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Up to date
and recommendation
Dr. mohammed alhojele
The literature on Vitamin D has exploded
in recent years.
EPIDEMIOLOGY
APPROACH TO PATIENT WITH VIT D
DEFIANCE
VITAMIN D UP TO DATE
RECOMMENDATION
 Vitamin-D is a fat soluble vitamin
 Vitamin – D function like a hormone
Forms of vitamin D:
Vitamin D in the diet occurs in two forms
 Vitamin D2 (Ergocalciferol)
 Vitamin D3 (Cholecalciferol)
Causes of Vit d deficiency
 Inadequate exposure to sunlight.
 Inadequate dietary vit D.
 Vit D malabosrption.
 Severe hepatocellular disease.
 Increased catabolism (e.g. drugs).
 Increased loss (nephrotic syndrome).
Dietary sources of
Vitamin D
Dietary sources of
Vitamin D
Epidemiology
Worldwide
In SAUDI ARABIA
It has been estimated that 1 billion people
worldwide have vitamin-D deficiency.
It is estimated that 50 to 70 percent of the
European and 30 to 77 percent of the US adult
population is vitamin D deficient.
IN SAUDI ARABIA
Approach to patient with
vitamin D Deficiency
symptoms (adult and
child)
 Diagnosis
 Management
 Screening
In child
• Rickets:
Rickets in children is characterized by
bone deformities due to incomplete
mineralization
In adult
• The majority of patients with moderate
to mild vitamin D deficiency are
asymptomatic
Diagnosis
the 25-hydroxy vitamin D test is the most accurate way to
measure how much vitamin D is in your body.
Methods of Vitamin D Measurement=
LC-MS/MS liquid chromatography mass spectrometry
HPL high-performance liquid chromatography(gold standard)
RIA radioimmunoassay
CLIA chemiluminescent immunoassay
How Accurate Are the
Measurements?
Objectives:
To compare the performance of 3 commonly used 25-hydroxyvitamin D (25-OHD)
assays among a sample of the Saudi population.
Methods:
This cross-sectional study was carried out between January 2011 and December 2012 at King Fahd
Hospital of the University, Al-Khobar, Saudi Arabia. 200 adults. Assays were also compared through
commonly used cut-points for classification of vitamin D deficiency.
Results:
The average age of patients was 45.7±16.1 years. A significant difference between the assays was found..by
Using 30 ng/mL as a cutoff value,
22%only was found to have normal levels by using LC-MS/MS.
And 6% of 25-OHD using CLIA
, 9% using RIA,
Conclusion:
high prevalence of hypovitaminosis D among the Saudi population can be partially explained by
the use of assays that underestimate vitamin D levels.
Serum from 59 postmenopausal women was sent to either of
two national laboratories. In one laboratory, nearly all levels
were higher than 30 ng/mL; in the other, nearly all levels were
lower than 30 ng/mL.
Because of variation in laboratory measurement of
vitamin D levels, accurate diagnosis of
hypovitaminosis D is problematic. Until better standardization is
achieved, clinicians should be cautious about drawing
conclusions from a single 25-OHD measurement.(2015)
The USPSTF found evidence suggesting that results vary by
testing method and between laboratories using the same
testing methods.
accuracy of these tests is difficult to determine due to the
lack of studies and the lack of consensus on the cut point
values used to define vitamin D deficiency
What is optimal level for skeletal?
The IOM supports 25(OH)D concentrations above 20
ng/mL (50 nmol/L). These recommendations are based
upon evidence related to bone health.
