Vitamin D supplementation

[DrMetal]

Riddle me this:

If someone is osteopenic, we give Calcium/Vitamin D supplementation. The vitamin D in caltrate is 400 U of D3, BID, so that's 5600 U of D3 per week. (that D3 is a calcitriol analog, right? read to go).

If we later find out same patient is 25-hydroxy deficient (the typical lab we check), does it then make sense to add ergocalciferol (a D2 analog), 50KU/week, on top of the D3 we're giving? Put another way, if you're already giving a D3 analog, why would you give a D2 analog that requires further hydroxylation to become active? Isn't that a little overkill, or is it necessary to make sure you have enough active D3?

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[aafisahar]

Eh doesn't really matter but it's something we do to make us feel better.

IIRC d2 needs sunlight to convert to D3, so might as well give D3 so that you take out the sunlight factor. You can make >20,000 units of D3 from sunlight per day, so very unlikely that you'll overdose them in any meaningful way.

 

[DrMetal]

Eh doesn't really matter but it's something we do to make us feel better.

IIRC d2 needs sunlight to convert to D3, so might as well give D3 so that you take out the sunlight factor. You can make >20,000 units of D3 from sunlight per day, so very unlikely that you'll overdose them in any meaningful way.

Ok, but is it necessary to prescribe both: Caltrate(Ca/D3 600/400) BID + Ergocalciferol 50KU QWeekly ?

I see this on the charts all of the time. For your typical IM patient already taking 8 medications, might be nice to take one of them off if not necessary, no?

Need endocrin input, paging @Raryn

 

[Raryn]

Riddle me this:

If someone is osteopenic, we give Calcium/Vitamin D supplementation. The vitamin D in caltrate is 400 U of D3, BID, so that's 5600 U of D3 per week. (that D3 is a calcitriol analog, right? read to go).

If we later find out same patient is 25-hydroxy deficient (the typical lab we check), does it then make sense to add ergocalciferol (a D2 analog), 50KU/week, on top of the D3 we're giving? Put another way, if you're already giving a D3 analog, why would you give a D2 analog that requires further hydroxylation to become active? Isn't that a little overkill, or is it necessary to make sure you have enough active D3?

D3 isn't a calcitriol analog, it's cholecalciferol, which just like ergocalciferol must be hydroxylated in the body to make 25-OH vitamin D and then 1,25-OH vitamin D (which is calcitriol).

The big difference is D3 has slightly better absorption, but if the patient needs vitamin D, you can give them an adequate dose of either.

For historical reasons, prescription vitamin D is ergocalciferol but the OTC stuff is cholecalciferol, but there's no real reason why. Hell, you can buy 50k international unit capsules of D3 on Amazon even.

 

[DrMetal]

D3 isn't a calcitriol analog, it's cholecalciferol, which just like ergocalciferol must be hydroxylated in the body to make 25-OH vitamin D and then 1,25-OH vitamin D (which is calcitriol).

The big difference is D3 has slightly better absorption, but if the patient needs vitamin D, you can give them an adequate dose of either.

For historical reasons, prescription vitamin D is ergocalciferol but the OTC stuff is cholecalciferol, but there's no real reason why. Hell, you can buy 50k international unit capsules of D3 on Amazon even.

Got it thanks.

So, does it make sense to give someone both Caltrate BID and ergocalciferol 50K q weekly? Isn't this overkill, or do we do it on purpose to ensure enough calcitriol is eventually made?

 

[Raryn]

Got it thanks.

So, does it make sense to give someone both Caltrate BID and ergocalciferol 50K q weekly? Isn't this overkill, or do we do it on purpose to ensure enough calcitriol is eventually made?

Depends on their vitamin D. Most people don't need quite that much, though it's unlikely to be harmful.

The stuff in the caltrate isn't enough supplementation for most, but I'll usually just add 2000 or so a day of D3. You could instead just do 50k a week of D2, but it's likely overkill, yes.

 

[DrMetal]

Depends on their vitamin D. Most people don't need quite that much, though it's unlikely to be harmful.

The stuff in the caltrate isn't enough supplementation for most, but I'll usually just add 2000 or so a day of D3. You could instead just do 50k a week of D2, but it's likely overkill, yes.

That's what I thought, thanks.

 

[tylerb1800]

For vitamin d deficiency, I typically will do cholecalciferol 50,000 IU weekly for 8 weeks then cholecalciferol 1,000 to 2,000 IU daily. In practice, everyone treats vitamin d disorders a bit differently from what I have observed.

 

[rokshana]

It’s not necessarily an added benefit per se to continue the otc d3, but many times pts don’t remember to restart them once the ergocalciferol is completed… and they eventually become deficient again…once the tank is topped off, you gotta maintain it.

 

[DrMetal]

In my opinion, before taking any supplements we need to visit a doctor because he knows more than us, and as my doctor said:

[sarcasm\] Yeah, because every patient follows that creed. [\sarcasm]

 

[rokshana]

In my opinion, before taking any supplements we need to visit a doctor because he knows more than us, and as my doctor said: vitamin overdose is more dangerous than deficiency. However, I have a small experience with vitamin D, so I can't talk much about it.

