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Gut doctors becoming aware of importance of vitamin D – May 2012

Many items in the journal Gut and the Journal of Crohn's and Colitis Spring 2012

OC-037? Vitamin D deficiency is common in intestinal failure patients

Gut 2012;61:A16 doi:10.1136/gutjnl-2012-302514a.37
Bapen symposium: “original communications”
A Culkin, B Rye, C Hanson
St Mark's Hospital, Harrow, UK

Introduction Vitamin D is essential due to its role in bone health and its immunomodulatory propeties.1 Patients with intestinal failure (IF) are at risk of Vitamin D deficiency due to inadequate absorption and lack of exposure to UVB light. Deficiency has been demonstrated in IF patients dependent on home parenteral nutrition.2 We aimed to determine the prevalence of vitamin D deficiency in hospital patients with IF and the efficacy of subsequent prescribed treatment.

Methods All patients admitted to St Mark's Hospital with IF over a 12-month period were included and data on demographics, serum total vitamin D concentration, IF aetiology and vitamin D supplementation prescribed were obtained. If deficiency was identified (?50?nmol/l) the efficacy of treatment provided was assessed. Descriptive analysis and t-tests were performed.

Results Eighty-four patients were included in the study (42 female, mean age 53±15?years, 92% Caucasian). The aetiology of IF included

  • short bowel (n=30),
  • fistula (n=34),
  • small bowel obstruction (n=13),
  • malabsorption (n=5) and
  • others (n=2).

Vitamin D was measured in 76% (n=64) of patients and 75% (n=48) were deficient (mean 41±25?nmol/l, range 9–126).
Vitamin D concentrations were

  • lower in men (33.4±15.3?nmol/l) compared to
  • women (49.5±29.5?nmol/l) (p=0.009).

No association was demonstrated with age, aetiology of IF, or ethnicity.
There was a trend towards reduced Vitamin D and increasing BMI (p=0.187, r2=0.028).
No seasonal variation was demonstrated between summer (June–November, 42.8±26.5?nmol/l) and winter (December–May, 39.3±21.6?nmol/l) (p=0.57).
Only 26% (n=22) of patients had repeat vitamin D concentrations before discharge. There was a significant increase in vitamin D concentrations from 35±22?nmol/l to 44.8±14.3?nmol/l, (p=0.03).

Twenty-nine patients received intramuscular Vitamin D at a dose of 300?000?IU. In these patients there was an increase in concentration before (28.4±13.6?nmol/l) and after (42.8±12.7?nmol/l). Due to the small numbers of patients it was not possible to determine the efficacy of the different vitamin D preparations or the effect of the multivitamin preparation used in parenteral nutrition (Cernevit®) on serum concentrations.

Conclusion Vitamin D deficiency is common and occurs in three-quarters of IF patients. Male gender was associated with lower concentrations. Robust policies need to be in place for the identification of vitamin D deficiency including the supplementation and monitoring of vitamin D deficiency in patients with IF to ensure adequate serum concentrations are achieved.

Competing interests None declared.

References 1. Michal L, Melamed. 25-Hydroxyvitamin D levels and the risk of mortality in the general population Arch Intern Med 2008;168:1629.

2. Tee CT, et al. Hypovitaminosis D in patients on long-term parenteral nutrition. Proc Nut Soc 2010;69:E554.
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PWE-247? Are we measuring vitamin D in inflammatory bowel disease (IBD) patients?

Inflammatory bowel disease III
S K Butt, K Besherdas
Department of Gastroenterology, Chase Farm Hospital, London, UK

Introduction There is increasing interest in the role of vitamin D in IBD, outside of its traditional role in metabolic bone disease. Novel insights into additional roles for vitamin D are being established and these include anti-inflammatory and immune-modulating effects. Active vitamin D is known to exert its biological functions via the vitamin D receptor (VDR). Immune cells have been found to express VDR and possess the enzymes necessary to produce active vitamin D. This suggests vitamin D may have actions beyond endocrine activity. Furthermore, Vitamin D deficiency has been linked to higher rates of cancers including colorectal cancer.

Previous studies have found that almost 50% of the IBD patients were vitamin D deficient at some point and 11% were severely deficient.