Other experts (the Endocrine Society [ENDO], the
National Osteoporosis Foundation [NOF], the
International Osteoporosis Foundation [IOF], the
American Geriatric Society [AGS]) suggest that a
minimum level of 30 ng/mL (75 nmol/L) is necessary
for bone health
International
agencies
Deficiency Insufficiency Sufficiency Toxicity
US Endocrine Societya
International Osteoporosis Foundation
US National Osteoporosis Foundation
American Geriatric Society
nmol/l <50 52.5–72.5 75 >250
ng/ml <20 21–29 30 >100
US Institute of Medicinea
UK National Osteoporosis Society
nmol/l <30 30–50 ≥50 >125
ng/ml <12 12–20 ≥20 >50
Nordic Nutrition Recommendationsa
World Health Organization
German Nutrition Society
nmol/l <25 <50 >50
ng/ml <10 <20 >20
ESCEOa
nmol/l <25 50–75 >75 >125
Conclusion
 Vitamin D supplementation correction is advised in all persons
whose serum 25(OH)D falls below 50 nmol/l (20 ng/ml),
 and achieving a target of 75 nmol/l (30 ng/ml) is particularly
suited for frail, osteoporotic, and older patients
 Despite high prevalence of vitamin D deficiency,
universal screening is not recommended
management
When to treat?
Symptomatic:
Signs & symptoms of ostemalcia,
Signs & symptoms of Rickets.
Asymptomatic:
When vitamin-D levels are in the deficient
range even if asymptomatic.
Which Vitamin D Supplement Boosts
Levels More — D2 or D3?
In randomized trial, 33 adults received 50,000 IU weekly
of either D2 or D3; mean baseline 25(OH)D was about
28 ng/mL. After 12 weeks, increases in 25(OH)D levels
were significantly greater with D3 than with D2
(increase from baseline, about 40 vs. 22 ng/mL).
• (Columbia,2011 published April 26, 2011)
Treatment of deficiency
According to the Endocrine Society Practice Guidelines:
Age Initial therapy for 6 weeks Maintenance
Upto 1 year 2000 IU/day or 400–1000 IU/day
50,000 IU/wk
1-18 years 2000 IU/day or 600–1000 IU/day
50,000 IU/wk
>18 years ~6000 IU/day or 1500–2000 IU/day
50,000 IU/wk (both for 8
wks)
In obese patients, patients with malabsorption syndromes, and patients on medications
affecting vitamin D metabolism, two to three times higher doses are recommended.
A blood test is recommended to monitor
blood levels of 25(OH)D three months after
beginning treatment.
Whom to screen?
 Chronic Kidney Disease.
 Hepatic Failure
 Dark skinned infants and infants born to vitamin-D
deficient mothers.
 Home-based patient with minimal access to sun
exposure
 In the presence of non-specific symptoms like poor
growth, gross motor developmental delay and unusual
irritability
31
Whom to screen?
 Obese children and adults (BMI>30 kg/M2)
 Post bariatric surgery
 Granuloma forming disorders:
 Sarcoidosis, Tuberculosis,
 Histoplasmosis
 Hyperparathyroidism.
 Malabsorption syndrome:
Cystic Fibrosis, IBD (Inflammatory Bowel Disease), Crohn’s Disease
 Medications:
 Anticonvulsants, Glucocorticosteroids,
 AIDS medication, Antifungal (ketoconazole).
Research associated Vitamin D to
Cancer
Cardiovascular
Osteoporosis
CANCER
Abstract ( June 2014)
Background
The evidence on whether vitamin D supplementation is effective in decreasing
cancers
Objectives
To assess the beneficial and harmful effects of vitamin D supplementation for
prevention of cancer in adults.
Main results
14 trials tested vitamin D₃, one trial tested vitamin D₂, and three trials tested
calcitriol supplementation. Cancer occurrence was observed in 1927/25,275
(7.6%) recipients of vitamin D versus 1943/25,348 (7.7%) recipients of control
interventions (RR 1.00 (95% confidence interval (CI) 0.94 to 1.06); P = 0.88; I² =
0%; 18 trials; 50,623 participants;
Authors' conclusions
There is currently no firm evidence that vitamin D supplementation decreases
or increases cancer occurrence
CARDIO VASCULAR
OUTCOME
• OBJECTIVE: The aim of this study was to summarize the evidence on the effect of
vitamin D on cardiovascular outcomes
• RESULTS: We found 51 eligible trials with moderate quality. Vitamin D was
associated with no significant effects on the patient-important outcomes of death
[RR, 0.96; 95% confidence interval (CI), 0.93, 1.00; P = 0.08], myocardial infarction
(RR, 1.02; 95% CI, 0.93, 1.13; P = 0.64), and stroke (RR, 1.05; 95%CI, 0.88, 1.25; P =
0.59).
