How to proceed when it comes to vitamin D

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doi:10.12788/jfp.0215

Practice Alert

How to proceed when it comes to vitamin D

J Fam Pract. 2021 July;70(6):289-292 | 10.12788/jfp.0215

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References

1. USPSTF. Screening for vitamin D deficiency in adults: US Preventive Services Task Force recommendation statement. JAMA. 2021;325:1436-1442.

2. Michos ED, Kalyani RR, Segal JB. Why USPSTF still finds insufficient evidence to support screening for vitamin D deficiency. JAMA Netw Open. 2021;4:e213627.

3. Burnett-Bowie AAM, Cappola AR. The USPSTF 2021 recommendations on screening for asymptomatic vitamin D deficiency in adults: the challenge for clinicians continues. JAMA. 2021;325:1401-1402.

4. Institute of Medicine. Dietary reference intakes for calcium and vitamin D. National Academies Press; 2011. Accessed May 22, 2021. https://pubmed.ncbi.nlm.nih.gov/21796828/

5. 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 Endocrinolgy Metab. 2011;96:1911-1930.

6. Shahangian S, Alspach TD, Astles JR, et al. Trends in laboratory test volumes for Medicare part B reimbursements, 2000-2010. Arch Pathol Lab Med. 2014;138:189-203.

7. Herrick KA, Storandt RJ, Afful J, et al. Vitamin D status in the United States, 2011-2014. Am J Clin Nutr. 2019;110:150-157.

8. Forrest KYZ, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults. Nutr Res. 2011;31:48-54.

9. Kahwati LC, LeBlanc E, Weber RP, et al. Screening for vitamin D deficiency in adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325:1443-1463.

10. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2016. Endocr Pract. 2016;22(supp 4):1-42.

11. AAFP. Clinical preventive services. Accessed May 22, 2021. www.aafp.org/family-physician/patient-care/clinical-recommendations/aafp-cps.html

12. USPSTF. Falls prevention in community-dwelling older adults: interventions. Accessed May 22, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/falls-prevention-in-older-adults-interventions

13. USPSTF. Vitamin supplementation to prevent cancer and CVD: preventive medication. Accessed May 22, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-supplementation-to-prevent-cancer-and-cvd-counseling

14. USPSTF. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: preventive medication. Accessed May 22, 2021. https://uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-d-calcium-or-combined-supplementation-for-the-primary-prevention-of-fractures-in-adults-preventive-medication

15. NIH. Vitamin D. Accessed May 22, 2021. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

16. Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab. 2011;96:53-58.

17. Jackson RD, LaCroix AZ, Gass M, et al. Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med. 2006;354:669-683.

Alternatives to universal screening. Screening for vitamin D deficiency might benefit some patients, although there is no evidence to support it. Universal screening will likely lead to overdiagnosis and overtreatment based on what is essentially a poorly understood blood test. This was the concern expressed by the NAM.^4,16 An editorial accompanying publication of the recent USPSTF recommendation suggested not measuring vitamin D levels but instead advising patients to consume the age-based RDA of vitamin D.³ For those at increased risk for vitamin D deficiency, advise a higher dose of vitamin D (eg, 2000 IU/d, which is still lower than the upper daily limit).³

Evidence is insufficient to recommend vitamin D and calcium supplementation, alone or in combination, to prevent fractures in men or premenopausal women.

Other options are to screen for vitamin D deficiency only in those at high risk for low vitamin D levels, and to test for vitamin D deficiency in those with symptoms associated with deficiency such as bone pain and muscle weakness. These options would be consistent with recommendations from the Endocrine Society.⁵ Some have recommended that if testing is ordered, it should be performed by a laboratory that uses liquid chromatography-mass spectrometry because it is the criterion standard.²

Treatment options. Vitamin D deficiency can be treated with either ergocalciferol (vitamin D₂) or cholecalciferol (vitamin D₃). These treatments can also be recommended for those whose diets may not provide the RDA for vitamin D. Both are readily available over the counter and by prescription. The Task Force found that the harms of treating vitamin D deficiency with vitamin D at recommended doses are small to none.¹ There is possibly a small increase in kidney stones with the combined use of 1000 mg/d calcium and 10 mcg (400 IU)/d vitamin D.¹⁷ Large doses of vitamin D can cause toxicity including marked hypercalcemia, nausea, vomiting, muscle weakness, neuropsychiatric disturbances, pain, loss of appetite, dehydration, polyuria, excessive thirst, and kidney stones.¹⁵A cautious evidence-based approach would be to selectively screen for vitamin D deficiency, conduct diagnostic testing when indicated, and advise vitamin D supplementation as needed.