Vitamin D deficiency has been demonstrated to be independently associated with higher disease activity scores in patients compared to those that had normal levels of vitamin D. Furthermore, vitamin D deficient Crohn's patients have a poorer quality of life when compared to patients who are not vitamin D deficient. Currently, ECCO guidelines do not mention measurement of vitamin D in patients with IBD but given its effects, we set out to identify whether we were checking for and correcting for vitamin D deficiency in our IBD patients.

Methods The aim of the study was to investigate whether we were measuring vitamin D levels at any encounter in out IBD patients. This study was conducted in a busy District General Hospital in North London. Information was gathered using the hospital powerchart system and the IBD database of patients.

Results A total of 225 patients were correctly identified as having IBD. Of these,

  • 157 (70%) had Ulcerative colitis and
  • 68 (30%) had Crohn's disease. 2

(4 (15%) Ulcerative colitis patients and

  • 8 (12%) Crohn's patients

had their vitamin D checked on hospital records.
The range of vitamin D levels were 14–84 with lower limit of normal being 50. 13/32 (41%) patients has low vitamin D levels Of these only two patients were also under the Rheumatology team for co-existing arthropathy/arthritis.

Conclusion This study demonstrates that despite evidence of Vitamin D and its role in anti-inflammatory and immune-modulating effects (in addition to bone protection) we are not actively measuring and treating its deficiency. Perhaps guidance from ECCO may encourage our testing of vitamin D in IBD patients.

Competing interests None declared.

(Summary: 41% had less than 20 nanograms of vitamin D yet ECCO {?} still not even recommend vitamin D testing, much less treatment)

PWE-241? Vitamin D status in inflammatory bowel disease: are clinicians seeing the light?

Gut 2012;61:A396 doi:10.1136/gutjnl-2012-302514d.241
Inflammatory bowel disease III
R O Butcher, L E Loo, E Nixon, X McFarlane, J K Limdi
Department of Gastroenterology, Pennine Acute Hospitals, Manchester, UK

Introduction There has been resurgent interest in recent years in the pro-hormone vitamin D beyond its classical role in bone metabolism recognising its plausible effects in immune regulation. The aim of our study was to review practice relating to vitamin D assessment among IBD patients.

Methods We conducted a retrospective review of 300 consecutive patients attending IBD clinics at our hospital. Clinical data including demographics, disease characteristics and therapy were obtained from case note and electronic patient record review. Measurement of serum 25-hydroxyvitamin D (25-OHD) concentration subsequent to IBD diagnosis was noted.

Results Of 300 IBD patients reviewed 141 were female. The median age was 47.5 (range 16–91) and mean disease duration 9.6?years.

  • 137 patients had Crohn's disease,
  • 152 patients ulcerative colitis and
  • 11 patients had IBD-type unclassified (IBDU).

126 (42.0%) patients were current or ex-smokers. Vitamin D status was assessed in 45 (15.0%) patients. In 41 patients (91.1%) measurement was undertaken within the last 2?years.

The mean and median serum 25-OHD level was 19.1 and 17.0?ng/ml respectively (range 5–49.9).
Nine (20.0%) of these patients had levels <10?ng/ml consistent with deficiency and 17 (37.8%) levels <20?ng/ml.
Of the nine patients with vitamin D deficiency (three males; six females), six had Crohn's disease and three had ulcerative colitis. Of the Crohn's patients, three had ileo-colonic, two colonic and one ileal disease. Three had non-stricturing and non-penetrating disease, two stricturing and one penetrating disease. Of the ulcerative colitis patients one had extensive disease, one left-sided disease and one had proctitis. All patients had received steroids during the course of their disease and three patients received azathioprine, four anti-TNF (three infliximab; one adalimumab) and four had previous surgery.

Patients with vitamin D deficiency had significant disease requiring immunomodulator, anti-TNF therapy and surgery in this cohort.

Conclusion Vitamin D assessment in IBD patients is suboptimal.
Hypovitaminosis D is under-recognised and consequently undertreated.
The myriad emerging roles of vitamin D in the pathogenesis of IBD emphasise the importance of recognition and optimisation of vitamin D status to above 30?ng/ml in this patient group.

Competing interests None declared.