• CONCLUSIONS: Trial data available unable to demonstrate a statistically significant
reduction in mortality and cardiovascular risk associated with vitamin D
purpose of this review
To investigate the effects of vitamin D or vitamin D-related supplements, taken with or
without calcium supplements, for preventing fractures in post-menopausal women
and older men.
Conduct of this review
The review authors searched the medical literature up to December 2012, and
identified 53 relevant medical trials, with a total of 91,791 people taking part. The
Findings of this review
here is high quality evidence that vitamin D alone, in the formats and doses tested, is
unlikely to be effective in preventing hip fracture (11 trials, 27,693 participants; risk
ratio (RR) 1.12, 95% confidence intervals (CI) 0.98 to 1.29) or any new fracture (15
trials, 28,271 participants; RR 1.03, 95% CI 0.96 to 1.11).
here is high quality evidence that vitamin D plus calcium results in a small reduction in
hip fracture risk (nine trials, 49,853 participants; RR 0.84, 95% confidence interval (CI)
0.74 to 0.96; P value 0.01).
conclusion
Vitamin D alone is unlikely to prevent fractures in the doses and formulations tested
so far in older people. Supplements of vitamin D and calcium may prevent hip or any
type of fracture
Pediatric
pregnant
old age
Screening
sun exposure
Pediatric
• The AAP recommends that all infants and children,
including adolescents, have a minimum daily intake
of 400 IU of vitamin D beginning soon after birth
instead of previous recommendation that start after
2 month and only 200IU
Infants ingesting less than 1 L (33.8 fl oz) of formula
per day, as well as all breastfed or partially breastfed
infants, should receive 400 IU of supplemental
vitamin D daily. Grade C
PREGNANCY
At this time, there is insufficient evidence to
recommend vitamin D supplementation for the
prevention of preterm birth or preeclampsia.
At this time there is insufficient evidence to
support a recommendation for screening all
pregnant women for vitamin D deficiency
1- supplementation In general, vitamin D 10
micrograms (400 units) a day is recommended for all
pregnant women.. This should be available through the
Healthy Start programmed (also KSA) .
2-screening There are no data to support routine
screening for vitamin D deficiency in pregnancy in
terms of health benefits or cost effectiveness.
Vitamin D supplements of at least 800
IU per day should be considered for
people with suspected vitamin D
deficiency or who are otherwise at
increased risk for falls. [B]
IN ELDERLY
The USPSTF recommends exercise or physical therapy
and vitamin D supplementation to prevent falls in
community-dwelling adults aged 65 years or older
who are at increased risk for falls. grade B
Post menopausal women
• Women after menopause recommended to
take 1200 mg calcium per day and 600-1000 IU
of vitamin d obtained from dietary sources or
supplements for bone health .
Screening
We recommend screening for vitamin D deficiency
in individuals at risk for deficiency. We do not
recommend population screening for vitamin D deficiency
in individuals who are not at risk
The USPSTF concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening for
vitamin D deficiency in asymptomatic adults. Grade I
48
NICE recommendations:
sunlight
• When to go out in the sun:
 11am and 3pm
 April – October in UK
 In our country recommended in winter season
10Am- 2pm
In summer seasons: either
9 AM-10.30 or
2pm-3pm
 Short periods exposing (less than the time it takes for skin to
redden or burn) (10-15 min )small areas – Hands, arms, lower
legs
49
NICE recommendations: sunlight
darker skin need more time in sunlight to
produce the same amount of vitamin D as
people with lighter skin
Older people should be advised about
supplements and minimise expose to sun
because increased risks of skin cancer as they
get older
TAKE HOME MESSEGE
 We need to stop checking vitamin D levels
and wasting health resources, and instead
encourage regular outdoor exercise and a
healthy diet that includes fatty fish and dairy
products.
