SOAP. – Vitamin D Deficiency

Definition

A.Vitamin D deficiency is defined as having a serum 25(OH)D level lower than 15 ng/mL. Vitamin D insufficiency is defined as having a serum 25(OH)D level lower than 30 ng/mL. Recommended vitamin D levels range between 30 and 40 ng/mL.

Incidence

A.Vitamin D deficiency is seen in all ages. It is highest in the elderly, institutionalized, and/or hospitalized patients. It is found to be more common in women than in men (83% vs. 48%), the difference most likely being less skin exposure to the sun. There is a higher incidence in the winter months, again because of less sun exposure during the winter months.

Pathogenesis

A.The best source of vitamin D is direct sunlight exposure to the skin. It is also absorbed by ingesting foods that are rich in vitamin D. The liver is responsible for breaking vitamin D down. The liver hydroxylates the vitamin D to storage form, 25[OH]D, which then breaks down into the bioactive form in the kidney, 1,25-dihydroxyvitamin D (1,25[OH]2D). The 1,25(OH)2D is regulated by the parathyroid hormone (PTH) and causes calcium absorption to occur in the intestine, which in return affects bone metabolism and muscle function. When any part of this cascade is interrupted, the cascade is broken and vitamin D deficiency occurs.

Predisposing Factors

A.Race (darker skin population).

B.Age: Elderly population highest risk.

C.Long-term institutionalized individuals (nursing home).

D.Obese individuals.

E.Decreased sun exposure (individuals who spend very little time outdoors in the sun).

F.People with serious nervous or digestive disorders (chronic kidney disease and malabsorption problems).

G.Medications: Drugs, such as dilantin, phenobarbital, and rifampin, induce hepatic p450 enzymes and accelerate catabolism of vitamin D.

Common Complaints

A.Complaints vary from none to severe.

B.Chronic muscle aches/pain/fatigue/weakness.

C.Joint pain and bone pain.

Other Signs and Symptoms

A.Fracture of bone.

B.Frequent falls and muscle weakness.

C.The most severe form of vitamin D deficiency can cause nutritional rickets.

Subjective Data

A.With patients presenting with complaints, assess onset, duration, and course of complaints.

B.Assess daily nutritional habits. Does the patient get enough calcium and vitamin D in current diet?

C.Does the patient live in the home or an institution? Is the patient allowed to spend time outdoors in sunlight? What time of the season/year is it? Is 20 to 30 minutes in the sun without sunscreen reasonable?

D.Is the patient currently taking any vitamin supplements? if so, review vitamin and ingredients in that particular vitamin.

E.Review the patient history and determine if the patient has a chronic condition, malabsorption condition, chronic kidney condition, or medications interfering with absorption. If there is no current diagnosis of a GI problem, inquire regarding food intolerances, stool patterns, constipation, and diarrhea history.

F.Does the patient currently take a vitamin D and/or calcium supplement?

G.Has the patient had a recent vitamin D level drawn?

H.Inquire regarding the patient’s fatigue level.

I.Assess for muscle weakness and frequent falls, especially if a pattern of more falls in the winter months is noticed.

J.Has the patient been diagnosed with osteoporosis? if so, the patient needs to be screened for vitamin D deficiency.

Physical Examination

A.Check pulse and blood pressure (BP).

B.Inspect:

1.Observe the patient walk in the room and assess for stability.

2.Observe the skin color and overall appearance and type of skin texture.

3.Note any deformities in the spine:

a.Kyphosis.

b.Bowing of the legs.

c.Waddling of gait.

C.Palpate:

1.Joints or areas of complained tenderness with which the patient presented.

2.The abdomen if intestinal absorption problems are suspected and workup is needed.

D.Auscultate:

1.Heart.

2.Lungs.

Diagnostic Tests

A.Serum 25(OH)D: Normal (30–80 ng/mL).

B.PTH: Normal (14–72 pg/mL).

C.Calcium level: Normal (8.5–10.2 mg/dL).

Differential Diagnoses

A.Vitamin D deficiency.

B.Osteoporosis.

C.Rickets.

D.Cystic fibrosis.

E.Malabsorption syndrome.

F.Chronic kidney disease.

Plan

A.General interventions:

1.Educate the patient regarding the importance of calcium and vitamin D for the body.

2.Vitamin D levels should be monitored. Vitamin D levels should range between 30 and 60 ng/mL.

B.Patient teaching:

1.Educate the patient about vitamin D deficiency and the importance of getting vitamin D into the diet on a daily basis.

2.Suggest eating foods that are higher in vitamin D in the diet. These foods include fish oil, cod liver, salmon, and foods fortified with vitamin D such as milk and cereals.

3.Discuss how inadequate sun exposure can increase the risk of vitamin D deficiency. Recommend 20 to 30 minutes of sunlight during summer months without use of sunscreen, if this is not contraindicated to other chronic conditions.

4.Foods higher in calcium should also be included in the diet on a daily basis.

C.Pharmaceutical therapy:

1.Vitamin D level recommendations:

a.For vitamin D levels less than 20 ng/mL: Vitamin D2 or D3 50,000 IU weekly for 8 weeks and recheck vitamin D level. If still less than 30 ng/mL at that point, repeat the dose for another 8 weeks and recheck when second course is finished.

b.Vitamin D levels between 20 and 30 ng/mL: Vitamin D3 600 to 800 IU daily.

c.Cholecalciferol (vitamin D3) is preferred to ergocalciferol (vitamin D2) for supplementation when available.

2.Calcium levels should be maintained with a recommended dietary intake of 1,000 to 1,200 mg/d.

D.For malabsorption problems

Recommend magnesium 250 mg daily supplement. May also refer to a GI specialist for workup.

Follow-Up

A.Follow-up should be performed according to recommendations based on laboratory results. Initial laboratory results should be repeated in 8 weeks with initial treatment. As soon as vitamin D levels are stable, repeat lab work routinely to confirm that levels remain within enormal range. If levels continue to fall, refer to a specialist.

Consultation/Referral

A.Consult with a physician or refer the patient to a gastroenterologist for those who consistently have low vitamin D levels or if malabsorption problems are diagnosed.

Individual Considerations

A.Pregnancy:

1.No contraindications for treatment during pregnancy. The same prescribing dose is safe for pregnancy and breastfeeding patients.

B.Geriatrics:

1.Vitamin deficiencies are commonly seen in this population.

2.All patients diagnosed with osteoporosis should be assessed for vitamin D deficiency.

3.Patients with a serum 25(OH)D level of less than 10 are at risk for developing osteomalacia.

4.Research indicated that high doses of vitamin D (60,000 IU D3/mo to achieve 25(OH)D level of 30 ng/mL) increased falls 15% and fractures 26% secondary to a negative effect with balance. Recommendations for patients ≥70 years of age are 24,000 IU of D3/mo, which has no effect with lower extremity function/balance.

5.The U.S. Preventive Services Task Force reported that although vitamin D supplementation with calcium was associated with increased renal stone risk, calcium supplementation alone was not. However, the benefits for geriatrics with vitamin D in combination with calcium supplement outweighed the risk of kidney stones. Recommendations for geriatrics are vitamin D 400 to 800 IU/d and calcium 1,000 to 1,200 mg/d.