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Vitamin D recommendations by Italian Endocrinologists – 40 ng if pregnant, 30 ng if high risk – April 2018

Italian Association of Clinical Endocrinologists (AME) and Italian Chapter of the American Association of Clinical Endocrinologists (AACE) Position Statement: Clinical Management of Vitamin D Deficiency in Adults

Nutrients 2018, 10(5), 546; https://doi.org/10.3390/nu10050546

VitaminDWiki

High risk adults should have also included

  • Dark skin
  • Wear concealing clothing
  • People who get very little noon-day sun
  • Diabetic
  • On dialysis
  • Multiple Sclerosis
  • Gut problems
  • Gallbladder removed
  • HIV
  • Depression
  • Anemia
  • Little Magnesium in water
  • Take drugs which remove Magnesium from Body
  • Drink > 1 can of soft drink daily
  • Autistic
  • Breastfeeding
  • Smoker or both parents smoke
  • Both parents known to be vitamin D deficient ((Vitamin D deficiency in both parents associated with 41 X higher risk of deficient adolescents – April 2018|41 X increased risk)
  • People who have health problems related to Vitamin D running in their family

See also VitaminDWiki


 Download the PDF from VitaminDWiki

Roberto Cesareo 1,* , Roberto Attanasio 2OrcID, Marco Caputo 3, Roberto Castello 4, Iacopo Chiodini 5,6OrcID, Alberto Falchetti 7OrcID, Rinaldo Guglielmi 8, Enrico Papini 8, Assunta Santonati 9, Alfredo Scillitani 10, Vincenzo Toscano 11, Vincenzo Triggiani 12, Fabio Vescini 13, Michele Zini 14 and on behalf of AME and Italian AACE Chapter 1

Vitamin D deficiency is very common and prescriptions of both assay and supplementation are increasing more and more. Health expenditure is exponentially increasing, thus it is timely and appropriate to establish rules. The Italian Association of Clinical Endocrinologists appointed a task force to review literature about vitamin D deficiency in adults. Four topics were identified as worthy for the practicing clinicians. For each topic recommendations based on scientific evidence and clinical practice were issued according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) System.

  • (1) What cut-off defines vitamin D deficiency: even though 20 ng/mL (50 nmol/L) can be considered appropriate in the general population, we recommend to maintain levels above 30 ng/mL (75 nmol/L) in categories at risk.
  • (2) Whom, when, and how to perform screening for vitamin D deficiency: categories at risk (patients with bone, liver, kidney diseases, obesity, malabsorption, during pregnancy and lactation, some elderly) but not healthy people should be screened by the 25-hydroxy-vitamin D assay.
  • (3) Whom and how to treat vitamin D deficiency: beyond healthy lifestyle (mostly sun exposure), we recommend oral vitamin D (vitamin D2 or vitamin D3) supplementation in patients treated with bone active drugs and in those with demonstrated deficiency. Dosages, molecules and modalities of administration can be profitably individually tailored.
  • (4) How to monitor the efficacy of treatment with vitamin D: no routine monitoring is suggested during vitamin D treatment due to its large therapeutic index. In particular conditions, 25-hydroxy-vitamin D can be assayed after at least a 6-month treatment.

We are confident that this document will help practicing clinicians in their daily clinical practice.

At Risk (and thus need >30 ng)

  • Osteomalacia
  • • Osteoporosis (particularly if bone active drugs are to be used)
  • • Older adults with history of falls
  • • Older adults with history of non-traumatic fractures
  • • Pregnant and lactating women
  • • Obese children and adults
  • • People not exposed to sufficient sun exposure
  • • Malabsorption syndromes (congenital or acquired) and bariatric surgery
  • • Chronic kidney disease
  • • Hepatic failure
  • • Cystic fibrosis
  • • Hyperparathyroidism
  • • Drug interfering with vitamin D metabolism (anti-seizure medications, glucocorticoids, AIDS medications, anti-fungals, cholestyramine)
  • • Granulomatous disorders and some lymphomas (in these cases, also 1.25(OH)2D should be tested)