References

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Vitamin d up to date

  • 1. Up to date and recommendation Dr. mohammed alhojele
  • 2. The literature on Vitamin D has exploded in recent years.
  • 3. EPIDEMIOLOGY APPROACH TO PATIENT WITH VIT D DEFIANCE VITAMIN D UP TO DATE RECOMMENDATION
  • 4.  Vitamin-D is a fat soluble vitamin  Vitamin – D function like a hormone Forms of vitamin D: Vitamin D in the diet occurs in two forms  Vitamin D2 (Ergocalciferol)  Vitamin D3 (Cholecalciferol)
  • 5.
  • 6. Causes of Vit d deficiency  Inadequate exposure to sunlight.  Inadequate dietary vit D.  Vit D malabosrption.  Severe hepatocellular disease.  Increased catabolism (e.g. drugs).  Increased loss (nephrotic syndrome).
  • 7.
  • 11. It has been estimated that 1 billion people worldwide have vitamin-D deficiency. It is estimated that 50 to 70 percent of the European and 30 to 77 percent of the US adult population is vitamin D deficient.
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  • 15. Approach to patient with vitamin D Deficiency symptoms (adult and child)  Diagnosis  Management  Screening
  • 16. In child • Rickets: Rickets in children is characterized by bone deformities due to incomplete mineralization In adult • The majority of patients with moderate to mild vitamin D deficiency are asymptomatic
  • 17. Diagnosis the 25-hydroxy vitamin D test is the most accurate way to measure how much vitamin D is in your body. Methods of Vitamin D Measurement= LC-MS/MS liquid chromatography mass spectrometry HPL high-performance liquid chromatography(gold standard) RIA radioimmunoassay CLIA chemiluminescent immunoassay
  • 18. How Accurate Are the Measurements?
  • 19. Objectives: To compare the performance of 3 commonly used 25-hydroxyvitamin D (25-OHD) assays among a sample of the Saudi population. Methods: This cross-sectional study was carried out between January 2011 and December 2012 at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia. 200 adults. Assays were also compared through commonly used cut-points for classification of vitamin D deficiency. Results: The average age of patients was 45.7±16.1 years. A significant difference between the assays was found..by Using 30 ng/mL as a cutoff value, 22%only was found to have normal levels by using LC-MS/MS. And 6% of 25-OHD using CLIA , 9% using RIA, Conclusion: high prevalence of hypovitaminosis D among the Saudi population can be partially explained by the use of assays that underestimate vitamin D levels.
  • 20. Serum from 59 postmenopausal women was sent to either of two national laboratories. In one laboratory, nearly all levels were higher than 30 ng/mL; in the other, nearly all levels were lower than 30 ng/mL. Because of variation in laboratory measurement of vitamin D levels, accurate diagnosis of hypovitaminosis D is problematic. Until better standardization is achieved, clinicians should be cautious about drawing conclusions from a single 25-OHD measurement.(2015)
  • 21. The USPSTF found evidence suggesting that results vary by testing method and between laboratories using the same testing methods. accuracy of these tests is difficult to determine due to the lack of studies and the lack of consensus on the cut point values used to define vitamin D deficiency
  • 22. What is optimal level for skeletal? The IOM supports 25(OH)D concentrations above 20 ng/mL (50 nmol/L). These recommendations are based upon evidence related to bone health. Other experts (the Endocrine Society [ENDO], the National Osteoporosis Foundation [NOF], the International Osteoporosis Foundation [IOF], the American Geriatric Society [AGS]) suggest that a minimum level of 30 ng/mL (75 nmol/L) is necessary for bone health
  • 23. International agencies Deficiency Insufficiency Sufficiency Toxicity US Endocrine Societya International Osteoporosis Foundation US National Osteoporosis Foundation American Geriatric Society nmol/l <50 52.5–72.5 75 >250 ng/ml <20 21–29 30 >100 US Institute of Medicinea UK National Osteoporosis Society nmol/l <30 30–50 ≥50 >125 ng/ml <12 12–20 ≥20 >50 Nordic Nutrition Recommendationsa World Health Organization German Nutrition Society nmol/l <25 <50 >50 ng/ml <10 <20 >20 ESCEOa nmol/l <25 50–75 >75 >125
  • 24.
