vitamin d simon pearce consultant endocrinologist, rvi, newcastle
TRANSCRIPT
![Page 1: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/1.jpg)
Vitamin D
Simon Pearce
Consultant Endocrinologist, RVI, Newcastle
![Page 2: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/2.jpg)
Vitamin D
• Basic background
• Public health
• Cases & Clinical scenarios
![Page 3: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/3.jpg)
Synthesis, activation & action
Skin Liver Kidney
Active vitamin D hormone
Calcium & skeletal
homeostasis
Immune system tissues
Metabolic & vascular
tissues
CellularHomeostasis& apoptosis
![Page 4: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/4.jpg)
Vitamin D- natural sources
• Ergocalciferol– ‘Vitamin D2’– UV irradiated fungi/ yeast
• Colecalciferol– ‘Vitamin D3’– UV irradiated plankton– UV irradiated animal skin/ fur
![Page 5: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/5.jpg)
• >90% of humankind’s vitamin D comes from UV-B exposure of skin
• 20-30 min of direct skin exposure to midday sun on face and arms, 2 or 3 times weekly provides sufficient for a fair-skinned person
• Above 43oN, the angle of sun to atmosphere filters out useful UV wavelengths between October and April.
Vitamin D- natural sources
![Page 6: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/6.jpg)
• Sun block lotion SPF-8 prevents 95% of dermal vitamin D synthesis
• Wearing a hat, veil or head scarf very substantially reduce skin vitamin D synthesis
• Pigmented skin or elderly (thin skin) needs more exposure for same vit D production
• Impossible to overdose on skin synthesised vitamin D; possible to sunburn
Vitamin D- natural sources
![Page 7: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/7.jpg)
Scale of the public health problem
• Seasonal & geographic variation in prevalence of 25-OHD <40nmol/L• MRC 1958 birth cohort at age 45yrs =7437 whites• Spring nadir for 25OHD <20 nmol/L =16%
<50 nmol/L =50%
Hyppönen & Power 2007
![Page 8: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/8.jpg)
Vitamin D- natural sources
• Food– Oily fish (top of the marine ecosystem)– Salmon, trout, mackerel, herring, fresh tuna, sardines,
pilchards, anchovies– Fish oils (cod liver oil)
• 2 portions of oily fish weekly (100-125g) sufficient to provide sufficient Vit D
• Less Vitamin D in farmed fish• Heavy metals in some sea fish
![Page 9: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/9.jpg)
Vitamin D- natural sources• Common misconceptions
– Negligible amount of vit D in milk– None in green vegetables
• Small amounts in Egg yolk (20 yolks per day sufficient)
• Small amount in mushrooms (100 per day sufficient)• Small amounts in animal liver (inc. seal liver)
• Statutory supplementation in UK– Infant milk formula (500 IU/l)– Margarines (150-300 IU/100g)
![Page 10: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/10.jpg)
How to determine vitamin D status?
• Measure serum 25 hydroxyvitamin D (25-OHD)– Robust marker of vit D stores– Half-life 3-4 weeks
• Don’t measure 1,25 dihydroxyvitamin D– Active ‘D hormone’– Circulating levels reflect PTH action and calcium
supply– Often falsely normal or even elevated in D
deficiency
![Page 11: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/11.jpg)
How to determine vitamin D status?
25-OHD
(nmol/l)
Vit D status Manifestation Action
<25 Deficient Rickets
Osteomalacia
Treat with
high dose D
25-50 Insufficient Associated with disease risk
Supplement with vit D
50-75 Adequate Healthy Lifestyle advice
>75 Optimal Healthy None
![Page 12: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/12.jpg)
Interpretation of serum 25-OHD
Hypponen & Power 2007
Men (n=3725)
Women (n=3712)
• UK-wide white cohort born 1958
![Page 13: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/13.jpg)
Interpretation of serum 25-OHD
Hypponen & Power 2007
Men (n=3725)
Women (n=3712)
• UK-wide white cohort born 1958
![Page 14: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/14.jpg)
Case 1
![Page 15: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/15.jpg)
35 yo, Pakistani-born Lady
• Living in Fenham for 11 yrs
• Migratory aches and pains, hips, legs, back during 3rd pregnancy
• GP re-assured, but ? Depressed
• 4/12 post partum-feels low, aches and pains persist= Fluoxetine 20mg od
• Presents limping, with pain in R hip
![Page 16: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/16.jpg)
GP did blood tests
• Calcium =1.89 mmol/l (2.12-2.6)
• Alk Phos = 231 KIU/l (<120)
• Rh factor negative
• Refer endocrinology
![Page 17: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/17.jpg)
Endocrinology blood tests
• PTH 684 ng/l
• 25-OH vitamin D = 7 nmol/l
• Diagnosis = Osteomalacia
![Page 18: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/18.jpg)
Generalised Aches & Pains =not always depressionSievenpiper J et al. BMJ
![Page 19: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/19.jpg)
Treatment
• Oral ergocalciferol 10,000 IU daily for 3 months
• Feels a lot better, aches and pains gone, smiling in clinic
• But……..