It’s pretty hard to overdose on vitamins…even vitamin d toxicity is difficult to achieve

 

[Raryn]

In my opinion, before taking any supplements we need to visit a doctor because he knows more than us, and as my doctor said: vitamin overdose is more dangerous than deficiency. However, I have a small experience with vitamin D, so I can't talk much about it.

We are doctors.

 

[DrMetal]

We are doctors.

I see myself more as a veterinarian.

 

[tylerb1800]

Hey, I need an advice.

I want to take some vitamins for my body health.

Can someone help me or advice me which vitamins I should take?

Thanks

No one here will be providing you medical advice.

 

[Holemm_ev]

How can people overdose on vitamins?

 

[DrMetal]

I was just asking a simple question. How did this thread get trolled out?!

 

[rokshana]

How can people overdose on vitamins?

Fat soluble vitamins are not renally cleared, but stored in adipocytes…take more than you use…you can build up to toxic levels.

 

[Wren Wilkinson]

For vitamin D deficiencies, I usually take 200,000 units of vitamin D3 intramuscularly first and then every 2 months for 2 months if its level remain at 30 ng / ml

 

[Redpancreas]

It’s pretty hard to overdose on vitamins…even vitamin d toxicity is difficult to achieve

Not if the gummies taste good and are sugar free (zero guilt)

To the question at hand, this is how I go about it.

Warning: This could be completely wrong and has no evidence behind it because I keep hearing different things from Rheumatologists, Endocrinologists, and Women's Health Experts, etc. trying to advocate for their own subsets and populations so I just do my own thing.

1.) Is the patient a 65+ and female? If so, screen her for osteoporosis and even if there's osteopenia treat a vitamin deficiency aggressively (at this point I'd check UptoDate to ensure I'm doing it right to make sure) and maintain maintenance vitamin D therapy afterwards.

2.) If not, is this just a vitamin D level you found that is low? Why was it checked in the first place? I don't treat unless there's a medical indication. I would give Vitamin D 2000U for one month and maintain of 1000U daily for a few months. I don't like just treating the Vitamin D lab for no reason. I've seen it checked for no reason on hospital admission labs.

 

[rokshana]

Not if the gummies taste good and are sugar free (zero guilt)

To the question at hand, this is how I go about it.

Warning: This could be completely wrong and has no evidence behind it because I keep hearing different things from Rheumatologists, Endocrinologists, and Women's Health Experts, etc. trying to advocate for their own subsets and populations so I just do my own thing.

1.) Is the patient a 65+ and female? If so, screen her for osteoporosis and even if there's osteopenia treat a vitamin deficiency aggressively (at this point I'd check UptoDate to ensure I'm doing it right to make sure) and maintain maintenance vitamin D therapy afterwards.

2.) If not, is this just a vitamin D level you found that is low? Why was it checked in the first place? I don't treat unless there's a medical indication. I would give Vitamin D 2000U for one month and maintain of 1000U daily for a few months. I don't like just treating the Vitamin D lab for no reason. I've seen it checked for no reason on hospital admission labs.

Seriously, what is the point of this post? Have you thought about…maybe reading actual guidelines on vitamin D deficiency? There are plenty of them out there…you know from societies that evaluate and treat vit D def.
And is there a reason you would use a homeopathic dose of vit d in the face of an actual deficiency? It takes forever to get vit d up with high doses… or are you just looking to milk your pt by making g them come in because you are undertreating them?

or did you just stay at a holiday inn?

 

[Redpancreas]

Seriously, what is the point of this post? Have you thought about…maybe reading actual guidelines on vitamin D deficiency? There are plenty of them out there…you know from societies that evaluate and treat vit D def.
And is there a reason you would use a homeopathic dose of vit d in the face of an actual deficiency? It takes forever to get vit d up with high doses… or are you just looking to milk your pt by making g them come in because you are undertreating them?

or did you just stay at a holiday inn?

To be fair, I did say I would replete aggressively in a patient with osteopenia/porosis and am aware of the 50K option. I think the frustration is because I feel there are differing guidelines with no great consensuses and don't like checking Vitamin D on a routine wellness exam and then treating a number with a subjective cutoff when the patient has no comorbid conditions like an osteoporosis or malabsorptive condition. Since I think you are a specialist in one of these fields involved in vitamin D metabolism, I welcome you to tear my incoming response apart and in the process educate me.

What's the cut-off for a deficiency? Is it less than 20? 40? Is it when our hospitals lab value turns red? After that, when should be treat a patient with a defined deficiency? Should we do it in a patient coming in who has no major comorbids where we find a low Vitamin D in someone from the northern US with darker skin? My thought is that less is more and that unless we have a reason for a vitamin D defiency or a condition where a vitamin D defiency can do harm (osteoporosis) I don't think we need to overcomplicate things. That's my point. Feel free to point me to any studies which say not treating people for asymptomatic vitamin D deficiencies clearly puts them at risk for depression, heart disease, or osteoporosis in the future and I will gladly change my tune.