supplement selected, patients should be discouraged from attempting to obtain vitamin D from unprotected exposure to ultraviolet radiation such as sunlight or tanning beds. The American Academy of Dermatology (AAD) recommends obtaining vitamin D exclusively from dietary and/or vitamin supplement sources to reduce the risk of cancer or premature aging of the skin. 16 Role of the pharmacist Patients prescribed a high-dose weekly regimen for vitamin D deficiency must be counseled on the appropriate dosing interval. A challenge with vitamin D is that toxicity may not be apparent to the patient or health care provider and therefore it is important to inquire how the patient is taking the product. Also from a safety perspective, pharmacists should be vigilant for prescriptions with weekly doses incorrectly written for daily administration. An otherwise healthy adult seeking advice on vitamin D supplementation may be recommended 600 to 800 IU of vitamin D per day, or 1,000 IU daily if elderly. Patients intending to address bone health must also be receiving adequate calcium from diet or supplements. Consider referring patients to their physician if they have risk factors for vitamin D deficiency and may benefit from laboratory measurement of serum concentrations to determine if they require larger replacement doses. Some pharmacies present patients with rows of vitamin D products from which to choose. To assure purity and quality, the patient may select dietary supplement products with the USP Verified logo on the label. Although tablets may be cheapest, patients with difficulty swallowing them may prefer gel capsules or chewable tablets or gummies. To reduce pill burden, patients may find it more convenient to take vitamin D3 once weekly or once monthly, while D2 dosing intervals should not exceed 2 weeks, owing to pharmacokinetic differences. 5 Once-yearly mega-doses of vitamin D (eg, 500,000 IU vitamin D3) are not recommended. 5,17 Vitamin D3 supplements are available up to 10,000 IU per capsule, and higher strength preparations may prove more cost-effective for the patient as well. Individuals may be counseled to take vitamin D supplements with any small amount of fat-containing food or drink to enhance absorption. Gel capsule products already contain oil to allow absorption. However, some patients may report an allergy (e.g., rash) to the oil and require a change in product. Conclusion/Summary Vitamin D plays a key role in skeletal health, with deficiency resulting in low bone mineral density and risk of fractures, as well as increased risk of falls in the elderly. Additionally, observational studies suggest a potential impact on all-cause mortality as well as deaths from cardiovascular and, in those with a personal history of the disease, cancer. Although skin tissue produces 22 Palmetto Pharmacist Volume 55 Number 5

significant amounts of vitamin D in response to sunlight, 41.6% of American participants in the NHANES III study had serum vitamin D concentrations under 20 ng/ml, agreed by experts across organizations to be inadequate for optimal bone health. Multiple organizations publish guidance on regimens and goals of vitamin D supplementation. Among these are the IOM, NOF, AGS, and Endocrine Society. While there is overlap of their recommendations, there are also differences and it is beneficial to consider the population each organization is targeting. IOM publishes dietary reference intakes intended to meet the bone health needs of nearly all people assuming minimal sun exposure. NOF guidelines are specifically to prevent and treat osteoporosis in postmenopausal women and men over age 50. The AGS statement intends to reduce falls and fall-related injuries in patients over age 65. Like IOM, the Endocrine Society guidelines are intended for bone health and muscle function and both state a lack of evidence for extraskeletal benefit. IOM and Endocrine Society both give guidance for adults of all ages, divided into those above and below 70 years. With these populations and goals in mind, IOM considers a vitamin D serum concentration above 20 ng/ml adequate for practically all individuals, NOF suggests a goal of approximately 30 ng/ml, and AGS and Endocrine Society target at least 30 ng/ml. None recommend routine screening of all adults for deficiency. In patients without diagnosed deficiency, IOM recommends 600 IU/day for adults up to 70 years of age, and 800 IU/day for those over 70 years. Endocrine Society recommends at least that amount, noting at least 1,500 to 2,000 IU/day may be needed to reach 30 ng/ml. NOF recommends 800 to 1,000 IU/day, and AGS recommends supplementation with at least 1,000 IU/day but prefers 4,000 IU/day from all sources. For patients determined vitamin D deficient by laboratory evaluation, NOF and Endocrine Society suggest 50,000 IU/week for 8 to 12 weeks and 1,500 to 2,000 IU/day thereafter. Increasing supplement sales and easy access to the community pharmacist increase the likelihood that patients will ask pertinent questions related to Vitamin D supplementation. Patients can be told their RDA is 600 IU, or 800 IU if they are over 70 years, and a patient receiving 1,000 IU/day from all supplements is well below the safe upper limit. Individuals considering doses in excess of guideline recommendations should be referred to their physician to consider goals of therapy and laboratory evaluation. The evidence exists for bone health and reduced risk of falls. Prospective trials on mortality benefits are underway, however this data will likely not be available over the next few years. References 1. Kupferschmidt K. Uncertain verdict as vitamin D goes on trial. Science. 