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Skepticism mounts on need for vitamin D supplementation.

SNOWMASS, COLO. -- Serious questions exist about the safety and efficacy of the popular practice of high-dose vitamin D supplementation across a broad swath of the population.

One of these concerns is that not all of the extra calcium absorption promoted by boosting vitamin D is going into bone to prevent fractures. Some of it may actually be taken up by atherosclerotic plaque, increasing the risk of cardiovascular events, Dr. Lenore M. Buckley cautioned at a symposium sponsored by the American College of Rheumatology.

This is of particular concern in patients with known coronary disease and for those at high risk, including individuals with rheumatoid arthritis, systemic lupus erythematosus, diabetes, or psoriasis, added Dr. Buckley, professor of internal medicine at Virginia Commonwealth University, Richmond.

Discussing findings from a recent cross-sectional study involving 340 African American patients with type 2 diabetes, Dr. Buckley said that serum 25-hydroxyvitamin D levels were positively associated with increased calcified atherosclerotic plaque in the aorta and carotid arteries (J. Clin. Endocrinol. Metab. 2010 Jan. 8, 2010; [doi: 10.1210/jc.2009-1797]

"The effects of supplementing vitamin D to raise the serum 25-hydroxyvitamin D level on atherosclerosis in African Americans are unknown. Prospective trials are needed," the investigators said.

Recently, a large prospective randomized trial assessed the effects of using calcium supplements on vascular event rates, but it did not involve African Americans. The trial involved 1,471 healthy postmenopausal New Zealand women who were randomized to receive either supplemental calcium or placebo.

By 5 years of follow up, there were a total of 101 myocardial infarctions, strokes, and sudden deaths in 69 women in the supplemental calcium group compared with 54 such events in 42 control subjects (BMJ 2008;336:262-6).

The numbers needed to treat (NNT) were "particularly disturbing," in Dr. Buckley's view.

The NNT required for 5 years of supplemental calcium to cause one additional MI, compared with placebo, was 44. The NNT for one stroke was 56. And the NNT to cause one additional cardiovascular event was 29. In contrast, the NNT to prevent one symptomatic fracture was 50.

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The vascular event rate was higher in women with high compliance with calcium supplementation. The event rate was also higher during months 30-60 of follow-up, which is consistent with an initial latent period during which undetected vascular damage may occur.

There is a noticeable, if anecdotal, increase in the number of physicians ordering serum vitamin D tests to screen for deficiency. The vitamin D assay has become one of the most-ordered lab tests in the U.S., despite the assay's questionable reliability, its $40-$200 cost, and considerable unresolved debate as to what constitutes an optimal blood level.

In fact, the Centers for Medicare and Medicaid Services is considering denying Medicare coverage for vitamin D tests for screening purposes, according to Dr. Buckley.

There is solid evidence that vitamin D supplementation reduces fracture risk in the elderly, especially in those with low serum levels. But the impetus for the upsurge in vitamin D screening and supplementation is the hope that it might protect against a broad range of chronic diseases, including cancers, dementia, autoimmune diseases, and cardiovascular disease. However, that hope is driven mostly by epidemiologic data, which must be viewed as hypothesis-generating rather than definitive.

The classic example of how misleading epidemiologic associations can be is the expectation that estrogen replacement would reduce cardiovascular risk in postmenopausal women; when the Women's Health Initiative and other prospective trials were eventually carried out, it turned out just the opposite was true, Dr. Buckley noted.

"The question we have to ask is: What does that low serum vitamin D level mean? Is it the thing that predisposes, or is it somehow a byproduct of illness?" she said.

There is intriguing evidence to indicate the optimal level of vitamin D to promote bone health, muscle strength, immunity, and other key functions may vary by race. Data from the National Health and Nutrition Examination Survey show that very few white children aged 1-12 years are vitamin D deficient using the classic threshold of 15 ng/mL. In contrast, about 10% of non-Hispanic black 1- to 6-year-olds are vitamin D deficient, as are close to 30% of those in the 7- to 12- years-old age bracket (Pediatrics 2009; 124: e362-70 [doi: 10.1542/peds.2009-0051]).

Many observers see this racial disparity as a public health problem reflecting unequal access to services. But there is a conundrum here: If vitamin D deficiency is rampant in black children, why do they have greater bone strength and muscle mass, on average, than white children?

Such observations make "one wonder whether the definition of normal levels should vary by race," according to the rheumatologist.

Support for this theory comes from studies showing that pushing serum vitamin D levels to 30 ng/mL or higher in whites reduces their parathyroid hormone levels, while pushing levels above 20 ng/ml in African Americans--young or old--doesn't further decrease parathyroid hormone or increase bone density.

Asked by audience members what she does about vitamin D in her own practice, Dr. Buckley said she generally tries to get patients into the 20-29 ng/mL range, while in African Americans and patients with known cardiovascular disease she aims for 15 ng/mL or slightly more--"and I worry that might be too high sometimes."

Dr. Buckley added that she reserves expedited supplementation--50,000 IU weekly for 8 weeks--mainly for vitamin D deficient elderly patients at high risk for fracture or fall. That's where there is supporting evidence of benefit. There is no evidence to support supplementation in young or middle-aged patients whose increased fracture risk is decades away.

Like many others, Dr. Buckley eagerly awaits fresh guidance in the form of updated recommendations on vitamin D from the Institute of Medicine.

Rumor has it that the IOM report, due this spring, will recommend an increase in the currently recommended supplemental 400 IU/day for 50- to 70-year-olds not getting sufficient vitamin D from the sun. Her hope is the IOM will address the thorny issues of who should receive supplementation, and how fast it should be done.

Dr. Buckley reported having no financial conflicts of interest relevant to her talk.
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Comment:Skepticism mounts on need for vitamin D supplementation.(NEWS)
Author:Jancin, Bruce
Publication:Family Practice News
Geographic Code:8NEWZ
Date:Feb 15, 2010
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