![Page 20: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/20.jpg)
• After topping up her vitamin D levels, she will need long-term maintenance
– 1000 to 2000 IU calciferol daily– Regular sunlight exposure
• Don’t forget the baby: who was slow to walk and had rickets with tibial deformities
![Page 21: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/21.jpg)
NICE antenatal care guideline
![Page 22: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/22.jpg)
Case 2
![Page 23: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/23.jpg)
20 month old girl
• Mother reports lower limb deformity
• 4th child, term birth, no problems
• Breast fed until 8 months
• Pain on walking, difficulty climbing stairs
• Nigerian mother, asylum seeker housed in tower block
• 3 older brothers born in Nigeria, no problems
![Page 24: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/24.jpg)
• Ca 1.92 mmol/l (2.3-2.7)• PO4 1.26 mmol/l (1.1-1.85)• Alk Phos 1077 KIU/l (<375)
• Treatment
• Ergocalciferol oily solution, 3,000 IU/ml. 2mls daily
• Mother and brothers, also to take supplements: Dalivit 0.6 mls daily
![Page 25: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/25.jpg)
Healthy Start/ Sure Start
• The UK health departments recommend a daily dose of vitamins A, C and D for:– breastfed infants from 6 months (or from 1 month if there is any doubt
about the mother's vitamin status during pregnancy)– formula-fed infants who are over 6 months and taking less than 500
ml infant formula per day– children under 5 years of age
• This recommendation is particularly important for children who are picky or fussy eaters, those of Asian, African, Afro-Caribbean or middle eastern origin and those living in northern areas of the UK.
![Page 26: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/26.jpg)
![Page 27: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/27.jpg)
Case 3
![Page 28: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/28.jpg)
45 yo woman
• Multiple sclerosis diagnosed age 29
• Only 2 major attacks
• Feeling increasingly weak for 30 months• Painful to move legs, can’t stand up• Using wheelchair, even in house• Needs husband to pull her out of bed in
morning
![Page 29: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/29.jpg)
Fell out of bed one day• Wedge # of L2 vertebral body
• BMD measured; T score -3.4 at spine
• Bone chemistry• (PTH 43)
• Treated with calcichew D3 one daily
Serum Feb April
Calcium 2.60 2.30
PO4 1.11 0.77
Alk Pase 62 48
25-OHD 10 11
![Page 30: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/30.jpg)
• Allergic to fish; none since teenager
• Not really leaving the house due to mobility
• No overseas holiday for 5 yrs
![Page 31: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/31.jpg)
Treatment• Oral colecalciferol 20,000 IU capsules, 3 per week
(Dekristol; pharmacy special order, approved by APC)
• Vomiting and diarrhoea (contains fish oil!)
• IM ergocalciferol 300,000 IU monthly for 3 months, • Oral vitamin D3 2 x 25ug capsules daily (2000 IU)
from Holland and Barrett
• 1 year later; walks unaided up to 200 m, no pain
![Page 32: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/32.jpg)
How to determine vitamin D status?
25-OHD
(nmol/l)
Vit D status Manifestation Action
<25 Deficient Rickets
Osteomalacia
Treat with
high dose D
25-50 Insufficient Associated with disease risk
Supplement with vit D
50-75 Adequate Healthy Lifestyle advice
>75 Optimal Healthy None
![Page 33: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/33.jpg)
![Page 34: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/34.jpg)
Also OTC Boots (12.5 ug capsules) £2.99 for 90Holland & Barrett (25 ug capsules) £6.99 for 100
![Page 35: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/35.jpg)
Dosing issues
• 100 IU calciferol daily increases serum 25-OHD by 2.5 nmol/l
• RDA is 400 IU (10 ug)• Increase serum 25-OHD by 10 nmol/l
• Typical Newcastle patient with vitamin D insufficiency has levels between 20 and 30 nmol/l
• Need to aim for 70 nmol/l or better• Toxicity seen at levels of 500 nmol/l or higher• 1- 2000 IU daily is appropriate maintenance dose
(Adults)
![Page 36: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/36.jpg)
Tips on treatment
• Most people who you suspect are D deficient, are D deficient
• Supplementation is not the same as treatment
• If a child has rickets, the siblings and mother should also be treated
• Compliance with calcium containing preparations (calcichew D3) is poor, better to prescribe D only compounds for longterm use
![Page 37: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/37.jpg)
The End
![Page 38: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/38.jpg)
Questions
• Is it worth screening all new patients from overseas at risk of vit D?
-When people first arrive, they aren’t deficient
-Probably takes 5 years or a pregnancy to manifest severe D deficiency
-Worth giving dietary/sunlight exposure advice to all at risk groups
![Page 39: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/39.jpg)
Questions
• Treatment- injection vs oral medication and how long for?
-Oral is better (all round); but current supply issues.
-In severe deficiency a short course of monthly IM insures treatment is received
-If GI problem, IM worthwhile
![Page 40: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/40.jpg)
Questions
• How often to monitor bloods once on treatment?
-Depends on manifestations, but maybe never or once in a year until dietary intake is no longer an issue
-If Alk. Phos raised, recheck in 3 and 6 months; although it may take longer to normalise
![Page 41: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/41.jpg)
Questions
• When to refer?- and who to endocrine vs bone clinic
- Doubt about diagnosis; conflicting biochem (eg. Hypercalcaemia)
- Failure to respond to treatment- Other nutritional issues (IDA frequently co-exists)- Childhood with bone disease- Vitamin D is actually a hormone
![Page 42: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/42.jpg)
Questions
• Patients with aches and pains and confirmed vit D def- should we be x-raying joints
I generally don’t, unless there is very localised pain (not generalised aches & pains)
Pain not improved by 3 months treatment should trigger an X-ray
![Page 43: Vitamin D Simon Pearce Consultant Endocrinologist, RVI, Newcastle](https://reader031.vdocuments.us/reader031/viewer/2022032701/56649c775503460f9492c179/html5/thumbnails/43.jpg)
Dosing of colecalciferol in Autumn
From Heaney RP et al.
Placebo
10,000 U/d
5,000 U/d
1,000 U/d