2012 Sep 21;337(6101):1476-8. 2. Schöttker B, Jorde R, Peasey A, et al. Vitamin D and mortality: meta-analysis of individual participant data from a large consortium of cohort studies from Europe and the United States. BMJ 2014;348:g3656. 3. Dietary Reference Intakes for Calcium and Vitamin D [Internet]. Institute of Medicine. Washington (DC): National Academies Press; 2011. Available from: http://www.ncbi.nlm.nih.gov/books/nbk56070/. 4. National Osteoporosis Foundation. Clinician s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2014. 5. American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. Recommendations abstracted from the American Geriatrics Society consensus statement on vitamin D for prevention of falls and their consequences. JAGS 2013;62:147-152. 6. Holick MF, Binkley NC, Bischoff-Ferrari HA. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30. 7. Pazirandeh S, Burns DL. Overview of vitamin D. [updated 2014 Nov; cited 2014 Dec 18]. In: UpToDate [Internet]. Hudson, OH: Wolters Kluwer Health. Available from: http://www.uptodate.com/contents/ overview-of-vitamin-d. 8. Office of Dietary Supplements. Vitamin D: fact sheet for health professionals [Internet]. Washington, DC: National Institutes of Health. [updated 2011 Jun 24; cited 2014 Dec 19]. Available from: http://ods.od.nih.gov/factsheets/vitamind-healthprofessional/. 9. Committee to Review Dietary Reference Intakes for Vitamin D and Calcium. Dietary reference intakes for calcium and vitamin D [Internet]. Washington, DC: Institute of Medicine of the National Academies; 2011 Mar. Available from: http://www.iom.edu/~/media/ Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calciumand-Vitamin-D/Vitamin%20D%20and%20Calcium%202010%20 Report%20Brief.pdf. 10. Dawson-Hughes B. Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment. [updated 2014 Nov; cited 2014 Dec 19]. In: UpToDate [Internet]. Hudson, OH: Wolters Kluwer Health. Available from: http://www.uptodate.com/contents/vitamin-ddeficiency-in-adults-definition-clinical-manifestations-and-treatment. 11. Bischoff-Ferrari HA, Dawson-Hughes B, Willet WC et al. Effect of vitamin D on falls. JAMA 2004b;291:1999 2006. 12. Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med 2009;169:551-61. 13. DeLuca HF. Overview of general physiologic features and functions of vitamin D. Am J Clin Nutr. 2004 Dec;80(6 Suppl):1689S-96S. 14. Rosen CJ, Abrams SA, Aloia JF, et al. IOM committee members respond to Endocrine Society vitamin D guideline. J Clin Endocrinol Metab. 2012 Apr;97(4):1146-52. 15. Heaney RP, Recker RR, Grote J et al. Vitamin D(3) is more potent than vitamin D(2) in humans. J Clin Endocrinol Metab 2011;96:E447-52. 16. American Academy of Dermatology. Position Statement on Vitamin D. [updated 2009 Nov 14; cited 2014 Dec 22]. Available from: https:// www.aad.org/forms/policies/uploads/ps/ps-vitamin%20d.pdf. 17. Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA 2010;303:1815-22. Palmetto Pharmacist Volume 55, Number 5 23

Table 1. Categorization of serum vitamin D levels by guidelines body D,E,F,H Organization Institute of Medicine 2010 Publication Date Serum Concentration < 12 ng/ml 12-20 ng/ml 20 ng/ml > 50 ng/ml Description National Osteoporosis Foundation 2014 approximately 30 ng/ml Optimal Associated with vitamin D deficiency, leading to rickets in infants and children and osteomalacia in adults Generally considered inadequate for bone and overall health in healthy individuals Generally considered adequate for bone and overall health in healthy individuals Emerging evidence links potential adverse effects to such high levels, particularly > 60 ng/ml American Geriatrics Society 2013 30 ng/ml Target in older adults, particularly in frail adults A Review of Vitamin D Supplementation in the Adult Patient Corresponding Course Program Number: 0171-9999-15-053-H01-P 1. Complete and mail entire page. SCPhA members can take journal CE for free; $15 for non-members. Check must accompany test. You may also complete the test and submit payment online at www.scrx.org. 2. Mail to: Palmetto Pharmacist CE, 1350 Browning Road, Columbia, SC 29210-6309. 