Vitamin D and Calcium Guideline
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Vitamin D and Calcium Guideline
Vitamin D
Functions of Vitamin D 2
Serum Levels 2
Deficiency 2
Toxicity 2
Dietary Reference Intakes 3
Sources of Vitamin D 3
Therapeutic Options 4
Adults 4
Children (0–18 years) 5
Special populations 5
References 6
Calcium
Functions of Calcium 7
Serum Levels 7
Deficiency 7
Toxicity 7
Special considerations: cardiovascular disease 7
Dietary Reference Intakes 8
Food Sources of Calcium 9
References
Clinician Lead and Guideline Development 10
Most recent guideline approval: November 2011
Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health
care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate
practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace
the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the
guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline
does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of
the circumstances presented by the individual patient.
Vitamin D and Calcium Guideline
Copyright © 2012 Group Health Cooperative. All rights reserved.Vitamin D
Functions
Vitamin D is a fat-soluble vitamin that helps the body to absorb calcium.
Serum levels
Routine screening for vitamin D deficiency is not recommended.
Consider vitamin D testing for:
• Patients with osteoporosis or a low-trauma impact fracture
• Patients who are homebound or in long-term care facilities
• Patients with a medical condition that increases the risk of vitamin D deficiency or insufficiency
(e.g., kidney disease or liver disease)
• Patients on certain medications (e.g., antiseizures, glucocorticoids, AIDS medications, antifungals,
cholestyramine)
• Patients with malabsorption syndromes (e.g., cystic fibrosis, inflammatory bowel disease, bariatric
surgery, radiation enteritis)
• Patients with hypocalcemia, hypophosphatemia, or hyperparathyroidism
• Patients with suspected rickets
• Dark-skinned infants
Deficiency
Too little vitamin D can lead to:
• Osteoporosis or osteomalacia in adults
• Rickets in children
Toxicity
Too much vitamin D can lead to:
• Hypercalcemia, which can present as nausea, vomiting, constipation, poor appetite, weight loss,
polyuria, confusion, and disorientation
• Nephrolithiasis
• Nausea, vomiting, constipation, poor appetite, and weight loss
Vitamin D and Calcium Guideline 2Dietary reference intakes for vitamin D
For information on side effects, contraindications, formulary status (e.g., prior authorization), and other
pharmacy-related issues, see the Group Health Formulary.
As human milk is a poor source of vitamin D, breastfed infants should be prescribed a daily vitamin D
supplement.
Table 1. Recommended Dietary Allowance (RDA) for vitamin D 1
Age RDA (IU/day) Upper Limit (IU/day)
1
Infants 0–6 months 400 1,000
1
Infants 6–12 months 400 1,500
1–3 years 600 2,500
4–8 years 600 3,000
9–13 years 600 4,000
14–18 years 600 4,000
19–30 years 600 4,000
31–50 years 600 4,000
51–70 years 600 4,000
Over 70 years 800 4,000
Females 14–18 years, 600 4,000
pregnant/lactating
Females 19–50 years, 600 4,000
pregnant/lactating
1
These RDAs are based on the IOM recommendations.
Sources of vitamin D
The body makes vitamin D when the skin is directly exposed to sun. Despite the importance of sun
exposure for the vitamin D synthesis, sunscreen or protective clothing should be worn when out in the
sun for more than a few minutes to lower the risk for skin cancer.
Table 2. Food sources of vitamin D 1
Food Portion size IUs per serving
Vitamin D–fortified milk (nonfat, 8 oz 115–124
reduced-fat, whole)
Vitamin D–fortified yogurt 6 oz 88
Salmon (sockeye), cooked 3 oz 447
Mackerel 3 oz 388
Tuna 3 oz 154
Vitamin D–fortified orange juice 8 oz 137
1
These food sources are a subset of those identified by the NIH Office of
Dietary Supplements.
Vitamin D and Calcium Guideline 3Therapeutic options
Vitamin D is available in two forms, D2 (ergocalciferol) and D3 (cholecalciferol). Both forms and multiple
dosing regimens effectively raise serum vitamin D levels. There is insufficient evidence to determine a
preferred regimen. The cumulative amount of vitamin D appears to be most important.
The following recommendations were adapted from UpToDate and from the Endocrine Society clinical
practice guideline (Holick 2011).
Adults
Table 3. Recommended pharmacologic options for treating vitamin D deficiency in ADULTS 1
Eligible Medication Dose Duration Repeat vitamin D level at 12 weeks, or
population 4 weeks after completion of therapy:
Less than 20 ng/mL Greater than 20 ng/mL4
Adults with Vitamin D2 50,000 8 weeks Continue treatment The amount of vitamin D
vitamin D (ergocalciferol) IU/week for another 8 weeks needed to maintain
deficiency then retest. 3 optimal levels is usually
Vitamin D3 3,000–5,000
(less than 800–2,000 IU/day. 5
(cholecalciferol) IU/day 6
20 ng/mL) 2
1
Risks of treatment include hypervitaminosis D, hypercalciuria, and hypercalcemia. Hypercalciuria may
occur without hypercalcemia. In patients on long-term high-dose vitamin D therapy, it is prudent to
measure serum calcium and 24-hour urine for calcium/fractional excretion of calcium once after 6–12
months of therapy.
