In this episode, TRC Healthcare editor, Rachel Cole, PharmD, answers the question… To Vitamin D or Not to Vitamin D?
That’s right, this episode we explore the latest guidelines on Vitamin D Supplementation.
This is an excerpt from our October 2024 Pharmacy Essential Updates continuing education webinar series.
The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- Article: To “D” or Not to “D”…That is the Question
- Chart: Calcium and Vitamin D
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Transcript:
00:00:04 Narrator
Welcome to Clinical Capsules, your go-to podcast for quick, evidence-based insights from TRC Healthcare.
00:00:11 Narrator
This year, we’re celebrating 40 years of keeping healthcare professionals ahead of critical medication updates and guidelines.
00:00:18 Narrator
Every 2nd and 4th Tuesday, our expert editors from Pharmacist’s Letter, Prescriber Insights, and Pharmacy Technician’s Letter will break down the most impactful clinical developments – giving you clear, actionable takeaways in just minutes.
00:00:32 Narrator
Today, you’ll hear an excerpt from our October 2024 Pharmacy Essential Updates continuing education webinar series. In this segment, Assistant Editor and Pharmacist Rachel Cole examines the role of empiric vitamin D supplementation.
00:00:47 Narrator
Let’s dive in.
00:00:54 Rachel Cole
Let’s dig into the question to D or not to D and take a fresh look at vitamin D.
00:01:00 Rachel Cole
We know there’s been a lot of discussion about vitamin D over the years, and now we’re getting more evidence about whether vitamin D supplements are needed for most patients.
00:01:10 Rachel Cole
O our article on this topic, talks about recent guidelines from the Endocrine Society and that they may bring more clarity about the role of empiric vitamin D supplements in certain groups over the years.
00:01:22 Rachel Cole
Been a lot of interest in using vitamin D for a variety of health benefits.
00:01:27 Rachel Cole
And many people have been interested in supplementation, including at high doses of vitamin D.
00:01:32 Rachel Cole
But some new data may provide more specific direction regarding who would benefit the most from empiric vitamin D.
00:01:39 Rachel Cole
And also additional guidance on screening.
00:01:42 Rachel Cole
That’s because recent randomized trials showed that vitamin D supplements don’t benefit a variety of conditions like heart disease, various types of cancer or dementia. And I think this is surprising to many of us because low vitamin D levels have been associated with an increased risk for these issues.
00:01:59 Rachel Cole
And others.
00:02:01 Rachel Cole
And there were years of promising observational data, but we haven’t seen those results pan out in randomized control trials, which are better able to show cause and effect.
00:02:10 Rachel Cole
Rather than just an association or link.
00:02:14 Rachel Cole
Plus, most evidence suggests vitamin D supplements don’t reduce falls in older patients.
00:02:19 Rachel Cole
And there’s no good evidence that vitamin D supplements boost energy.
00:02:23 Rachel Cole
So we’ve really been learning more about the role of vitamin D supplements in adults and that there may not be as much benefit as we once thought.
00:02:32 Rachel Cole
Based on that earlier observational data.
00:02:35 Rachel Cole
Now, this also ties in with the idea of screening for low vitamin D levels.
00:02:40 Rachel Cole
I think this has also become more common over the years, but screening for vitamin D is often not necessary.
00:02:46 Rachel Cole
In fact, a number of groups have come out to say that there’s not enough evidence to recommend screening for vitamin D deficiency in most children and adults.
00:02:56 Rachel Cole
So we want to advise saving vitamin D screening for certain groups of patients, such as patients with osteoporosis or patients who are at risk of low vitamin D levels due to such as chronic kidney disease or malabsorption.
00:03:10 Rachel Cole
For example, this can include patients with inflammatory bowel disease, such as Crohn’s disease, but again, routine screening is not needed for most children and adults. Also keep in mind these new guidelines do not address individuals with underlying conditions.
00:03:27 Rachel Cole
That alter vitamin D Physiology or decrease absorption or activation or increased renal losses. It also doesn’t address those known to be at high risk of fractures.
00:03:41 Rachel Cole
So let’s now take a look at how much vitamin D most patients should usually get.
00:03:46 Rachel Cole
Daily intake recommendations vary by.
00:03:49 Rachel Cole
So in general, suggest getting 10 micrograms per day or 400 international units for children up to 18 years.
00:03:58 Rachel Cole
15 micrograms per day, or 600 international units for adults up to age 70 and 20 to 25 micrograms per day, or 800 to 1000 international units for older patients.
00:04:11 Rachel Cole
And those are the doses suggested in order to maintain bone health from both foods and supplements.
00:04:17 Rachel Cole
Now some guidelines have different recommendations for some patients, but this is a good general way to remember what amount of vitamin D most patients need.
