Vit D the article

[Guest guest]

I'm sending two posts from last fall , an article on Vit D that my

primary doctor gave me and a post I sent to the bartters list at the

same time explaining the cirmstances behind why my doctor thought I

was low on Vit D.

Debbie

Vitamin D deficiencies in Pain Patients by Mark L Gostine, MD and

Fred N. , MD published in Practical Pain Management Magazinde

July/Aug 2006

(blurb by photo at top of article.) This condition, associated with

muscle weakness, myopathy, and consequently muscluloskeletal pain,

was found to be prevalent in the patient population studied.

( Main body of article)

Vitamin D's role in calcium metabolism is well known. In the last

ten years, since the vitamin D recpetor (VDR) was cloned and

recognized, researchers realized the compound is more accurately

carergorized as a hormone with many activities unrelated to calcium

physiology. Vitamin D modulates the immune system,is an important

antiproliferative, and may help treat cancer. (1-3) Vitamin D

receptors are present in blood forming elements, pancreatic islet

cells, the nervous system, and muscle tissues.

Vitamin D technically refers to both vitamin D2 and bitamin D3.

Vitamin D2 is the provitamin ergosterol found in plants, while

vitamin D3 , or cholecalciferol is found in animals. Either form can

prevent osteomalacia and rickets, although vitamin D3 is more active.

Vitamin D defidiencies were once very common but were generally

eliminated with the advent of vitamin D fortified foods.

Unfortunately, the prevalence once again seems to be widespread in

diverse populations. Dark skinned individuals,the obese, the elderly,

and those in northern latitudes seem to be more at risk. (4-6)

The recurrence of hypovitaminosis D is related to a variety of

factors in the modern lifestyle. These include the explosion of non

dairy beverage consumption, a lifetime spent predominantly indoors,

fear of sun exposure, and the widespread adoption of sun screens.

Although the recommended dietary allowance (RDA) for vitamin D is 400

units, there is no certainty that this is the proper amount for

general health. The RDA was determined based on the average amount of

vitamin D in a teaspoon of cod liver oil, the amount needed to

generally prevent rickets in children (7) This amount is inadequate

in adults because it does not take into account their larger body

mass. Inpatients who had taken 400 units of vitamin D remained

vitamin D deficient . (8) Up to l0,000 units per day do not elevate

blood levels above normal limits. (9)

Bile is necessary for proper vitamin D absorption. Patients who have

had gastric bypass surgery, or who have inflammatory bowel disease,

are at higher risk of low vitamin D levels secondary to their

gastrointestinal alterations or disease. Once vitamin D is absorbed

from the GI tract it is modified with a sequence of two

hydroxylations in the liver and kidneys to become calcitriol, or

1,25(OH)2D. Calcitriol is the most active form of vitamin D and is

tightly regulated by enzymatic modification to ensure proper calcium

homeostasis. Increased calcium and phosphate levels inhibit enzymatic

conversion of provitamins to calcitriol. Conversely, low calcium and

phosphate levels, parathyroid hormone and estrogen all raise blood

levels of the most active form of vitamin D. Normal blood levles of

vitamin D are reported as 25 to 80 ng/ml; however, parathyroid

hormone activity can be increased to levels as high as 30 ng/ml

resulting in increased bony turnover. (l0)

PHYSIOLOGIC ACTIVITY OF VITAMIN D

Vitamins D's primary action is to enhance the absorption of both

calcium and phosphate from the gastrointestinal tract, decrease the

kidney's excretion of calcium, and to complement the activity of

parathyroid hormone (PTH) to mobilize calcium from the bone when

calcium blood levels are low. Calcitriol exerts its effects on the

vitamin D receptors (VDR) in the cell's cytosol. The calcitriol and

vitamin D receptor complex migrate to the nucleus where they can

induce gene transcription.The thyroid and steroid supergene family

include the VDR(ll) consistent with the idea tha vitamin D is more

accurately characterized as a hormone whith many activities unrelated

to its role in calcium homeostasis.

In the small intestine, calcium absorption channels appear to be up

regulated in the presence of vitamin D. Most of the absorption takes

place in the proximal small intestine but a limited amount takes

place in the distal ileum and can be negatively impacted by

inflammatory boiwel disease. Bitamin D doses not appear to have a

direct effect on bone mineralization; ratheris exerts its effect

primarily by increasing the absorption of intestinal calcium .

Childrens with rickets caused by mutations of the VDR , can have

their bone mineteralization restored with intravenous calcium and

phosphate, indicating that calcitriol exerts its primary influence on

bones via calcium absorption and not directly on the bones itself.

Indeed, super high doses of vitamin D increases bone mobilization of calcium.

