Dr. Kenneth Madden (biography and disclosures)
What I did before
Every year, one-third of older adults (age greater than 65) experience one or more falls.1 One therapy with the potential to reduce both falling and fractures is vitamin D supplementation, possibly due to a direct stimulation of vitamin D receptors on muscle tissue.2 Often the patients that would most benefit from vitamin D (frail older adults with frequent falls) have swallowing issues that make swallowing large vitamin pills difficult. Since “there is no correct dose” and it is “only a vitamin” I often administered larger doses (such as yearly courses of 50 000 IU cholecalciferol once per week X 8 weeks) to make administration easier for patients with swallowing issues.
What changed my practice
Unfortunately, a closer look at the issue revealed the appropriate dose of vitamin D necessary to safely reduce fall and fracture risk remains controversial. A recent meta-analysis of all studies done to date3 demonstrated that “high dose” vitamin D reduced falls by 23 percent (RR 0.77, 95% confidence interval 0.71 to 0.92) when “high dose” was defined as 700 to 1000 IU per day. Lower doses (less than 700 IU) had no effect on fall risk. The effects of doses higher than 1000 IU had not been examined previously to the publication of this meta-analysis. It is also important to remember that large doses of vitamins are not necessarily benign; the increase in mortality with high-dosage vitamin E4 should serve as a cautionary example.
After the publication of the above meta-analysis, a randomized, controlled, double blind study5 examined the effect of a massive yearly doses of vitamin D on falls and fractures. The investigators recruited a large number of older adult women (median age of 76 years, n=2258) that were at high risk for falls (defined as the subject being a self-reported faller, having a previous fracture, or having a family history of maternal hip fracture). The study intervention was 500 000 IU cholecalciferol given as 10 tablets taken on a single day. Unfortunately, the large-dose vitamin D group both fell and had more fractures than the placebo group. In fact, there was approximately one more fracture per 100 person-years in the vitamin D group as compared to the placebo group. Of even more concern, fracture rates in the treatment group were highest in the first 3 months following the large dose of vitamin D, suggesting a direct toxic effect.
What I do now
There is support for using vitamin D to prevent falls in older adults, but only in a dose ranging from 700 IU to 1000 IU per day. I no longer give patients larger doses of vitamin D at less frequent intervals; in fact this practice might have been causing harm. There is no literature to determine what the impact of a more temperate but larger dose of vitamin D will have on fall and fracture rates. Like any other medication, large doses of vitamins can be harmful.
References: (Note: Article requests require a login ID with CPSBC or UBC)
- Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7. (View article with CPSBC or UBC)
- Bischoff-Ferrari HA, Borchers M, Gudat F, Durmuller U, Stahelin HB, Dick W. Vitamin D receptor expression in human muscle tissue decreases with age. J Bone Miner Res 2004;19:265-9. (View article with CPSBC or UBC)
- Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ 2009;339:b3692. (View article with CPSBC or UBC)
- Miller ER, 3rd, Pastor-Barriuso R, Dalal D, Riemersma RA, Appel LJ, Guallar E. Meta-analysis: high-dosage vitamin E supplementation may increase all-cause mortality. Ann Intern Med 2005;142:37-46. (View article with CPSBC or UBC)
- Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA 2010;303:1815-22. (View article with CPSBC or UBC)
Notes from the BC Guidelines
http://www.bcguidelines.ca/guideline_vitamind.html
There is good evidence that supplementation with at least 800 international units (IU) of vitamin D3 per day, combined with calcium, is required to reduce the risk of fragility fractures, therefore 800 – 1000 IU daily is recommended (although the optimum daily requirement of vitamin D3 is not known).4,5,6 Weekly dosing (one week’s adult dose of vitamin D3 taken as a single weekly dose, i.e. 7000 IU) or monthly dosing (one month’s adult dose of vitamin D3 taken once a month, i.e. 30,000 IU) may be more convenient for some patients and has been shown to be safe.1,4,7 At this time, high doses of vitamin D3 once a year is not recommended as recent evidence has shown possible increased fracture risk.8
Population at Risk
The BC population is at risk of low vitamin D levels from autumn to spring. There is no clinical utility in performing vitamin D tests on patients who are thought to be at risk for sub-optimal vitamin D levels and who would benefit from vitamin D supplementation.
Vitamin D Supplementation without Testing
Because vitamin D supplementation in the general adult population is safe, it is reasonable to advise supplementation without testing. Routine testing of vitamin D levels [25-hydroxyvitamin D or 25(OH)D] is not medically necessary prior to or after starting vitamin D supplementation.
Utilization and Cost of Serum Vitamin D Testing in BC
Utilization of vitamin D testing [as 25(OH)D] in BC has increased ten-fold in the past five years. Medical Service Plan expenditures are approximately $3 million annually for outpatient vitamin D testing with a cost per test of $93.63 in 2009.
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Thank you. Easy to read, clear and concise, and answers a question I’ve been wondering about. confirms that my current approach mirrors best evidence
The optimum & convenient dose of Vitamin D had been bouncing around the long term care directors email board for months.T
here was consensus that 10,000-20,000 units Vit D a week was the best approach in a nursing home population The Fraser Health Authority has recently given direction to care homes that 20,000 a week is their recommended dose. they based thsi on International lit reviews.