00:04:28 Rachel Cole
And in terms of how patients should get their vitamin D, it’s sometimes referred to as the sunshine vitamin because our bodies make vitamin D in response to exposure to sunlight, but don’t recommend sun exposure without sunscreen as a way to increase vitamin D levels.
00:04:45 Rachel Cole
Due to concerns of skin cancer risk from sun exposure in general.
00:04:48 Rachel Cole
Instead, we can help clarify how patients can get vitamin D from food and supplements if needed.
00:04:56 Rachel Cole
So first we want to think about how much vitamin D patients may be getting from foods.
00:05:02 Rachel Cole
Unfortunately, there aren’t too many foods that have high vitamin D levels, but we can educate patients about food sources.
00:05:10 Rachel Cole
Fatty fish and egg yolks are the best natural food sources of vitamin D, but other foods may be fortified with vitamin D.
00:05:17 Rachel Cole
For example, there’s about one microgram or 40 international units of vitamin D in an egg yolk 2 to 3 micrograms in a cup of fortified orange juice or milk.
00:05:28 Rachel Cole
And 12 micrograms in 3 ounces of salmon.
00:05:31 Rachel Cole
These are just examples and we can check labels for specifics since the amounts vary for some fortified products.
00:05:38 Rachel Cole
But the amount of vitamin DA patient gets through food really depends on their diet.
00:05:45 Rachel Cole
Now you may have noticed that there have been changes over the years in how food or supplement labels list the amount of vitamin D on their ingredient panel or labels.
00:05:54 Rachel Cole
I think many of us may be used to seeing vitamin D listed in international units or IU.
00:06:00 Rachel Cole
But a rule a few years ago requires vitamin D amounts to be listed in metric units. So just as a quick refresher, you can quickly convert vitamin D from the old international units to the newer unit of micrograms by dividing by 4.
00:06:14 Rachel Cole
41 microgram equals 40 international units of vitamin D for example, 400 international units of vitamin D equals 10 micrograms. 1000 international units of vitamin D is 25 micrograms.
00:06:30 Rachel Cole
So I think you can see that we play a huge role as pharmacists and technicians to stay alert for errors and to help convert doses if needed.
00:06:39 Rachel Cole
The updated labels will have to list doses in metric units.
00:06:43 Rachel Cole
But some manufacturers choose to keep both units to limit confusion, so we can help sort through any confusing lab.
00:06:51 Rachel Cole
But regardless, not all adults need a vitamin D supplement.
00:06:57 Rachel Cole
Despite fortified foods, 41% of the US population is deficient in vitamin D.
00:07:04 Rachel Cole
This could be due to multiple factors, including deficiency in the diet and lack of sun exposure, among other reasons.
00:07:12 Rachel Cole
And because of this, the endocrine Society now recommends empurric supplementation in certain groups of patients.
00:07:19 Rachel Cole
What this means is that these patients need more than the usual recommended daily amount of vitamin D, regardless of their vitamin D level. Patients will usually need to get this added amount from vitamin D pills or drops like a prenatal vitamin or foods.
00:07:36 Rachel Cole
And either type of vitamin D is appropriate for supplementation.
00:07:40 Rachel Cole
Vitamin D3.
00:07:41 Rachel Cole
Which is colicalciferol or vitamin D2, which is ergocalciferol.
00:07:48 Rachel Cole
O let’s take a look at the four groups of patients that the Endocrine Society recommends empiric vitamin D.
00:07:53 Rachel Cole
4 empiric vitamin D supplementation is now recommended for four key groups of patients, children and adolescents 1 to 18 years of age.
00:08:04 Rachel Cole
Patients 75 years and up.
00:08:06 Rachel Cole
Patients who are pregnant and patients who have pre diabetes and over the next few slides will elaborate on why vitamin D is recommended for these patients.
00:08:16 Rachel Cole
And some nuances to be aware of.
00:08:20 Rachel Cole
So starting with children guidelines, recommend these patients get vitamin D supplements to prevent nutritional rickets, and because of the potential to lower the risk of respiratory tract infections, the guideline does not provide a dosage recommendation for this group.
00:08:37 Rachel Cole
And dosages in the trials range from 300 to 2000 international units daily.
00:08:43 Rachel Cole
They do provide the average weighted dosages for their respiratory tract infection outcomes, which were about 1200 international units to 1500 international units per day.
00:08:55 Rachel Cole
This is much higher than what is typically found in children’s multivitamins, which is typically 400 to 600 international units.
00:09:04 Rachel Cole
Continue to recommend that kids get a multivitamin and encourage parents or caregivers to talk to their child’s pediatrician to determine whether higher amounts of vitamin D are needed.
00:09:15 Rachel Cole
Screening is not recommended in this population.
00:09:19 Rachel Cole
Unless again, there may be an underlying cause for malabsorption.