3. Continuing Education statements of credit will be issued within six weeks from the date of the quiz, evaluation form and payment are recieved. Notification will be sent via eamil if you have not successfully completed the quiz. 4. Participants scoring 70% or greater and completing the program evaluation form will be issued CE credit. Participants recieving a failing grade on any examination will have the examination returned. The participant will be permitted to retake the examination one time at no extra charge. South Carolina Pharmacy Association is accredited by the Accreditation Council for Pharmacy Education as providers for continuing education. This article is approved for 1 contact hour of contiuning education credit (ACPE: UAN: 0171-9999-15-053-H01-P). This CE credit begins 08/18/2015 and expires 08/18/2018. CE credit will be uploaded to the CPE Monitor System. Name License # Birth Month/Day (MM/DD) Address NABP eid Phone Email EVALUATION (circle the appropriate response) 1. Did the article achieve the stated objects? (Note at all) 1 2 3 4 5 (Completely) 2. Overall evaluation of the article? (Poor) 1 2 3 4 5 (Excellent) 3. Was the information relevent to your practice? (No) 1 2 3 4 5 (Yes) 4. How long did it take you to read the article and complete the exam? CE credit will ONLY be awarded when a submitted test is accompanied by completing the evaluation above or online at www.scrx.org. 24 Palmetto Pharmacist Volume 55 Number 5

Self-Assessment Questions 1. JM is a 34-year-old man who has decided to get fit and wants to take vitamin D for bone and muscle health. An appropriate recommendation would be: a. Supplementation is not recommended. It is rare for an asymptomatic adult to be below organizational recommendations for serum vitamin D. b. Vitamin D 600 IU/day from all sources per IOM and Endocrine Society. c. An extra 15 minutes of direct sunlight per day d. Vitamin D 800 to 1,000 IU/day according to NOF, assuming patient is not diagnosed as deficient. 2. Which of the following best represents the pathway of endogenous vitamin D production? a. Cholecalciferol is produced by the skin, converted to calcidiol in the liver, which is then converted to calcitriol in the kidney. b. Ergocalciferol is produced by the skin, converted to calcidiol in the kidney, which is then converted to calcitriol in the liver. c. Cholecalciferol and ergocalciferol are produced by the kidneys, then converted to the active calcitriol by ultraviolet light exposure in the skin. d. Vitamin D3 is produced by the skin, converted to cholecalciferol in the liver, which is then converted to calcitriol by the kidney. 3. Which of the following patients would be a candidate for calcitriol? a. A vitamin-d-deficient individual with difficulty swallowing tablets and a previous adverse reaction to oil-containing capsules. b. An otherwise-healthy vegan individual seeking to avoid animal products. c. A patient on renal dialysis and documented vitamin D deficiency. d. An individual who would prefer weekly dosing intervals. 4. Consequences of deficiency of vitamin D include: a. Decreased intestinal absorption of calcium and an association with new cancer diagnoses. b. Muscle weakness, which may be subclinical, or progression to rhabdomyolysis. c. Kidney damage and reduced bone mineral density. d. Increased risk of fall events in geriatric patients and rickets in children. 5. A 45 year old generally healthy patient was evaluated during a routine check-up and had blood work completed that indicated a vitamin D level of 10 ng/ml. What is the most appropriate recommendation? a. The patient is not considered vitamin D deficient and does not require supplementation. b. Vitamin D 50,000 IU per day for 7 days, then 2,000 IU per week thereafter c. Vitamin D 50,000 IU per week for 8 weeks, then 1500 IU per week thereafter d. Vitamin D 50,000 IU per week for 8 weeks, then 1500 IU per day thereafter 6. According to numerous guiding organizations, a vitamin D level below would indicate a suboptimal level for skeletal health. a. 10 ng/ml b. 20 ng/ml c. 30 ng/ml d. 40 ng/ml (continued on next page) Palmetto Pharmacist Volume 55, Number 5 25

(continued) 7. To assess vitamin D status in patients, laboratories measure: a. Cholecalciferol, or vitamin D3 b. Calcidiol, or 25-hydroxyvitamin D c. Total colecalciferol and ergocalciferol d. Calcitriol, or 1,25-dihydroxyvitamin D 8. A 61-year-old female would like to know an appropriate daily dose of vitamin D to reduce her risk of osteoporosis. You suggest: a. 800 IU daily for women over age 60, according to IOM. b. At least 1000 IU daily for adults over age 60, according to AGS. c. 600 IU daily for women under age 65, according to NOF. d. 800 to 1000 IU daily for adults over age 50, according to NOF. Oath of a Pharmacist "I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow: I will consider the welfare of humanity and relief of suffering my primary concerns. I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients. I will respect and protect all personal and health information entrusted to me. I will accept the lifelong obligation to improve my professional knowledge and competence. I will hold myself and my colleagues to the highest principles of our profession s moral, ethical and legal conduct. I will embrace and advocate changes that improve patient care. I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists. I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public. 26 Palmetto Pharmacist Volume 55 Number 5