4. AAFP
,2009
A group of international experts
concluded that approximately 66 percent of persons internationally
(all ages) failed to maintain healthy bone density and tooth
attachment because of inadequate vitamin D level
5.
6.
7.
8.
9. Definitions
• AAFP , ENDOCRINE SOCITEY
• In adult
• vitamin D deficiency is defined as a serum 25-hydroxyvitamin D
level of less than 20 ng per mL (50 nmol per L)
• insufficiency is defined as a serum 25-hydroxyvitamin D level of 20
to 30 ng per mL (50 to 75 nmol per L)
10. UPTODATE
• Vitamin D sufficiency is defined as a 25(OH)D concentration greater than
20 ng/mL
• ●Vitamin D insufficiency is defined as a 25(OH)D concentration of 12 to
20 ng/mL
• ●Vitamin D deficiency is defined as a 25(OH)D level less than 12 ng/mL
• ●A "risk" of vitamin D toxicity is defined as a 25(OH)D level >100 ng/mL
12. Manifestation of vitamin d deficiency
• Bone discomfort or pain (often throbbing) in low back, pelvis, lower
extremities
• Increased risk of falls and impaired physical function
• Muscle aches
• Proximal muscle weakness
• Symmetric low back pain in women
16. SCREENING OF VITAMINE D Deficiency
• Endocrine Society
• Canadian Society of Endocrinology and Metabolism
• National Osteoporosis Foundation,
• published a clinical practice guideline in 2011 titled "Evaluation,
Treatment and Prevention of Vitamin D Deficiency."
• The committee recommended screening of only those individuals
who are at high risk for vitamin D deficiency
19. • Patients with serum 25(OH)D levels <12 ng/Ml
IF there is clinical concern for a secondary cause of vitamin D
deficiency (eg, malabsorption, celiac disease).
20. •
serum calcium, phosphorus, alkaline phosphatase, parathyroid
hormone (PTH), electrolytes, blood urea nitrogen (BUN),
creatinine, and tissue transglutaminase antibodies (to assess for
celiac disease).
•
Radiographs are necessary only in certain settings, such as the
presence of bone pain
24. What to eat
Egg yolk 20 IU
Mackerel (canned) 250 IU per 3.5 oz
Salmon (canned) 300 to 600 IU per 3.5 oz
Salmon (fresh, farmed) 100 to 250 IU per 3.5 oz
Salmon (fresh, wild) 600 to 1,000 IU per 3.5 oz
Sardines (canned) 300 IU per 3.5 oz
Tuna (canned) 230 IU per 3.6 oz
25.
26. Sun Exposure
• especially between the hours of 10:00 am and 3:00 pm produces
vitamin D in the skin that may last twice as long in the blood
compared with ingested vitamin D.
• the amount of vitamin D produced in response to exposure of the
full body is equivalent to ingesting 10,000-25,000 IU.
• A variety of factors reduce the skin’s vitamin D-3 production,
including increased skin pigmentation, aging, and the topical
application of a sunscreen.
27. If the 25(OH)D concentration remains
persistently low despite several
attempts at correction with oral
vitamin D, a trial of UVB light therapy
(ie, by tanning lamps) may be
considered to improve vitamin D status.
28. Management of vitamin D deficient
adults who are vitamin D deficient be treated with
50,000 IU of vitamin D2 or vitamin D3 once a week for 8 wk
or
its equivalent of 6000 IU of vitamin D2 or vitamin D3 daily to
achieve a blood level of 25(OH)D above 30 ng/ml
29. • Re check vitamie d level after completion of therapy,
• if values have notel reached or exceeded the
• minimum level,
• a second eight-week course
• of ergocalciferol should be prescribed
30. • If the serum 25-hydroxyvitamin D levels still have not risen, the
most likely cause is no adherence to therapy or 2ndry causes
• After vitamin D levels are replete, maintenance dosages of
cholecalciferol should be instituted at 800 to 1,000 IU per day
from dietary and supplemental sources
31. Management of high risk group
• obese patients.
• patients with malabsorption syndromes patients .
• On medications affecting vitamin metabolism
we suggest a higher dose at least 6000 –10,000 IU/d) of vitamin D to
treat vitamin D deficiency to maintain a 25(OH)D level above 30
ng/ml, followed by maintenance therapy of 3000–6000 IU/d
32. Mangement of insufficient
• initial supplementation with 800 to 1000 international units (20
to 25 micrograms) daily may be sufficient.
• A repeat serum 25(OH)D level should be obtained after
approximately three months of therapy to assure obtaining the
goal serum 25(OH)D level.
• If goal level is not achieved, higher doses may be necessary
33. vitamin D toxicity
• occurs only after ingestion of large doses of vitamin D (>10,000
IU/day) for prolonged periods in patients with normal gut
absorption or those ingesting excessive amounts of calcium.
Patients with vitamin D toxicity can present with clinical symptoms
of hypercalcemia, including
• nausea, dehydration, and constipation, or symptoms of
hypercalciuria such as polyuria and kidney stones.
. Most patients with vitamin D toxicity have levels greater than 150
ng/ml.
35. OPTIMAL INTAKE TO PREVENT DEFICIENCY
• ●Adults who do not have regular, effective sun
exposure year round should consume at least 600 to
800 international units daily.
• 800 to 1000 international units daily, respectively) to
older adults (≥65 years) to reduce the risk of fractures
•
36. Role of Vitamin D in Other Conditions
• Research suggests that suboptimal vitamin D levels are associated
with increased risk of cardiovascular disease.
• nested case-control study from the Nurses' Health Study reported
that the risk of colon cancer was inversely related to serum levels
of 25-hydroxyvitamin D.
• Vitamin D deficiency has been linked to depression and decreased
cognitive function