Management of inflammatory bowel disease with vitamin D: Beyond bone health

Journal of Crohn's and Colitis Volume 6, Issue 4 , Pages 397-404, May 2012
Neeraj Narula, John K. Marshall
Received 2 August 2011; received in revised form 4 October 2011; accepted 30 October 2011. published online 28 November 2011.

A relationship between vitamin D and several disorders, including Crohn's disease (CD), has recently been proposed. Vitamin D appears to have several important actions beyond the maintenance of bone health, including various effects on the immune system. Vitamin D deficiency has been implicated in the development of CD, and its analogues may have a role in the treatment of CD. Current research also suggests a role for vitamin D in counteracting some IBD-specific complications, including osteopenia, colorectal neoplasia, and depression. There remains a need for prospective studies to further delineate these relationships. Given current evidence and the apparent safety of vitamin D supplementation, it appears reasonable to screen for and treat vitamin D deficiency in patients with IBD.

Vitamin D deficiency in Crohn's disease: Prevalence, risk factors and supplement use in an outpatient setting

Journal of Crohn's and Colitis, Volume 6, Issue 2 , Pages 182-188, March 2012
Treasa Nic Suibhne, Gerry Cox, Martin Healy, Colm O'Morain, Maria O'Sullivan
Received 26 May 2011; received in revised form 10 August 2011; accepted 11 August 2011. published online 26 September 2011.

Background and aims
Vitamin D deficiency impacts on bone health and has potential new roles in inflammation. We aimed to determine the prevalence of and risk factors for vitamin D deficiency and to explore vitamin D supplement usage in patients with Crohn's disease (CD) in an outpatient setting, compared with controls.

Serum 25-hydroxyvitamin D 25(OH)D concentrations were measured by radioimmunoassay in 151 participants, comprising 81 CD patients and 70 age-, sex- and socio-economic status-matched healthy controls. Levels of 25(OH)D <50nmol/L were classed as deficient. Data on vitamin supplement usage were recorded for all participants at interview.

Vitamin D deficiency was common in patients with CD (63%) and significantly higher in winter than summer (68% v 50%; p<0.001, ?2). Notably, the deficiency rate remained high even in summer (50%). On regression analysis, 25(OH)D levels were inversely associated with winter season. Disease-specific factors for lower serum 25(OH)D levels were longer disease duration and smoking. Overall, 43% of patients reported using a vitamin D-containing supplement, primarily at low dosages (200–400IU/d); however, this level of supplement did not prevent deficiency. For the majority of CD patients, 25(OH)D remained below optimal levels proposed to confer bone and immune health benefits.

Vitamin D deficiency was common in patients with CD and associated with longstanding disease, smoking and winter. While over 40% of patients used a vitamin D-containing supplement, the dosages were inadequate to prevent deficiency. Appropriate vitamin D screening and supplementation should be considered in the context of health promotion of outpatients with CD.

Vitamin D as a therapy for colitis: A systematic review

Imogen Nicholson, A. Mark Dalzell, Wael El-Matary
Received 20 November 2011; received in revised form 5 January 2012; accepted 5 January 2012. published online 30 January 2012.

Background and aim
The effect of vitamin D supplementation on immune disorders has been a topical research focus.
The aim of this systematic review was to examine the current evidence of the effect of vitamin D supplementation as a therapy for colitis.

The following databases were searched: MEDLINE, Pubmed, Scopus, Web of Knowledge, Cinicaltrials.gov and the Cochrane Central Register of Controlled Trials using the terms ‘inflammatory bowel disease’ ‘Crohn's disease’ ‘ulcerative colitis’ ‘colitis’ and ‘vitamin D’. Both human and animal studies published in English language were examined. The reference lists of included studies and review articles were manually searched for any relevant studies.

Four studies were included in this systematic review. All reported an improvement in disease activity with vitamin D supplementation. The only high quality human study reported a non-significant reduction of relapse rate for Crohn's disease. No major adverse effects of vitamin D supplementation were reported.

Although there is some evidence that supplemental vitamin D, as an adjunctive treatment, may help in controlling colitis, this evidence is not enough to justify using vitamin D in treating inflammatory bowel disease (IBD). Large high quality placebo-controlled randomised controlled trials are needed to explore a possible benefit of using vitamin D in treating IBD.

See also VitaminDWiki

see wikipage such as http://www.vitamindwiki.com/tiki-index.php?page_id=2582

See also pubmed