2
Vitamin D levels greater than 20 ng/mL may be treated with the usual vitamin D supplement dosing.
There is no need for follow-up testing in patients with vitamin D levels greater than 20 ng/mL.
3
If still less than 20 ng/mL, then increase dose to 50,000 IU twice a week and evaluate for
malabsorption.
4
If originally deficient, recheck once more in 4 months to be sure that levels are maintained.
5
There is no consensus in the literature regarding appropriate maintenance dosing. The vitamin D
source may be cholecalciferol 400 IU or 1000 IU, cal carbonate/vit D 600/400, or
cal citrate/vit D 315/200.
6
The recommendations for daily dosing of vitamin D3 are based on local expert opinion. The Endocrine
Society clinical practice guidelines recommend 6,000 IU/day; however, the Group Health guideline
team considered this dose to be too high.
Vitamin D and Calcium Guideline 4Children (0–18 years)
Table 4. Recommended pharmacologic options for treating vitamin D deficiency in CHILDREN 1
Eligible Medication Dose Duration Repeat vitamin D level at 10 weeks or
population 4 weeks after completion of therapy:
Less than 20 ng/mL Greater than 20 ng/mL 3
Patients aged Vitamin D2 50,000 6 weeks Continue treatment The amount of vitamin D
0–18 years (ergocalciferol) IU/week for another 6 weeks, needed to maintain
with vitamin D then retest. 2 optimal levels is usually
Vitamin D3 2,000
deficiency 400–1,000 IU/day. 4
(cholecalciferol) IU/day
(less than
20 ng/mL)
1
Risks of treatment include hypervitaminosis D, hypercalciuria, and hypercalcemia. Hypercalciuria may
occur without hypercalcemia. In patients on long-term high-dose vitamin D therapy, it is prudent to
measure serum calcium and 24-hour urine for calcium/fractional excretion of calcium once after 6–12
months of therapy.
2
If still less than 20 ng/mL, increase dose to 50,000 IU twice a week and evaluate for malabsorption.
3
If originally deficient, recheck once more in 4 months to be sure that levels are maintained.
4
There is no consensus in the literature regarding appropriate maintenance dosing. The vitamin D
source may be cholecalciferol 400 IU chewable or drops.
Special populations
Patients requiring higher dosing
Selected patients (e.g., obese patients, patients with malabsorption syndromes, and patients on
medication affecting vitamin D metabolism) may require a higher dose of vitamin D to treat deficiency
(at least 6,000–10,000 IU/day) followed by maintenance therapy of at least 3,000–6,000 IU/day
(Holick 2011).
Patients requiring lower dosing
Consider lower dosing (less than 50,000 IU/week) in patients with hyperparathyroidism, sarcoidosis,
tuberculosis, and lymphoma.
Vitamin D and Calcium Guideline 5References Dawson-Hughes B. Treatment of vitamin D deficiency in adults. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2012. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911–1930. Institute of Medicine (IOM). Dietary Reference Intakes for Calcium and Vitamin D. www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin- D/Vitamin%20D%20and%20Calcium%202010%20Report%20Brief.pdf. Misra M. Vitamin D insufficiency and deficiency in children and adolescents. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2012. National Institutes of Health (NIH) Office of Dietary Supplements. Dietary Supplement Fact Sheet: Calcium. http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional. Vitamin D and Calcium Guideline 6
Calcium
Functions
• Building and maintaining strong bones and teeth
• Mediating skeletal and vascular muscle function
• Sending and receiving nerve signals
• Releasing hormones and other chemicals
Serum levels
Routine screening for serum calcium levels is not recommended.
Deficiency
Inadequate intake of calcium produces no obvious signs or symptoms in the short term; over the long
term, insufficient calcium intake can lead to:
• Osteoporosis or osteomalacia in adults
• Rickets in children
Toxicity
Too much calcium can lead to:
• Constipation, fatigue, and depression
• Nephrolithiasis
Special considerations: cardiovascular disease
A recent meta-analysis that included 15 randomized controlled trials with 11,971 participants investigated
whether calcium supplements increase the risk of myocardial infarction. Results from this analysis
suggested that, when given alone, calcium may increase the risk of myocardial infarction (hazard ratio
1.31; 95% CI, 1.02–1.67; NNT = 69). However, this study should be interpreted with caution as it had
several methodological limitations: the analysis only included studies involving calcium supplements, not
calcium plus vitamin D, which is a more common regimen; none of the studies were designed primarily to
examine cardiovascular disease; dietary calcium intake was not controlled for in the analysis; and seven
of the trials had incomplete or no information on baseline cardiovascular risk factors. Additionally, the
analysis found no significant increase in clinical outcomes such as stroke or death—seemingly
contradictory findings that raise questions about the conclusions of the analysis (Bolland 2010).
