Abstract
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.
Highlights
Vitamin D3 is produced in the skin from 7-dehydrocholesterol by ultraviolet (UV) radiations at levels of sunlight exposure that do not induce skin burns (UV 290–315 nm) and is subsequently removed after its binding to vitamin D-binding protein (VDBP)
The tightly controlled production of 1.25(OH)2 D in the kidneys is stimulated by the parathyroid hormone (PTH) and is inhibited by calcium, phosphate and fibroblast growth factor (FGF)-23 [1]
We suggest to employ the same method for serial measurements of vitamin D in any patient
Summary
Vitamin D3 (cholecalciferol) is produced in the skin from 7-dehydrocholesterol by ultraviolet (UV) radiations at levels of sunlight exposure that do not induce skin burns (UV 290–315 nm) and is subsequently removed after its binding to vitamin D-binding protein (VDBP). The tightly controlled production of 1.25(OH) D in the kidneys is stimulated by the parathyroid hormone (PTH) and is inhibited by calcium, phosphate and fibroblast growth factor (FGF)-23 [1]. Physicians involved in the prescription of vitamin D demonstrate a variable clinical approach to the screening of its deficiency, the modalities of treatment and the monitoring of therapy over time. In order to overcome these shortcomings, the Italian Association of Clinical Endocrinologists (AME) appointed, in 2016, a panel of experts for the definition of the optimal management of vitamin deficiency in clinical practice. As recently underlined [5], further research is needed to inform better clinical guidelines in this area, and to assess implementation practices that will encourage evidence-based management practices for vitamin D insufficiency in adult populations. Greater understanding of physician management of uncertainty in clinical practice may help to avoid overutilization and inconsistent practice in similar clinical situations
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