The work on the adverse effects of a yearly dose is well known ,however the use of weekly doses in geriatrics or a monthly doses in fit adults has not been answered by this article.
1000 mg daily of vitamin D is a reasonable dose for older adults at risk of falls and osteoporosis
Fraser Health and many other organizations are using higher dose levels of vitamin D. 3500 IU +
details at
http://www.vitamindwiki.com/tiki-index.php?page_id=2166
I already advised 1000 units per day for the last few years
The knee-jerk response to the ‘falls after 500000iu annual dose’ study of accepting the 1000iu daily dose is unfortunate. Indeed we have evidence which is quite good on falls and Vitamin D but this is not the whole enchalada. There’s still the numerous other health benefits which only appear when Vitamin D levels are over 100 nmol/l. 1000iu only increases levels by 14 nmol/l given chronically and if your patients are like mine with old skin, clothed skin and indoor skin they have vit D levels of 30-40.With the 1000iu per day they get to an unimpressive 44-54 nmol/l, still in the “moderately deficient” group. We can do better than that for our patients.
Is there any evidence that 2000 units is better than 1000?
Nice and concise
I agree with the literature supporting a role for Vit D supplementation to reduce falls in at risk patients, primrily geriatric and long term care facility patients. Having said that, the majority of the literature is based on small non randomized controlled studies. It would be nice to see a more authoritative paper and / or position statment /guideline reviewed. While I too care for a large number of nursing home patients in the FHA there are concerns of giving all patients 20000 iu of Vitamin D3 weekly. What is the impact of not testing calcium levels in patients beofre doing this? Will we risk issues with nephrolithiasis and painful kidney stones??
What about patient size, ethnicity, etc on the issue of dose itself. What about bioavailability of the 20000 iu dose vs 2000 iu daily. These and a multitude of other questions need to be answered before jumping onto the Vitamin D3 weekly ward rounds.
This article also begs the quesiton about the multitude of other Vitamins, lotions and potions fed daily to patients by their families in ECU, in assisted living and residential care otherwise… Should we be endorsing this practice by signing the order to cover the facility. Given the lack of medicinal value to these products, it might be more appropriate to not sign off until a pharmacist has reviewed and rule out significant drug-drug interactions, especially with coumadin which every other person in LTC seems to be on these days, and if not that we get them from the hospital on Fragmin (sometimes 3-4 months post -op)
Just some thoughts to stimulate discussion.
It appears to me reading the posted comments and the article that there are still unanswered questions re-dosage.
I am not sure this will change my practice but it has stimulated further enquiry.
I’d like to hear more about the pathophysiology of Vitamin D toxicity… why does one dose help and and a higher one harm?
Very interesting
very helpful article
WILL DEFINITELY CHANGE MY RX OF VIT D DOSES.
IS THIS DOSING TRUE FOR ALL POST MENOPAUSAL FEMALES
this article conferm my practice I already advised 1000 units per day.
as i use this dose since long time I have no other comment
While I appreciate the thoughtful and succinct review, I am not sure all BC Geriatricians would agree with 1000iu/day for frail failing seniors here. So I’m in the minority here when I voted that I’d consider changing doses (currently I recommend 2000 iu/day, because I’ve seen several cases who appeared to need and benefit from this higher dose). Will wait for more research in meantime.
I really do not know the correct dosage of VitD however I do know that a tremendous number of falls in the elderly could be prevented by having patients use 4-wheeled walkers much sooner than we presently do. As soon as you notice loss of vibration sensation or any signs of instability is the time to start pushing( no pun intended) the use of the walker not after the falls and fractures are history.
I’ve been recommending 2000 IU Vitamin D per day for all adults in cloudy BC, lower doses in children. Why wait for frailty? Isn’t Vitamin D more properly classed as a hormone, than a Vitamin? I have not seen any evidence that this dose is toxic. Sunscreen and sun avoidance in summer makes me inclined to presribe this dose year round.
yes confirms what I already thought we don’t know anything about what the vit d dose should be
tnank you, srongly agree
I have been recommending 1000 IU daily for adults for a few years now. I would like to know more about the studies looking at weekly or monthly admin. I know it’s supposed to be safe but how good are the studies?
I routinely refuse to do vitamin D levels when patients request them but I have found that they will ask another physician, often a specialist, who orders it for them. Public education might be helpful so we can spend health care dollars on something more worthwhile.
I have numerous long-term care home patients and have been increasing their Vitamin D supplement to at least 1000IU daily at all annual care conferences. This was based on both some primary literature research I did as a resident on the effects of Vitamin D supplementation as an adjunct to treatment for depression in the elderly, as well as, recommended guidelines for Vitamin D supplement in Northern B.C. of around 2000IU daily. I will not change my practise from this as current research also seems to support a decrease in fall risk with supplementation.
A very productive but concise observation, it is appreciated highly and thank you.
Still not clear if vitamin D daily or weekly disrupts sleep.
My Vitamin D level is was 15 on this past Tuesday. I need to get it up to at least 20 by this upcoming Tuesday. It will be measured using a blood test. Is this possible?