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ICU death rate reduced 3X when a single dose of vitamin D changed the PTH – Nov 2015

A Randomized Study of a Single Dose of Intramuscular Cholecalciferol in Critically Ill Adults.

Crit Care Med. 2015 Nov;43(11):2313-20. doi: 10.1097/CCM.0000000000001201.
Nair P1, Venkatesh B, Lee P, Kerr S, Hoechter DJ, Dimeski G, Grice J, Myburgh J, Center JR.
1Intensive Care Unit, St. Vincent's Hospital, Sydney, NSW, Australia. 2Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia. 3Bone Biology Division, Garvan Institute for Medical Research, Sydney, NSW, Australia. 4Critical Care and Trauma Division, George Institute for Global Health, Sydney, NSW, Australia. 5Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia. 6Intensive Care Unit, Wesley Hospital, Brisbane, QLD, Australia. 7University of Queensland, Brisbane, QLD, Australia. 8Departement of Anesthesiology, LMU, Munich, Germany. 9Intensive Care Unit, St. George Hospital, Sydney, NSW, Australia.

VitaminDWiki Summary

50 adults in ICU – 56% of whom were vitamin D deficient (< 15 ng?)
RCT Injection of 150,000 or 300,000 IU of vitamin D (to all?)
3X less death rate in those who got enough vitamin D to change PTH level

Note: PTH will not change if
1) already have high level of vitamin D, or 2) did not get enough vitamin D

Note: Oral or topical dose will work just as well as injection in most cases
and topical "may" be faster

Note: One surgeon will not give elective surgery until the patient gets a loading dose of vitamin D
His "score card" is much better for surgeries with patients having lots of vitamin D

See also VitaminDWiki

If a person is, or is suspected to be, very vitamin D deficient a loading dose is typically given

  • Loading = repletion = quick replacement (previously known as Stoss)
  • Loading doses range in size from 100,000 IU to 1,000,000 IU of Vitamin D3
  • The size of the loading dose is a function of body weight - see below
    Unfortunately, some doctors persist in using Vitamin D2 instead of D3
  • Loading may be done as quickly as a single day, to as slowly as 3 months.
    It appears that spreading the loading dose over 4-20 days is a good compromise
  • Loading is typically oral, but sometimes by injection (I.M,)
  • The loading dose persists in the body for about 3 months
    The loading dose should be followed up with continuing maintenance
    Unfortunately, many doctors fail to follow-up with the maintenance dosing.
  • As about 1 in 300 people have some form of mild allergic reaction to vitamin D supplements,
    it appears prudent to test with a small amount of vitamin D before giving a loading dose
  • The causes of a mild allergic reaction appear to be: (in order of occurance)
    1) lack of magnesium - which can be easily added
    2) allergy to capsule contents - oil, additives (powder does not appear to cause any reaction)
    3) allergy to the tiny amount of D3 itself (allergy to wool) ( alternate: D3 made from plants )

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The items which are in both Intervention and Trauma/Surgery are listed here


OBJECTIVES:
To determine the effect of two doses of intramuscular cholecalciferol on serial serum 25-hydroxy-vitamin-D levels and on pharmacodynamics endpoints: calcium, phosphate, parathyroid hormone, C-reactive protein, interleukin-6, and cathelicidin in critically ill adults.
DESIGN:
Prospective randomized interventional study.
SETTING:
Tertiary, academic adult ICU.
PATIENTS:
Fifty critically ill adults with the systemic inflammatory response syndrome.
INTERVENTION:
Patients were randomly allocated to receive a single intramuscular dose of either 150,000 IU (0.15 mU) or 300,000 IU (0.3 mU) cholecalciferol.
MEASUREMENTS AND MAIN RESULTS:
Pharmacokinetic, pharmacodynamic parameters, and outcome measures were collected over a 14-day period or until ICU discharge, whichever was earlier. Prior to randomization, 28 of 50 patients (56%) were classified as vitamin D deficient. By day 7 after randomization, 15 of 23 (65%) and 14 of 21 patients (67%) normalized vitamin D levels with 0.15 and 0.3 mU, respectively (p=0.01) and by day 14, 8 of 10 (80%) and 10 of 12 patients (83%) (p=0.004), respectively.
Secondary hyperparathyroidism was manifested in 28% of patients at baseline. Parathyroid hormone levels decreased over the study period with patients achieving vitamin D sufficiency at day 7 having significantly lower parathyroid hormone levels (p<0.01).
Inflammatory markers (C-reactive protein and interleukin-6) fell significantly over the study period.
Greater increments in 25-hydroxy-vitamin-D were significantly associated with greater increments in cathelicidin at days 1 and 3 (p=0.04 and 0.004, respectively). Although in-hospital mortality rate did not differ between the groups, patients who did not mount a parathyroid hormone response to vitamin D deficiency had a higher mortality (35% vs 12%; p=0.05). No significant adverse effects were observed.
CONCLUSIONS:
A single dose of either dose of intramuscular cholecalciferol corrected vitamin D deficiency in the majority of critically ill patients. Greater vitamin D increments were associated with early greater cathelicidin increases, suggesting a possible mechanism of vitamin D supplementation in inducing bactericidal pleiotropic effects.
PMID: 26186566

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