Also immune system, nervous system, cardiovascular system
How do we get Vitamin D? oily fish – such as salmon, sardines and mackerel eggs fortified fat spreads fortified breakfast cereals some powdered milks
Not milk in UK
Immune system
Vitamin D Induction
of antimicrobial peptides (AMPs) at mucosal surfaces and in immune cells Down regulates proinflammatory cytokines
Low levels associated with increased risk of TB and Resp Tract Infections
Levels below 50nmol/l have x2 increased risk of developing MS
Cancer
Link with colon cancer. Inconsistent evidence for prostate and breast cancer.
Macrophages kill B-cell lymphoma cells by releasing AMPs in a vit D dependant fashion
Rituximab-mediated macrophage cytotoxicity improved with vit D
How much do we need? No real consensus for insufficiency Institute of Medicine (USA)
65 yrs age Housebound
800 units daily if mild deficiency
Palliative care relevance
Bisphosphonates
High incidence of deficiency in palliative care population
Other symptoms that may be related to Vitamin D deficiency – fatigue, pain ….
Bisphosphonate prophylaxis for SRE
Patients with vitamin D deficiency more likely to experience more severe and prolonged hypocalcaemia – should be assessed before treatment (BMJ 2015 Sept –Clinical review of bisphosphonates for prevention and treatment of osteoporosis)
PCF 5 – Caution – increased risk of hypocalcaemia in Vitamin D deficiency (from a case report 2005 –Am Journal hospice and PC)
Bisphosphonate prophylaxis for SRE
Study showed significant higher rates of acute phase response symptoms in women with lower vitamin D levels (J Bone Mineral Research 2010)
Deficiency in palliative care population High levels in general uk population (50% insufficiency and 16% severe in winter/spring) Prevalence between 33 and 88% in cancer population Reasons for increase in palliative care population – decreased sun exposure, food intake, malabsorption, liver and renal disease, steroids, anticonvulsants
Falls Prevention
Vit D supplements (700 – 1000u daily) Several
meta-analyses Relative risk reduction up to 20%
Vit D high intermittent high dose Increase
risk of falls and fracture
Combine with calcium and exercise
Symptom control issues Fatigue/qol study (Palliative Medicine Jan 2016) 30 patients 90% deficiency Fatigue ranked high in self assessmentsignificantly correlated with vit D levelscorrelated with PS Significant positive correlation of vitamin D with PS (Brisbane)
Pain Significant association with low vit D and higher opioid dose (100 Pall patients) If vit D