VItamin D Deficiency

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Recently, my rheumatologist checked my vitamin d levels, among other things. He

found that it was low. They state that with rheumatoid arthritis patients, a

deficiency can cause increased pain in joints and bone. So I was prescribed

50,000 IU once a week for 12 weeks, then I will be rechecked. There is hard data

from a rheumatology study that this treatment reduces joint and bone pain, as

well as corrects the deficiency. Just thought it might be of interest. I also

have osteopenia and malabsorption of vitamin d can be the underlying cause. It

is common in patients with immune system disease.

How is vitamin D deficiency treated and monitored?

Treatment. The initial treatment for vitamin D deficiency in patients with

normal renal and liver function should be large doses of ergocalciferol, 50,000

IU once a week for eight weeks, in addition to 1500 mg of elemental calcium

daily. For patients with malabsorption, larger doses of ergocalciferol (50,000

IU two to three times a week) may be necessary.

The vitamin D form of choice is ergocalciferol because:

It is inexpensive and readily available.

Even patients with malabsorption syndromes will absorb > 60 percent of vitamin D

in this form (1).

Other forms of vitamin D might be more appropriate under certain clinical

circumstances (see table below).

Monitoring. The parathyroid hormone (PTH) and 25-OH vitamin D levels should be

checked 8 weeks after initiating therapy with ergocalciferol. Once the PTH and

25-OH vitamin D concentrations normalize, then the patient can be placed on a

maintenance dose of vitamin D. The maintenance dose will vary depending on the

underlying cause of vitamin D deficiency. Patients with a deficiency from lack

of sun exposure and decreased dietary intake would require 1000 IU of

cholecalciferol or ergocalciferol a day. An individual with malabsorption may

require 25,000 to 50,000 IU (or more) per week. Anti-resorptive therapy for

osteoporosis can then be initiated if indicated by bone densitometry.

If PTH and 25-OH vitamin D levels do not normalize with time in patients with

gastrointestinal disorders, then ergocalciferol should be replaced with either

oral calcitriol (1,25 dihydroxy vitamin D) which may help absorb calcium better

on the luminal side of the gut or an injectable form of calcitriol. It is

important to monitor the calcium levels frequently (every two weeks) when

initiating the injectable form of calcitriol as it can cause hypercalcemia.

Osteopenia due to vitamin D deficiency should not be treated with an

anti-resorptive medication such as calcitonin or a bisphosphonate. These

medications could lead to severe hypocalcemia because the serum calcium level is

being maintained at the expense of the calcium in the bones. There have not been

any studies evaluating the effects of anti-resorptive medications in patients

with vitamin D deficiency. The large studies addressing the effects of

bisphosphonates on bone density excluded patients with hyperparthyroidism (2-4).