Recommendations and Suggestions

  • We recommend to maintain 25(OH)D levels above 30 ng/mL (75 nmol/L) in subjects:
    • • With osteopenia, osteoporosis or fragility fractures;
    • • On treatment for osteoporosis;
    • • Who belong to at risk categories (see above).
  • We suggest to consider serum PTH measurement when vitamin D values are lower than 30 ng/mL (75 nmol/L), particularly if tested in Summer and Autumn.
  • We suggest to employ the same method for serial measurements of vitamin D in any patient (panel agreed on the recommendation and downgraded it to suggestion due to feasibility reasons).
  • We recommend against routine 1,25-(OH)2 -vitamin D assessment
  • We suggest to perform DXA examination whenever the fracture risk is increased.
  • We suggest to check 25(OH)D levels in any patient with established osteoporosis before starting the treatment.
  • We recommend to rule out secondary causes of vitamin D deficiency whenever serum 25(OH)D levels are not normalized as expected after treatment.
    • Note by VitaminDWiki - cannot wait 6 months during pregancy to find out that not enough vitamin D was given
  • We suggest not to consider the dietary sources as adequate for the achievement of an optimal vitamin D status in Italy.
  • We suggest not to consider sun exposure as adequate for the achievement of an optimal vitamin D status in Italy
  • We recommend treatment with cholecalciferol by mouth as the first line therapy in most patients.
    • Note by VitaminDWiki: Other forms should be used if gut, liver, kidney problems
  • We suggest the following schedules for vitamin D supplementation:
    • Deficiency and insufficiency: 50,000 IU once a week for 8 weeks; alternatively, a daily dose of 5000 IU for 8 weeks;
    • Maintenance of sufficiency: 50,000 IU twice a month; alternatively, a daily dose of 1500–2000 IU.
  • We suggest an individually tailored approach for vitamin D administration, involving the patient‘s opinion about the schedule (daily, weekly or monthly) that may offer the best adherence.
  • We suggest the use of calcifediol in case of:
    • Hepatic impairment;
    • Congenital abnormalities of the hepatic 25-hydroxylase enzyme;
    • Malabsorption of cholecalciferol;
    • Obesity.
  • We recommend against routine use of 1.25(OH)2D or alpha-calcidiol for vitamin D deficiency.
  • We recommend to use 1.25(OH)2D or alpha-calcidiol only when treating:
    • Chronic renal failure;
    • Hypoparathyroidism.
  • We suggest to use cholecalciferol as add on to 1.25(OH)2D, or alpha-calcidiol, in patients with CRF or hypoparathyroidism associated with demonstrated vitamin D deficiency.
  • We recommend calcium plus vitamin D supplements in patients with insufficient calcium intake, particularly if osteoporotic and taking bone active drugs.
    • Note by VitaminDWiki – Yes, more Calcium as food, but not as supplement
  • We recommend a dosage of vitamin D up to a maximum of 4000 IU/day.
  • We recommend against doses above 10,000 IU/day.
    • Note by VitaminDWiki: Over 100,000 people routinely take >10,000 IU daily -with virtually no problems
  • We suggest a careful surveillance of any possible intake, because patients might inadvertently assume products containing additional amounts of vitamin D.
  • We recommend against routine serum 25(OH)D testing during vitamin D supplementation.
  • We suggest the assessment of vitamin D levels after at least 6 months of therapy, also if combined with bone active drugs, in patients:
    • With previous severe hypovitaminosis D or persistent risk of severe hypovitaminosis because of renal or liver failure, metabolic bone diseases, malabsorption, severe obesity, hypogonadism, glucocorticoid treatment;
    • At risk for hypercalcemia due to underlying diseases (i.e., granulomatosis and lymphoproliferative tumors) where 1.25(OH)2D assay is appropriate for monitoring;
    • Who assume high doses of vitamin D and present with symptoms of vitamin D toxicity.
  • We suggest the evaluation of concomitant medical treatments for a potential interference with vitamin D absorption and metabolism.
  • We suggest the correction of vitamin D deficiency even in patients on teriparatide
  • We suggest to assay 25(OH)D levels in pregnancy to screen for its deficiency.
  • We suggest the supplementation of pregnant women with cholecalciferol, aiming at a serum 25(OH)D level > 40 ng/mL (100 nmol/L).
  • We suggest to consider obese patients at high risk for vitamin D deficiency.
  • We suggest a duplicated, or triplicated, dose of vitamin D in obese patients and the use of calcifediol instead of vitamin D in this setting
    • VitaminDWiki has not seen this suggestion before
Created by admin. Last Modification: Thursday November 15, 2018 20:24:19 UTC by admin. (Version 6)

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