  • 25. Conclusion  Vitamin D supplementation correction is advised in all persons whose serum 25(OH)D falls below 50 nmol/l (20 ng/ml),  and achieving a target of 75 nmol/l (30 ng/ml) is particularly suited for frail, osteoporotic, and older patients  Despite high prevalence of vitamin D deficiency, universal screening is not recommended
  • 27. When to treat? Symptomatic: Signs & symptoms of ostemalcia, Signs & symptoms of Rickets. Asymptomatic: When vitamin-D levels are in the deficient range even if asymptomatic.
  • 28.
  • 29. Which Vitamin D Supplement Boosts Levels More — D2 or D3? In randomized trial, 33 adults received 50,000 IU weekly of either D2 or D3; mean baseline 25(OH)D was about 28 ng/mL. After 12 weeks, increases in 25(OH)D levels were significantly greater with D3 than with D2 (increase from baseline, about 40 vs. 22 ng/mL). • (Columbia,2011 published April 26, 2011)
  • 30. Treatment of deficiency According to the Endocrine Society Practice Guidelines: Age Initial therapy for 6 weeks Maintenance Upto 1 year 2000 IU/day or 400–1000 IU/day 50,000 IU/wk 1-18 years 2000 IU/day or 600–1000 IU/day 50,000 IU/wk >18 years ~6000 IU/day or 1500–2000 IU/day 50,000 IU/wk (both for 8 wks) In obese patients, patients with malabsorption syndromes, and patients on medications affecting vitamin D metabolism, two to three times higher doses are recommended. A blood test is recommended to monitor blood levels of 25(OH)D three months after beginning treatment.
  • 31. Whom to screen?  Chronic Kidney Disease.  Hepatic Failure  Dark skinned infants and infants born to vitamin-D deficient mothers.  Home-based patient with minimal access to sun exposure  In the presence of non-specific symptoms like poor growth, gross motor developmental delay and unusual irritability 31
  • 32. Whom to screen?  Obese children and adults (BMI>30 kg/M2)  Post bariatric surgery  Granuloma forming disorders:  Sarcoidosis, Tuberculosis,  Histoplasmosis  Hyperparathyroidism.  Malabsorption syndrome: Cystic Fibrosis, IBD (Inflammatory Bowel Disease), Crohn’s Disease  Medications:  Anticonvulsants, Glucocorticosteroids,  AIDS medication, Antifungal (ketoconazole).
  • 33. Research associated Vitamin D to Cancer Cardiovascular Osteoporosis
  • 35. Abstract ( June 2014) Background The evidence on whether vitamin D supplementation is effective in decreasing cancers Objectives To assess the beneficial and harmful effects of vitamin D supplementation for prevention of cancer in adults. Main results 14 trials tested vitamin D₃, one trial tested vitamin D₂, and three trials tested calcitriol supplementation. Cancer occurrence was observed in 1927/25,275 (7.6%) recipients of vitamin D versus 1943/25,348 (7.7%) recipients of control interventions (RR 1.00 (95% confidence interval (CI) 0.94 to 1.06); P = 0.88; I² = 0%; 18 trials; 50,623 participants; Authors' conclusions There is currently no firm evidence that vitamin D supplementation decreases or increases cancer occurrence
  • 37. • OBJECTIVE: The aim of this study was to summarize the evidence on the effect of vitamin D on cardiovascular outcomes • RESULTS: We found 51 eligible trials with moderate quality. Vitamin D was associated with no significant effects on the patient-important outcomes of death [RR, 0.96; 95% confidence interval (CI), 0.93, 1.00; P = 0.08], myocardial infarction (RR, 1.02; 95% CI, 0.93, 1.13; P = 0.64), and stroke (RR, 1.05; 95%CI, 0.88, 1.25; P = 0.59). • CONCLUSIONS: Trial data available unable to demonstrate a statistically significant reduction in mortality and cardiovascular risk associated with vitamin D
  • 38.
