Vitamin D: too much testing and treating?

Woodford, Henry J.; Barrett, Scott M.; Pattman, Stewart

doi:10.7861/clinmedicine.18-3-196

Cited by 47 publications

(46 citation statements)

References 12 publications

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“…In C3-Minority Metabolic Autoimmune-Inflammatory, over 50% of diseases are exclusive of this cluster. However, even if the medication is associated with overrepresented conditions, it does not have high exclusivity since these medicines have different authorised indications, for instance glucocorticoids and Vitamin D and analogues, which are even indicated off-label (34,35).…”

Section: Polypharmacy and Their Evolutionmentioning

confidence: 99%

Multimorbidity patterns, polypharmacy and their association with liver and kidney abnormalities in people over 65 years of age: a longitudinal study

Villén

Guisado-Clavero

Fernández-Bertolín

et al. 2020

Preprint

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Background: The implementation of individual clinical practice guidelines in patients with multimorbidity often results in polypharmacy. Our aim was to analyse medication use according to longitudinal multimorbidity patterns (MP) and determine during a 5-year period (2012-16) which MP are associated with abnormal liver and kidney function in primary care patients over 65 years of age living in Catalonia.Methods: Design: Longitudinal study (years 2012 to 2016) based on the electronic health records contained in Information System for Research in Primary Care database of the Catalan Institute of Health (SIDIAP). Variables: age, sex, MP, medication and polypharmacy (drug exposure obtained from the Pharmacy Invoice Registry). Medicines were classified in accordance with the Anatomical Therapeutic Chemical Classification System (ATC). Glomerular filtration rate was used to determine abnormal kidney function, and serum levels of alkaline phosphatase, alanine transaminase and gamma-glutamyl transpeptidase were used to diagnose abnormal liver function. Statistics: For medication use in MP, we calculated annual mean packages of each drug in each MP, and observed/expected ratios were obtained by dividing mean packages in the cluster by mean packages of the same drug in the overall population. Logistic regression models were fitted to estimate the association between MP at baseline and abnormal kidney and liver function tests during follow up.Results: 916,619 patients were included, and 743,827 completed the follow up. We identified one polypharmacy profile per MP, and concluded that the most prescribed drugs in each pattern corresponded to the diseases overrepresented in that specific MP. The median of drugs ranged from 3 (Cluster 1 - Non-Specific) to 8 (Cluster 10 - Multisystem Pattern). Abnormal kidney function was most commonly observed in the Cluster 4 - Cardio-Circulatory and Renal (Odds Ratio [OR] 2.19; Confidence interval [CI] 95% 2.15-2.23) and Cluster 3 - Minority Metabolic Autoimmune-Inflammatory (OR 2.16; CI 95% 2.12-2.20) MP. A higher risk of abnormal liver function was observed in the Cluster 8 - Digestive (OR 3.39; CI 95% 3.30-3.49), and Cluster 4 - Cardio-Circulatory and Renal (OR 1.96; CI 95% 1.91-2.02) MP.Conclusions: A higher risk of abnormal kidney and liver function was observed in specific MP. The long-term characterisation of MP and polypharmacy illustrates the burden of chronic multimorbidity and polypharmacy in the elderly population.

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Section: Polypharmacy and Their Evolutionmentioning

confidence: 99%

Multimorbidity patterns, polypharmacy and their association with liver and kidney abnormalities in people over 65 years of age: a longitudinal study

Villén

Guisado-Clavero

Fernández-Bertolín

et al. 2020

Preprint

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“…19 The costs associated with such testing are substantial, 18 with recent efforts made to develop a methodology for assessing the degree of inappropriate vitamin D testing. 20 In the United Kingdom, approximately 70% of vitamin D testing in one instance was inappropriate based on indication, 21 with another such study in Canada identifying a similar frequency of approximately 65%. 22 Vitamin D testing occurs despite a lack of guidelines supporting testing for general-risk individuals 4,5 and the existence of scoring systems to identify high-risk individuals.…”

