Combination vitamin D therapy in stage 5 chronic kidney disease.

OBJECTIVE: To review the data supporting combination therapy with vitamin D and vitamin D receptor activators (VDRAs) in patients with stage 5 chronic kidney disease (CKD). DATA SOURCES: Literature was searched using PubMed and EMBASE using the terms kidney disease, kidney failure-chronic, and vitamin D. Limits applied included humans, adults (19 years or older), and clinical trials (and related), with publication dates between January 1, 1980, and May 16, 2011. STUDY SELECTION AND DATA EXTRACTION: All English-language publications were analyzed for relevance. Studies appropriate to the objective were evaluated, including 3 prospective observational studies, 1 prospective cohort study, and 1 retrospective study. DATA SYNTHESIS: To our knowledge, there have been no randomized controlled trials evaluating the safety and efficacy of vitamin D supplementation in combination with VDRA therapy in patients with stage 5 CKD. Relatively small observational studies have demonstrated improvements in 25-hydroxyvitamin D (25-OHD) concentrations and markers of mineral and bone metabolism as well as reduced VDRA use in patients with stage 5 CKD. Not all patients in these studies were receiving VDRA therapy. Therapy was safe, with no patients exceeding the recommended upper limit for 25-OHD concentrations and only a small percentage experiencing transient/correctable hypercalcemia. CONCLUSIONS: Vitamin D supplementation to maintain 25-OHD concentrations at 20-30 ng/mL or higher with or without VDRA therapy is inexpensive, appears safe, and may have additional health benefits in patients with stage 5 CKD. Well-designed, randomized controlled trials are needed to determine the efficacy and safety of combination vitamin D therapy in patients with stage 5 CKD.

Managing osteoporosis in postmenopausal women.

PURPOSE: To describe strategies used in managing postmenopausal osteoporosis, including a bone-healthy lifestyle, adequate calcium and vitamin D intake, and drug therapy options; considerations in selecting osteoporosis drug therapy; and the role of health-system pharmacists in managing osteoporosis in postmenopausal women. SUMMARY: Postmenopausal women are at risk for osteoporosis and fractures. Weight-bearing and resistance exercise, limiting alcohol and caffeine intake, smoking cessation, and fall prevention strategies are part of a bone-healthy lifestyle used to manage postmenopausal osteoporosis. Supplements containing calcium and vitamin D are needed by many postmenopausal women because of an inadequate intake and other factors. The choice of osteoporosis drug therapy should take into consideration patient characteristics and preference and drug efficacy, safety, route of administration, dosing frequency, convenience, cost, and potential for nonadherence. Bisphosphonates generally are preferred for the prevention and treatment of osteoporosis in postmenopausal women, with raloxifene, teriparatide, and calcitonin salmon as alternatives. Denosumab, a fully human monoclonal immunoglobulin G(2) antibody, may become available soon for prevention and treatment of postmenopausal osteoporosis. Health-system pharmacists can improve the management of osteoporosis in postmenopausal women by counseling them on a bone-healthy lifestyle and making recommendations for calcium and vitamin D supplements and osteoporosis medications to prevent or treat the disease. CONCLUSION: A variety of approaches are available to promote bone health in postmenopausal women. Health-system pharmacists can promote interventions to optimize patient outcomes.

Prevalence of vitamin D insufficiency in elderly ambulatory outpatients in Denver, Colorado.

BACKGROUND: Vitamin D insufficiency is common in the elderly. However, previous studies have utilized 25-hydroxvvitamin D (25[OH]D) concentrations as low as <16 ng/mL for defining vitamin D insufficiency. Moreover, most of the studies have been conducted in European patients, in certain geographic areas of the United States, or in institutionalized elderly. OBJECTIVE: The goal of this study was to characterize vitamin D concentrations in ambulatory elderly living in metropolitan Denver, Colorado, utilizing 25(OH)D concentrations <32 ng/mL as the definition for vitamin D insufficiency. METHODS: Ambulatory older adults (aged 65-89 years) with clinic visits during December 2005 and January 2006 were enrolled. Serum concentrations of 25(OH)D, parathyroid hormone (PTH), calcium, phosphorus, creatinine, and albumin were measured; height and weight were also measured. Data regarding dietary and over-the-counter vitamin D intake were collected, as well as information on body mass index, history of osteoporosis, osteoporosis treatment, and history of falls and fractures. RESULTS: Eighty patients (mean [SD] age, 77.8 [5.3] years; age range, 66-89 years) completed the study; there were no dropouts. The majority of patients were white (88%) and female (68%). Fifty-nine (74%) were found to have vitamin D insufficiency. Mean total and over-the-counter vitamin D intake was significantly higher in sufficient (P < 0.01) and insufficient (P < 0.05) patients compared with deficient patients, but dietary intake did not differ significantly between groups. The majority of patients who were vitamin D insufficient consumed more than the recommended 400 to 600 IU/d of vitamin D. Obese patients were found to have significantly lower 25(OH)D concentrations (P < 0.001) and higher PTH concentrations (P = 0.04) than nonobese patients. CONCLUSIONS: Vitamin D insufficiency is prevalent in ambulatory, and especially obese, elderly living in Denver, Colorado, despite vitamin D intake consistent with national recommendations. Dietary intake of vitamin D appeared to be unreliable to prevent insufficiency. Based on our results, along with other published data, we feel that national recommendations for vitamin D intake in the elderly should be increased to at least 800 to 1000 IU/d of over-the-counter supplemental cholecalciferol.