14 Conservative Vitamin D recommendations in Ukraine
Ukrainian Consensus on Diagnosis and Management of Vitamin D Deficiency in Adults
Nutrients 2024, 16, 270. https://doi.org/10.3390/ nu16020270
Nataliia Grygorieva * , Mykola Tronko 2, Volodymir Kovalenko 3, Serhiy Komisarenko 4 , Tetiana Tatarchuk 5, Ninel Dedukh 1, Mykola Veliky 4®, Serhiy Strafun 6C , Yulia Komisarenko 7C , Andrii Kalashnikov 6 , Valeria Orlenko 2, Volodymyr Pankiv 8 , Oleg Shvets 9 , Inna Gogunska 10 and Svitlana Regeda 11
Vitamin D deficiency (VDD) is a global problem, however, there were no Ukrainian guidelines devoted to its screening, prevention, and treatment, which became the reason for the Consensus creation. This article aimed to present the Consensus of Ukrainian experts devoted to VDD management. Following the creation of the multidisciplinary Consensus group, consent on the formation process, drafting and fine-tuning of key recommendations, and two rounds of voting, 14 final recommendations were successfully voted upon. Despite a recent decrease in VDD prevalence in Ukraine, we recommend raising awareness regarding VDD's importance and improving the strategies for its decline. We recommend screening the serum 25-hydroxyvitamin D (25(OH)D) level in risk groups while maintaining a target concentration of 75-125 nmol/L (30-50 ng/mL). We recommend prophylactic cholecalciferol supplementation (800-2000 IU/d for youthful healthy subjects, and 3000-5000 IU/d for subjects from the risk groups). For a VDD treatment, we recommend a short-term administration of increased doses of cholecalciferol (4000-10,000 IU/d) with 25(OH)D levels monitored after 4-12 weeks of treatment, followed by the use of maintenance doses. Additionally, we recommend assessing serum 25(OH)D levels before antiosteoporotic treatment and providing vitamin D and calcium supplementation throughout the full course of the antiosteoporotic therapy.
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Methodology of Consensus Development
The Consensus creation was performed by the multidisciplinary expert group consisting of 15 leading Ukrainian scientists who have extensive experience in studying vitamin D and related topics. The 1st (N.G.), 6th (N.D.), and 11th (V.O.) authors of this article were members of the Task Force group who coordinated the experts' work. Based on careful analysis of the current literature with a high level of evidence, the Task Force members formulated 14 recommendations regarding VDD epidemiology, its screening, prevention, therapy, and monitoring. Following the agreement on the formation process of the Consensus between experts, the Delphi method , which is widely used for guideline creation [23,24], was chosen. The voting was performed on the SurveyMonkey® (https://www.surveymonkey.com, San Mateo, CA, USA) platform using 9-point grading of agreement with the recommendations (1—strongly disagree, 3—disagree, 5—neutral, 7—agree, and 9—strongly agree). Before voting, the experts agreed that Consensus would be achieved when more than 75% of the experts were in agreement with a recommendation on a voting scale of 7 points or higher. Otherwise, voting was to be repeated after the experts' discussion and modification of the recommendation.
Two rounds of voting regarding each recommendation were held. The final Consensus recommendations are presented in the text of the article with their justification based on the current evidence before each recommendation.
Full version of the Consensus was presented for the first time in "Pain, Joints, Spine" journal [25] in Ukrainian for wider use by the medical community in Ukraine.
9= strongly agree, 7= agree, 5 = neutral
1 Recommend more Vitamin D Awareness
2 Levels – deficiency to toxicity
VDD: <50 nmol/L (<20 ng/mL);
VDI: >50 nmol/L (>20 ng/mL) and <75 nmol/L (<30 ng/mL);
Sufficient level of vitamin D: 75-125 nmol/L (30-50 ng/mL);
Safe but not target level of vitamin D: >125-150 nmol/L (>50-60 ng/mL);
Zone of uncertainty with potential benefits or risks for vitamin D: >150-250 nmol/L (>60-100 ng/mL);
Excess/toxicity zone of vitamin D: >250 nmol/L (>100 ng/mL).
3 High-Risk groups should be tested
Persons with dark skin pigmentation;
Obese subjects (body mass index > 30 kg/m2);
Pregnant and lactating females;
Older subjects (>60 years old);
Subjects with bone or muscle pain;
Older subjects with a high risk of falls and a history of low trauma fractures;
Patients with metabolic bone diseases (osteoporosis and osteomalacia);
Immobilized persons and subjects during prolonged hospitalization;
Patients with liver or kidney failure;
Patients with endocrine disorders
- (I and II types of diabetes mellitus; hyperparathyroidism; thyroid diseases, etc.);
- Subjects with malabsorption syndromes
- (inflammatory bowel diseases, cystic fibrosis, enteritis after radiation, conditions after bariatric surgery, etc.);
Patients with chronic autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus, multiple sclerosis, etc.);
Patients with malignancy;
Subjects with granulomatous diseases (sarcoidosis, tuberculosis, histoplasmosis, berylliosis, coccidioidomycosis, etc.);
Persons with prolonged use of drugs with a negative impact on vitamin D metabolism
- (glucocorticoids, anticonvulsants, hypocholesterolemic, antifungal medications, AIDS drugs, etc.).
4 Consider relationships to other serum ingredients
5 Daily or weekly dosing
6 800-2000 IU in winter
7 Some need 800-2000 IU all year long
8 800-2,000 IU during pregnancy
9 Some conditions need 3,000 to 5,000 IU
10 Néed 4,000 -7,000 IU if have condition and <20 ng of Vitamin D
11 Start with 10,000 IU daily if <20 ng and have problems related to low Vitamin D
12 If <20 ng, treat till >30 ng, then drop back to 800-2000 IU
13 Only use active vitamin D for chronic hyperparathyroidism or CKD Bone problems
14 Osteroporosis
Conclusions
Despite a recently decreased frequency of VDD in the Ukrainian population, the expert group recommends raising awareness among the medical and public community regarding VDD's importance and improving the strategies for its decline. We recommend screening the serum total 25(OH)D level in separate risk groups while maintaining a goal concentration of 75-125 nmol/L (30-50 ng/mL). Also, we recommend prophylactic cholecalciferol prescription (800-2000 IU/d for young, healthy subjects, and 3000-5000 IU/d for persons with diseases or conditions with negative effects on vitamin D metabolism). For the VDD treatment, the expert group recommends the short-term administration of higher cholecalciferol doses (4000-10,000 IU/d) with monitoring of 25(OH)D levels after 4-12 weeks of treatment, followed by the use of maintenance doses. Furthermore, we recommend the assessment of serum 25(OH)D levels before initiating therapy in patients with osteoporosis and providing a prescription of cholecalciferol (800-2000 IU/d) in combination with calcium (1000 mg/d of elemental calcium) throughout the full course of antiosteoporotic treatment (Table A1).
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