(in bos box to the side) " We found that 84 percent of our

patients.... suffered from hypovitaminosis D. This can contribute

signifiiicantly to musculoskeletal complaints in the form of

soteomalacia and accelerated osteoarthritis in the pain management

patient population " (end of box)

(graph on the page)

Decade (age) Vitamin D level number of patients

20-39 l8 5

40-49 l7.6 13

50-69 l7.5 11

60-69 l5.3 l6

70-89 l9.8 ll

Vitamin D also has significant physiologic activity outside the

area of calcium metabolism. Calcitriol is a potent antiproliferative

and analogs, stripped of their calcium activity, are being

investigated for their antineoplastic properties (1) Because of its

ability to facilitate differentiation of the epidermis, vitamin D is

being investigated as a therapeutic agent in psoriasis. It is also

an important immune modulator affecting both mononuclear cell and

cytokine production. Low levels of calcitriol are found in relation

to a variety of common diseases such as multiple sclerosis, diabetes,

arthritis, and heart disease (l2)

Vitamin D deficiencies are associated with muscle

weakness,(l3)myopathy,(l4) and consequently muscle pain. Plotnikoff

and Quigley reported that l00% of African American, East African,

Hispanic and American Indian patients with persistent, nonspecific

musculoskeletal pain presenting to the Community University Health

Care Center, a university-affiliated inner city primary care clinic,

were vitamin D deficient (15)

STUDY POPULATION

The purpose of the study was to investigate to what extent

hypovitaminosis D exists in a predominantly Caucasian population of

patients presenting with a variiety of musculoskeletal complaints to

a Midwesern community based pain management center. Over a period of

twelve weeks, three patients a day were selected from the clinic

schedule at a designated appointment slot. This method was used

because it facilitated patient flow, could be delegated to clinic

staff and randomized the patients selected. There were 56 patients in

the study. They ranged in age from 26 through 84. The average age was

57. There were 47 females and 8 males. Patients' diagnosises

included spinal arthritis , fibromyalgia, pelvic pain, headaches, and

failed back surgery. Many of the patients had a past medical history

including obesity, hypertension and hyperlipidemia. None of the

patients sufferd from inflammatory bowel diseas.

METHODS

After informed consent, blood was drawn from patients from the

middle of January 2006 to the beginning of April 2006. Tests were

preformed by Mayo Medical Laboratoris Rochester ,MN. Vitamin D2

levels, vitamin D3 levels, and total vitamin D were assessed. The

normal reference range for total vitamin D is 25 to 80 ng/ml.

RESULTS

Of the 56 patients in the study, 46 were diagnosed with

hypovitaminosis D. The average total vitamin D level was l7.43. Over

half the patients qualified as having a moderately severe deficiency

(less than l7ng/ml. Vitamin D levels were analyzed by decade with the

two patients in their 20's included with patients in their 30's and

patients in their 70's and 80's also included together. In essence we

had five groups to consider, 20's and 30's ,40's , 50's ,60',70's and 80's.

There is no evident trend coomparing age to vitamin D level. Males

had a level on average of l6.3 ng/ml. and women had an average of l7.6 ng/ml.

DISCUSSION

et. al. (l6) looked at the incidence of vitamin D defiencies

in the inpatient population and found that 57 percent were vitamin D

deficient. What is striking in our pupulation is that neither light

skin nor outpatient status conferred any protection against

hypovitaminosis D. Indeed our prevalence of vitamin D defidiency is

84 %. This may reflect that hypovitaminosis D is wide spread in the

chronic pain population or may indicate that the problem has worsened

in the population at large since l998. Osteoporosis is widepread in

the elderly. It is also difficult to distinguish from osteomalcia by

radiographic studies although looser fractures are unique to

osteomalacia. Laboratory studies are helpful-including vitamin D

levels-and should be drawn in patients suspected of either diagnosis.

What constitutes Vitamin D deficiency is open for debate.Vitamin D

appears to protect against cancer and multiple sclerosois. The dose

necessary for vitamin D's antiproliferative and immune molulating

activity may be greater than the dose necessary to prevent rickets

and osteomalacia. In mice, a dose equivalent to 3600 IU's per day in

humans reverses symptoms of experimental allergic encephalomyelitis,

the cell-mediated automimmune disease model of multiple sclerosis. (2)

Parathyroid hormone can start to rise when vitamin d levels fall

below 30 ng/ml. Increased levels of PTH accelerate bony turnover. In

the Framingham Study patients with levels below 32ng/ml. were at

increased risk of knee osteoarthritis and pain. (l7) By this

standard, virtually all patients in our study, except two , were

vitamin d deficient.

There are multiple ways to correct vitamin D deficiencies . In

older adults, with potential problems of malabsorption, up to 4000

IU/D orally or prescription amounts of 50,000 units twice a week,

also orally, are appropriate for up to twelve weeks. Calcium

consumption of at least 800 mg per day is necessary. Follow blood

levels of both vitamin D and calcium during the correction phase.

Maintain patients on 2000 IU/D after the correction period.

CONCLUSIONS

Vitamin D deficiencies are very common even in lighter skinned

individuals. We found that 84 % of our patients presenting to our

pain management center suffered from hypovitaminosis D. This can

contribute significantly to musculoskeletal complaints in the form of

osteomalcccccacia and accelerated osteoarthritis in the pain

management patient population. Future research should examine if the

correction of hypovitaminosis D leads to improvement in reported pain.

Mark Gostine, MD and Fred , MD are cofounder of Michigan Pain

Consultants, a multidicsciplinary pain management practice with

headquarters in Grand Rapids , Michigan. Dr Gostine and Dr are

also principals of PRoCare Systems, a management service organization

for pain management practices with nationwide affiliations. They can

be reached through ProCare systems assssst

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Debbie and Ian McKinley (13 yrs BMD)no litters from

Kansas http://home.hit.net/~dimck/ Brighteye Bushy Tail Gretchen CD,CGC

11/11/92 - 10/07/03. Swiss Stars Harvest Moon CD,CGC, DD 6/l8/93-

5/9/04 Swiss Star's Maximum Risk 09/15/02 Sammy (rescue/rehome)

(rescue)