Vitamin D Pat Ahlquist

Aim 

What is it?



What does it do?



How do we get it?



Why is this important to us?



Why is this important to our patients?

Vitamin D 

Cholecalciferol (D3)



Ergocalciferol (D2)



Important for bone health



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