Another systematic review and meta-analysis did not find that calcium supplements, with or without
vitamin D, increased the risk of cardiovascular disease among adults. Results from this analysis should
also be interpreted with caution, as it included only a small number of studies, none of which were
designed to specifically assess the effects of supplementation on cardiovascular outcomes (Wang 2010).
Vitamin D and Calcium Guideline 7Dietary reference intakes for calcium
Table 1. Recommended Dietary Allowance (RDA) for calcium 1,2,3,4,5
Age RDA (mg/day) Upper limit (mg/day)
Infants 0–6 months 200 1,000
Infants 6–12 months 260 1,500
1–3 years 700 2,500
4–8 years 1,000 2,500
9–13 years 1,300 3,000
14–18 years 1,300 3,000
19–30 years 1,000 2,500
31–50 years 1,000 2,500
Males 51–70 years 1,000 2,000
Females 51–70 years 1,200 2,000
Over 70 years 1,200 2,000
Females 14–18 years, 1,300 3,000
pregnant/lactating
Females 19–50 years, 1,000 2,500
pregnant/lactating
1
These RDAs are based on the IOM recommendations.
2
Calcium may be taken as a supplement. Group Health carries the following
formulations:
– Calcium carbonate/vit D 600/400
– Calcium citrate/vit D 315/200
3
Calcium carbonate absorption may be impaired in patients with high gastric pH.
This includes patients taking acid-suppressing drugs (e.g., proton pump inhibitors)
and the elderly.
4
Calcium citrate may be preferred in patients with high gastric pH.
5
Generally, calcium absorption is enhanced with food. However, certain foods such
as spinach, rhubarb, nuts, beans, seeds, grains, or high-fat or high-fiber meals
may decrease absorption. Absorption is best if no more than 500–600 mg calcium
is taken at a time.
Vitamin D and Calcium Guideline 8Food sources of calcium
Table 2. Food sources of calcium 1
Food Portion size Milligrams (mg) per serving
Milk (nonfat, reduced-fat, whole) 8 oz 272–296
Soy beverage, calcium-fortified 8 oz 80–500
Yogurt, plain, low-fat 8 oz 415
Yogurt, fruit, low-fat 8 oz 313–384
Mozzarella cheese, part-skim 1.5 oz 333
Cheddar cheese 1.5 oz 306
Sardines (canned in oil with bones) 3 oz 324
Salmon (pink, canned, solid with bones) 3 oz 181
Fortified breakfast cereals 1 cup 100–1,000
Calcium-fortified orange juice 8 oz 378
1
These food sources represent a subset of those identified by the NIH Office of Dietary
Supplements.
References
Bolland MJ, Avenell A, Baron JA, et al. Effect of calcium supplements on risk of myocardial infarction and
cardiovascular events: meta-analysis. BMJ. 2010 Jul 29;341:c3691.
Institute of Medicine (IOM). Dietary Reference Intakes for Calcium and Vitamin D.
http://www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-
Vitamin-D/Vitamin%20D%20and%20Calcium%202010%20Report%20Brief.pdf.
National Institutes of Health (NIH) Office of Dietary Supplements. Dietary Supplement Fact Sheet:
Calcium. http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional.
Wang L, Manson JE, Song Y, Sesso HD. Systematic review: Vitamin D and calcium supplementation in
prevention of cardiovascular events. Ann Intern Med. 2010 Mar 2;152(5):315–323.
Vitamin D and Calcium Guideline 9Clinician Lead and Guideline Development Content Expert James Benson, MD, Endocrinology Clinical Improvement & Prevention Clinician Lead Paula Lozano, MD, MPH, Assistant Medical Director of Preventive Care Contact: lozano.p@ghc.org Guideline Coordinator Avra Cohen, RN, Clinical Improvement & Prevention Contact: cohen.al@ghc.org Guideline Team Members Travis Abbott, MD, Family Medicine Vivien Chan, PharmD, Pharmacy Emily Chao, MD, Pediatrics Rebecca Doheny, MPH, Epidemiologist, Clinical Improvement & Prevention Fred Heidrich, MD, Family Medicine Robyn Mayfield, Health Education Specialist, Clinical Improvement & Prevention Michelle Seelig, MD, Family Medicine Ann Stedronsky, Clinical Publications, Clinical Improvement & Prevention Most Recent Guideline Approval: December 2011 Process of Development This evidence-based guideline was developed using an explicit evidence-based process, including systematic literature search, critical appraisal, and evidence synthesis. The following specialties were represented on the development and/or update teams: endocrinology, family medicine, pediatrics, and pharmacy. Vitamin D and Calcium Guideline 10
You can also read