  • 39. purpose of this review To investigate the effects of vitamin D or vitamin D-related supplements, taken with or without calcium supplements, for preventing fractures in post-menopausal women and older men. Conduct of this review The review authors searched the medical literature up to December 2012, and identified 53 relevant medical trials, with a total of 91,791 people taking part. The Findings of this review here is high quality evidence that vitamin D alone, in the formats and doses tested, is unlikely to be effective in preventing hip fracture (11 trials, 27,693 participants; risk ratio (RR) 1.12, 95% confidence intervals (CI) 0.98 to 1.29) or any new fracture (15 trials, 28,271 participants; RR 1.03, 95% CI 0.96 to 1.11). here is high quality evidence that vitamin D plus calcium results in a small reduction in hip fracture risk (nine trials, 49,853 participants; RR 0.84, 95% confidence interval (CI) 0.74 to 0.96; P value 0.01). conclusion Vitamin D alone is unlikely to prevent fractures in the doses and formulations tested so far in older people. Supplements of vitamin D and calcium may prevent hip or any type of fracture
  • 41. Pediatric • The AAP recommends that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth instead of previous recommendation that start after 2 month and only 200IU Infants ingesting less than 1 L (33.8 fl oz) of formula per day, as well as all breastfed or partially breastfed infants, should receive 400 IU of supplemental vitamin D daily. Grade C
  • 42. PREGNANCY At this time, there is insufficient evidence to recommend vitamin D supplementation for the prevention of preterm birth or preeclampsia. At this time there is insufficient evidence to support a recommendation for screening all pregnant women for vitamin D deficiency
  • 43. 1- supplementation In general, vitamin D 10 micrograms (400 units) a day is recommended for all pregnant women.. This should be available through the Healthy Start programmed (also KSA) . 2-screening There are no data to support routine screening for vitamin D deficiency in pregnancy in terms of health benefits or cost effectiveness.
  • 44. Vitamin D supplements of at least 800 IU per day should be considered for people with suspected vitamin D deficiency or who are otherwise at increased risk for falls. [B] IN ELDERLY
  • 45. The USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. grade B
  • 46. Post menopausal women • Women after menopause recommended to take 1200 mg calcium per day and 600-1000 IU of vitamin d obtained from dietary sources or supplements for bone health .
  • 47. Screening We recommend screening for vitamin D deficiency in individuals at risk for deficiency. We do not recommend population screening for vitamin D deficiency in individuals who are not at risk The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. Grade I
  • 48. 48 NICE recommendations: sunlight • When to go out in the sun:  11am and 3pm  April – October in UK  In our country recommended in winter season 10Am- 2pm In summer seasons: either 9 AM-10.30 or 2pm-3pm  Short periods exposing (less than the time it takes for skin to redden or burn) (10-15 min )small areas – Hands, arms, lower legs
  • 49. 49 NICE recommendations: sunlight darker skin need more time in sunlight to produce the same amount of vitamin D as people with lighter skin Older people should be advised about supplements and minimise expose to sun because increased risks of skin cancer as they get older
  • 50. TAKE HOME MESSEGE  We need to stop checking vitamin D levels and wasting health resources, and instead encourage regular outdoor exercise and a healthy diet that includes fatty fish and dairy products.
  • 51.

Editor's Notes

  1. Vitamin d wiki 2013