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.
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
- Overview Thyroid and Vitamin D
- Critically ill need vitamin D – how much and which test to use is TBD – Nov 2014
- Surgical ICU – 2.7 X more likely go home if OK vitamin D – Sept 2015
- Review of Vitamin D (including free, frequency, injection, how much.) – Sept 2013
- Vitamin D supplementation protocols: loading, injection, etc – RCT June 2014
- Injection of 300,000 IU of vitamin D3 similar to 10 months of oral 25,000 IU – Jan 2014
- Overview Loading of vitamin D contains the following
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 )
- Defining normal level of vitamin D (need 4000-5000 IU) - Heaney Spring 2013 has the following chart
The items which are in both Intervention and Trauma/Surgery are listed here
- Sepsis: 4 fewer days in ICU if add Omega-3 – meta-analysis of 12 RCT – June 2017
- ICU cost reduced by at least 27,000 dollars if get high dose vitamin D in first week - April 2017
- Vitamin D and Glutamine reduced Trauma Center deaths by half – March 2017
- Hospital ICU added high dose vitamin D - malpractice lawsuit costs dropped from 26 million dollars to ZERO - Oct 2016
- Vitamin D and exercise after hip fracture surgery – far fewer deaths – July 2016
- 18 fewer hospital days if given 500,000 IU of vitamin D while ventilated in ICU – RCT June 2016
- ICU death rate reduced 3X when a single dose of vitamin D changed the PTH – Nov 2015
- Heart Attack ICU costs reduced $37,000 by $20 of Vitamin D – Nov 2015
- ICU survival increased with vitamin D single loading dose - JAMA Sept 2014
- Vitamin D intervention increased by 20 percent the survival of critically ill patients- RCT June 2014
- Vitamin D aided progesterone in reducing traumatic brain injury – RCT Dec 2012
- Vitamin D reduces sepsis
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.
Prospective randomized interventional study.
Tertiary, academic adult ICU.
Fifty critically ill adults with the systemic inflammatory response syndrome.
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.
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.