We all remember stories about people getting rickets from lack of vitamin D in the “olden days.” While that is almost unheard of in most developed countries, we are seeing many people with subclinical vitamin D deficiency. Vitamin D deficiency is associated with osteoporosis, increased risk of falls, and possibly fractures. Vitamin D is also believed to be important to the immune and cardiovascular systems, and a factor in breast cancer risk. In 2006, 41% of Americans were vitamin D deficient.
How do you know if you are vitamin D deficient? A simple blood test with your primary care doctor to measure your 25-hydroxyvitamin D (25OHD) level will tell you. Insufficiency is defined as a vitamin D level less than 30 ng/mL (some argue 27, but 30 is the current line in the sand), and a vitamin D level less than 20 is deficient by all standards.
Why are we deficient in vitamin D? Changes in milk intake, use of sun protection, and obesity have accounted for the decrease in vitamin D in our adults.
Do we know that replacing vitamin D will help us? Yes—well, sort of. In many trials, vitamin D supplementation to achieve vitamin D (25OHD) levels of 28 – 40 lowered fracture risk.
Can my vitamin D level get too high? Though there doesn’t appear to be any toxicity associated with vitamin D supplementation, there are concerns when levels go above 50. It is rare that I see a patient’s level above 50 and I’ve been in private practice for 10 years. Ideally, you want to maintain your vitamin D level between 30 and 50 ng/mL.
So how much vitamin D do you need? This is highly debated but we appear to be settling on a consensus. First, think about getting it through your diet, which will happen only with vitamin D fortified dairy products. The Recommended Dietary Allowance (RDA) of vitamin D for adults through age 70 is 600 IU with the RDA increasing to 800 IU after age 71.
You will need more if you:
– live in a sun deficient state
– are dark skinned
– consistently use sunscreen
– are obese
– take medications that accelerate the metabolism of vitamin D (such as phenytoin)
– don’t absorb well from your gut: inflammatory bowel disease and celiac disease.
What supplements do I need to take to get my vitamin D level above 30? The two commonly available forms of vitamin D supplements are ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). Studies suggest that vitamin D3 increases vitamin D levels faster than vitamin D2. For this reason I prescribe Vitamin D3 supplements.
Vitamin D3 is available in 400, 800, 1000, 2000, 5000, 10,000, and 50,000 unit capsules. 50,000 IU (1.25 mg) capsules are available as a prescription.
In patients with vitamin D levels less than 20, start with 50,000 international units (IU) of vitamin D3 once a week for six to eight weeks
After that, a maintenance dose of 800 – 2000 IU per day should be taken daily to maintain a vitamin D level above 30 ng/mL.
Three to four months after starting on vitamin D replacement, have your level rechecked to ensure you are on the right track.
The 50,000 IU (1.25mg) strength of vitamin D is prescription only, and may be covered by your insurance, but can be found for as low as $4 for a one-month supply (4 capsules). Lower strengths of vitamin D are available over the counter.
1) 1 in 4 patients skip meds to save money. If you are doing this, your doctor needs to know.
2) Communicating about the economics of medications is part of your doctor’s job.
3) Your doctor should realize that higher cost means less compliance (you won’t take your pills everyday). We both lose.
4) Both doctors and patients are on the same team: yours. Patients need to get the best health care within the constraints of the current system.
5) Writing the prescription isn’t always enough. Patients have to fill the prescription and take the medication as well.
6) Your out-of-pocket prescription drug costs can play a big role in how well you follow doctors’ orders.
7) Your doctor has an obligation to consider costs when prescribing meds.
8) It’s possible the biggest “side effect” of your medication is cost, and you need to know this before you get to the pharmacy.
9) You and your doctor can explore alternatives such as: generic medications, splitting higher-dose pills, reviewing med lists to cut out nonessential or less important drugs, patient assistance programs, and getting samples.
10) Initiating the conversation as a patient will help avoid potential awkwardness. Seriously? Yes, doctors say the reason they don’t bring cost of meds up with their patients more often is they want to avoid making their patient feel awkward.
No, it’s not insulin. New injections for diabetes may change the way we manage adult-onset diabetes. Approval of a new once-a-week injection called Bydureon is an exciting new option for blood sugar control. This new class of injectables may be popular for several reasons, not the least of which is they also result in weight loss. Yippee!
Though it sounds straight out of outer space, these drugs are called incretin mimetics, meaning they mimic the incretin hormones that tell your body to release insulin after eating. These drugs work in very cool ways by enhancing insulin secretion, slowing stomach emptying, reducing food intake, and promoting proliferation of β-cells (cells that make insulin).
Byetta (exenatide) was the first in this class and is used to improve blood sugar control in adults with type 2 diabetes. The most interesting part is that exenatide is an amino acid isolated from the salivary gland venom of the Gila monster. There are now three choices in this class: Byetta, Victoza and the newly approved Bydureon. All three may be used with other oral diabetes medicines. All three are used to treat adult onset diabetes and all three result in weight loss, a nice bonus.
Byetta (exenatide) is injected twice a day before your morning and evening meal.
While all of them may cause some nausea/vomiting, this is higher with Byetta and was the most common adverse event associated with Byetta. The nausea/vomiting decreases in frequency and severity over time.
Reports of pancreatitis have dogged all of these medications and are something we need to keep a close eye on.
Bydureon once weekly may also carry the indication for monotherapy (it may be used as a first line medication for adult onset diabetes) as opposed to the other two which are added to your other oral medications for diabetes (metformin, Januvia or Actos).
Byetta and Victoza are both typically considered Tier 2 medications by insurance, meaning you’ll have a moderate co-pay. It is likely that Bydureon will also be considered a Tier 2 drug, but possible that as a new medication it may be Tier 3, meaning a higher co-pay, or not covered. Byetta ranges from about $150 – $300 per injection, depending on the strength, and Victoza tends to cost about $125 – $175.