Section: Discussionmentioning

confidence: 99%

Is the Climb Worth the View? The Savings/Alert Ratio for Reducing Vitamin D Testing

et al. 2020

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Background Despite guideline recommendations, vitamin D testing has increased substantially. Clinical decision support (CDS) presents an opportunity to reduce inappropriate laboratory testing. Objectives and Methods To reduce inappropriate testing of vitamin D at the Vanderbilt University Medical Center, a CDS assigned providers to receive or not receive an electronic alert each time a 25-hydroxyvitamin D assay was ordered for an adult patient unless the order was associated with a diagnosis in the patient's chart for which vitamin D testing is recommended. The CDS ran for 80 days, collecting data on number of tests, provider information, and basic patient demographics. Results During the 80 days, providers placed 12,368 orders for 25-hydroxyvitamin D. The intervention group ordered a vitamin D assay and received the alert for potentially inappropriate testing 2,181 times and completed the 25-hydroxyvitamin D order in 89.9% of encounters, while the control group ordered a vitamin D assay (without receiving an alert) 2,032 times and completed the order in 98.1% of encounters, for an absolute reduction of testing of 8% (p < 0.001). Conclusion This CDS reduced vitamin D ordering by utilizing a soft-stop approach. At a charge of $179.00 per test and a cost to the laboratory of $4.20 per test, each display of the alert led to an average reduction of $14.70 in charges and of $0.34 in spending by the laboratory (the savings/alert ratio). By describing the effectiveness of an electronic alert in terms of the savings/alert ratio, the impact of this intervention can be better appreciated and compared with other interventions.

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“…There is a trend toward increased serum vitamin D measurement worldwide [27]. This increased number of laboratory tests substantially impact healthcare expenditures [28]. In Australia, the cost of vitamin D measurement increased an average of 59% each year, with a forecasted total cost of vitamin D measurement of A$95.6 million in 2010 [29].…”

Section: Discussionmentioning

confidence: 99%

High-dose versus low-dose ergocalciferol for correcting hypovitaminosis D after fragility hip fracture: A randomized controlled trial

Jarusriwanna

Phusunti

Unnanuntana

2020

Preprint

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Background: Hypovitaminosis D can be observed in most fragility hip fracture patients. However, measurement of 25-hydroxyvitamin D [25(OH)D] level is costly and may not be available in some centers. Without the baseline 25(OH)D level, the appropriate dose of vitamin D supplementation is not known. The aim of this study was to evaluate the effectiveness and safety of vitamin D supplementation in fragility hip fracture patients compared between high- and low-dose vitamin D supplementation. Methods: A total of 140 patients diagnosed with fragility hip fracture were randomly allocated to either the high-dose (60,000 IU/week) or low-dose (20,000 IU/week) vitamin D2 supplementation group for 12 weeks. The number of patients who achieved sufficient vitamin D level [25(OH)D level > 30 ng/mL], the proportion of patients who developed hypercalcemia, and the functional outcome were compared between groups. Results: Of the 140 patients who were enrolled, 21 patients were lost to follow-up during the study period. The remaining 119 patients (58 and 61 in the high- and low-dose group, respectively) were included in the final analysis. The high-dose group had a higher rate of serum 25(OH)D restoration to sufficient level than the low-dose group (82.8% vs 52.5%, respectively). Approximately 3.4% and 1.6% of patients in the high- and low-dose groups, respectively, had mild hypercalcemia, but none developed moderate, severe, or symptomatic hypercalcemia. There were no differences in functional outcome scores between groups.Conclusions: In treatment settings where baseline serum 25(OH)D level can’t be evaluated, we recommend high-dose vitamin D2 of approximately 60,000 IU/week for 12 weeks, with subsequent switch to a maintenance dose. This regimen effectively restored serum vitamin D to a sufficient level in 82.8% of patients without causing symptomatic hypercalcemia.Trial registration: The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database no. TCTR20180302007 on 20 February 2018.

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Vitamin D: too much testing and treating?

Cited by 47 publications

References 12 publications

Multimorbidity patterns, polypharmacy and their association with liver and kidney abnormalities in people over 65 years of age: a longitudinal study

Multimorbidity patterns, polypharmacy and their association with liver and kidney abnormalities in people over 65 years of age: a longitudinal study

Is the Climb Worth the View? The Savings/Alert Ratio for Reducing Vitamin D Testing

High-dose versus low-dose ergocalciferol for correcting hypovitaminosis D after fragility hip fracture: A randomized controlled trial

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