00:09:24 Rachel Cole
Were people 75 years of age and older routine testing of vitamin D levels is not recommended. However, empiric vitamin D supplementation is recommended because of its potential to lower mortality, but the mortality effect was small.
00:09:41 Rachel Cole
Taking about 900 international units or 22.5 micrograms of vitamin D daily for two years led to six fewer deaths per 1000 people.
00:09:52 Rachel Cole
And then evidence review showed no conclusive evidence that supplementation lowered risk for fractures, falls or infections in this age group.
00:10:02 Rachel Cole
Be aware that the vitamin D dosage ranged from 400 to over 3000 international units daily in clinical trials included in the guidelines systematic review, so specific dosing recommendations remain unclear.
00:10:17 Rachel Cole
And varied greatly, but the guidelines indirectly suggest that supplementation with about 1000 international units daily is reasonable. Help patients weigh pros and cons of taking vitamin D, for example.
00:10:31 Rachel Cole
Consider pilburden or cost.
00:10:34 Rachel Cole
And if these older patients want to take vitamin D, stick with lower daily dosing.
00:10:40 Rachel Cole
Such as 800 to 1000 international units daily in place of higher weekly dosing.
00:10:49 Rachel Cole
Moving on to our next group, the Endocrine Society also recommends vitamin D supplementation for pregnant patients with the goal of reducing preeclampsia, intrauterine or neonatal mortality, and preterm birth.
00:11:02 Rachel Cole
But doses and trials varied widely, but most supplemented with at least 400 international units of vitamin D but also up to 2000 international units. Plus the new recommendations for pregnant patients are based on studies with results that may be due to chance.
00:11:20 Rachel Cole
And most were conducted in countries where the standard of care differs from the US.
00:11:24 Rachel Cole
So for now, continue to follow the American College of Obstetricians and Gynecologists. Recommendations for all supplements.
00:11:32 Rachel Cole
During pregnancy and continue to recommend a typical prenatal vitamin, which usually contains vitamin D.
00:11:40 Rachel Cole
Finally, the fourth group of patients that new guidelines recommend in puric vitamin D4 is those with prediabetes.
00:11:48 Rachel Cole
And the reason behind these patients taking more vitamin D is that it has the potential to lower the risk of progression to diabetes.
00:11:56 Rachel Cole
But in patients with pre diabetes, pooled data show that the jury’s still out over whether taking vitamin D reduces the risk of developing diabetes or lowers A1C.
00:12:08 Rachel Cole
Plus this is with higher doses about 3500 international units daily for these patients continue to emphasize lifestyle changes with proven outcomes such as a healthy diet and regular exercise instead of vitamin D supplementation.
00:12:26 Rachel Cole
Again, routine screening is unnecessary unless there are signs of vitamin D deficiency.
00:12:33 Rachel Cole
Or an established indication, empiric supplementation is not recommended for most healthy adults underage 75.
00:12:43 Rachel Cole
If your patient wants to take vitamin D, here are some practice pearls to prevent errors or harm.
00:12:50 Rachel Cole
Keep patient’s profiles current with ages medical conditions.
00:12:55 Rachel Cole
Find out why patients are currently taking vitamin D if they already are.
00:12:59 Rachel Cole
Watch for mix ups among vitamin D forms.
00:13:04 Rachel Cole
Recommend lower daily doses over larger intermittent doses.
00:13:09 Rachel Cole
Make sure patients understand the frequency of dosing, whether it’s daily, weekly or monthly, and be alert for dosing errors with vitamin D prescriptions.
00:13:21 Rachel Cole
CR, resource calcium and vitamin D were more detailed information and recommendations on vitamin D.
00:13:30 Narrator
We hope you enjoyed and gained practical insights from listening to this presentation!
Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. Or find the show on YouTube by searching for ‘TRC Healthcare’ or clicking the link in the show notes. While you’re there, check out our other TRC podcasts like Medication Talk and Rumor vs Truth.
00:13:54 Narrator
Also in the show notes, we’ve linked directly to a few of the excellent resources mentioned today available to subscribers of Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights. On those websites you’ll also find a lot more evidence-based, concise, yet comprehensive resources on this and other medication therapy topics.
00:14:16 Narrator
If you aren’t already a subscriber… don’t miss out on these resources! Sign up today to stay ahead with trusted insights and tools. We are an industry leading, non-biased source of information and continuing education.
00:14:30 Narrator
And if you’re a student, good news—students can access a free version of Pharmacist’s Letter, we’ve linked to that directly in the show notes as well… Check it out!
00:14:42 Narrator
Find out more about our product offerings at trchealthcare.com.
You can also reach out to provide feedback or make suggestions by emailing us at [email protected].
00:14:55 Narrator
Thanks for listening to Clinical Capsules!
Clinical Capsules
