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Vitamin D Deficiency: Diagnosis and Treatment

Vitamin D Deficiency: Diagnosis and Treatment. Rob Benjamin, MD Pediatric Endocrinology Duke University Medical Center . I am on the Speakers’ Bureau for Pfizer and Novo Nordisk.

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Vitamin D Deficiency: Diagnosis and Treatment

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  1. Vitamin D Deficiency:Diagnosis and Treatment Rob Benjamin, MD Pediatric Endocrinology Duke University Medical Center I am on the Speakers’ Bureau for Pfizer and Novo Nordisk. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

  2. Disclosure • I am on the Speakers’ Bureau for Pfizer and Novo Nordisk. • I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

  3. Objectives • •1. Know the sources, metabolism, and actions of vitamin D • •2. Be familiar with laboratory evaluation and diagnostic criteria for vitamin D deficiency • •3. Understand the management of vitamin D deficiency

  4. Agenda • Case 1 presentation • Discuss vitamin D • Sources, metabolism • Laboratory workup • Case 2 presentation • Discuss vitamin D supplementation • All children • Deficient children

  5. Case 1 15 month old male with bowing of legs • African American • Exclusively breast fed • Started walking at 10 months of age • Winter-time • You suspect Vitamin D deficiency • Why is this patient at risk?

  6. Vitamin D Sources Images removed.

  7. Vitamin D Sources Images removed.

  8. Dietary Sources of Vit D Food source Vit D Content in IU • Breast milk • Fort. milk, formula, OJ • Cheese • Shitake mushr – Fresh • Shitake mushr - Dried • Cod liver oil • Canned fish in oil • Canned salmon w/bones • Cooked salmon/mack. 15-50 IU/L 400 IU/L 12-44 IU/100g 100 IU/100g 1660 IU/100g 1360 IU/Tbs 224-332 IU/100g 624 IU/100g 345-360 IU/100g

  9. Vitamin D Metabolism Liver Fat Soluble (25-hydroxylase) Kidneys Water Soluble (1--hydroxylase)

  10. Case 1 Revisited – Take Home Point 1 • Why is our patient at risk for vitamin D deficiency? • Insufficient sunlight • Insufficient dietary vitamin D

  11. Case 1 Labs • Ca 8.8 mg/dl (8.6-10.6) - Normal • Phos 3.0mg/dl (3.5-5.5) - Low • 1-25-vitamin D 75pg/ml (24-86) - Normal • Does this make you re-think your diagnosis? • i.e. what labs would you expect in vit D def?

  12. Labs with Vitamin D deficiency Misra M et al. Pediatrics 2008;122:398-417 Question: Why is Ca normal, Phos low, 1-25 vit D normal? The Answer: PTH!

  13. Vitamin D Deficiency 25-VITAMIN D 1-25 VITAMIN D GI ABSORPTION OF Ca and Phos PTH INCREASE

  14. PTH may ‘normalize’ Ca! Increased PTH BONE: resorption GUT: Ca reabsorption KIDNEY: Ca reabsorption Increased Calcium

  15. PTH Lowers Phos! Increased PTH BONE: resorption GUT: Phosreabsorp KIDNEY: Phosreabsorp Decreased Phosphorus

  16. PTH stimulates 1-25 synthesis Kidneys PTH 1--hydroxylase

  17. Case 1 revisited – Take home point 2 • Labs fit with early – moderate vit D deficiency • Low-normal Ca • Low Phos • Normal 1-25-vitamin D • 1-25-vitamin D should NOT be used to assess vit D status

  18. Case 2 • 14 year old healthy female with normal weight • Mom has read internet about vitamin D • She wants the level checked: • 25-vitamin D level 22ng/ml (30-100) • Should you treat this child? • What are the vitamin D cutoffs? • How much should we give • All children • Deficient children

  19. Vitamin D Status: 25-(OH)-D levels Images removed.

  20. Treatment Goals Vit D >20ng/ml probably OK for bone health Why do we usually aim for >30? • 1. Bone health • Fracture risk lower in post-menopausal women • Better calcium absorption • Lower PTH • 2. Non-skeletal benefits (quality data lacking) • Cancer (12 ) • Type 1DM, MS, other autoimmune • Cardiovascular health

  21. Supplements: Use d2 or D3 • D2 = Ergocalciferol • Prescription • Many different choices • 50,000 IU capsule • 8,000 IU/ml • D3 = Cholecalciferol • OTC, easy to find, cheap • May be better than D2 • Many different choices • 1000-5000 IU gelcaps • Liquid • Calcitriol: 1-25 vitamin D • Not used for most vit D def.

  22. Vit D Daily Doses – All Children Images removed.

  23. Vit D Replacement – Vit D deficient Images removed.

  24. Case 2 revisited – Take home point 3 • 14-year old healthy female • Vitamin D 22ng/ml • No need to treat • Future research needed for non-skeletal benefits • Population screening NOT recommended

  25. References • Holick MF et al. Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. J ClinEndocrinolMetab. 2011 Jul;96(7):1911-30. Epub 2011 Jun 6. • Misra M et al. Vitamin D deficiency in children and its management: review of current knowledge and recommendations. Pediatrics. 2008 Aug;122(2):398-417.

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