How you handle vitamin D


What do you do if a patient comes into your pharmacy looking for vitamin D supplements?

In November a review published in the BMJ concluded that current evidence does not support the use of vitamin D supplements to prevent disease, except potentially in those at high risk.

The researchers suggested that those at high risk of vitamin D deficiency should be advised about sunlight exposure and diet, and low-dose supplements should be considered on an individual basis.

Everyone else is recommended to get regular short bursts of sunshine and eat a healthy balanced diet.

Caution should also be taken when recommending vitamin D supplements, according to leaders in the field of endocrinology, since excessive levels can lead to toxicity, hypercalciuria and hypercalcaemia.

The main source of sufficient vitamin D for people residing in Australia is skin exposure to sunlight, they say.

Sydney pharmacist Nick Logan, who owns and manages Nick Logan Pharmacist Advice, agreed that supplementation should depend on the individual.

“I wouldn’t start treating vitamin D deficiency unless I had some clinical evidence – confirmation with a blood test,” he told AJP.

He also said he would refer those at high risk to their doctor first, before offering supplements.

“I would recommend people to see their doctor if they’re over 50, have dark skin, wear a lot of clothes or are confined indoors.”

We decided to ask readers how you approach counselling your patients who come into the pharmacy looking for vitamin D supplements. Respondents could choose more than one option.

The most popular approach for pharmacists was to check people for risk factors of vitamin D deficiency before recommending supplementation, such as living in residential aged care; having dark skin; wearing modest clothing; being obese; having very fair skin; and sun avoidance.

Fifty-seven percent of poll respondents said: “I only recommend vitamin D supplements to people I think are at high risk of deficiency”.

Just less than half of respondents (46%) admitted that if someone wanted to buy vitamin D supplements from them, they would sell it to them – but with appropriate counselling provided.

And 19% followed the advice of the BMJ researchers, which was to tell patients to spend more time in the sun if they think they are at risk of vitamin D deficiency.

Finally 12% said it would depend on the dosage of the supplement; 12% selected ‘other’; and a further 12% admitted they would sell vitamin D supplements to someone who wanted them, no questions asked.

Appropriate evidence-based supplementation in pharmacy is of vital importance at the moment, with pharmacists’ sale of OTC medicines and complementary products currently being scrutinised in the government’s Review of Pharmacy Remuneration and Regulation.

The review panel wrote in its discussion paper that “it was also claimed that many complementary products do not have evidence-based health benefits and as such, the sale of these products in a pharmacy setting may misinform consumers of their effectiveness and undermine the professional integrity of community pharmacists.”

Logan tells AJP it’s important that pharmacists focus on selling medicines that have a strong evidence base.

“I think going forward in Australia, particularly with the conversations happening about complementary medicines, the ones that have an evidence base should be the ones we focus on and talk to patients about,” he said.

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8 Comments

  1. Leopold Hamulczyk
    14/12/2016

    “I wouldn’t start treating vitamin D deficiency unless I had some clinical evidence – confirmation with a blood test,” he told AJP.
    In which case he shouldn’t recommend them at all, because he is not likely to be privy to such information. The doctor is, in which case it is up to the doctor to recommend it.

    • Nicholas Logan
      14/12/2016

      Exactly. Unless they tell me they have confirmed low vitamin d levels.

    • Debbie Rigby
      17/12/2016

      I think pharmacists can recommend vitamin D supplements empirically. Ask about a person’s sun exposure and sunscreen use, consider other risk factors, review their medicines (phenytoin) and conditions (osteoporosis/osteopenia), and where they live (below 37 degree latitude v likely to be deficient). You don’t always need a blood test. Just need higher doses to replete and then 1000IU daily for maintenance or 2000 daily in obese people.

      • Peter Allen
        19/12/2016

        ‘South of 37 degrees v likely to be deficient.’ BINGO! So EVERYBODY,
        take 1000U/day after topup. ‘Toxicity’ is a non-issue; I challenge to
        bring persuasive evidence.
        ‘Sun provides plenty’– but it doesn’t,
        that skin precursor does not convert to adequate plasma levels. Just ask
        the doctors who know you can’t predict adequate levels for
        sun–seekers.

  2. Cameron Stewart
    14/12/2016

    Heard on the wireless this morning the association between low Vit D and autism…?

    • PharmOwner
      14/12/2016

      Have to be careful with “chicken and egg” syndrome here. Low Vit D is also associated with multiple sclerosis and any number of ills. But does the disease itself result in low Vit D or does low Vit D precipitate the disease? Difficult to determine causality.

  3. David Haworth
    14/12/2016

    In midterm pregnancy onwards is the risk time…… therefore……

  4. Marc Sorenson
    14/12/2016

    A good article, and perhaps one of the few from Australia recommending sun exposure for anything. Congratulations. Sun exposure, of course, is the only natural way to obtain vitamin D, and it is impossible to develop vitamin D toxicity with sun-produced D, because the body will regulate the amount produced. It is also important to understand that vitamin D is only one of many photoproducts that are increased with sun exposure and are essential to human health. Here are a few more well-documented benefits of sun exposure, with or without vitamin D:

    •As sun exposure in the U.S. has DECREASED by 90% during the last century, melanoma incidence has INCREASED BY 3,000%.

    •A 20-year Swedish study shows that sun avoidance is as bad for the health as cigarette smoking.

    •A Spanish study shows that women who seek the sun have one-eleventh the hip fracture risk as those who avoid sun.

    •Men who work outdoors have half the risk of melanoma as those who work indoors.

    •Women who totally avoid the sun have 10-times the risk of breast cancer as those who embrace the sun.

    •Women who sunbathe regularly have half the risk of death during a 20-year period compared to those who stay indoors.

    •Sun exposure increases nitric oxide production, which leads to a decrease in heart attack risk.

    •Vitamin D, the sunshine vitamin, is essential to human survival, and sun exposure is the only natural way to obtain it. Sunbathing can produce 20,000 units of vitamin D in 20 minutes of whole-body exposure.

    •Sun exposure dramatically improves mood through the production of serotonin and endorphin.

    •Beyond vitamin D, sun exposure also stimulates the production of endorphin, nitric oxide and BDNF, all of which are vital to human health.

    •Regular sun exposure also reduces high blood pressure, heart disease, psoriasis and multiple sclerosis (MS).

    •As sunscreen use has increased dramatically, melanoma has INCREASED exponentially.

    • Recent research shows that sun deprivation in the U.S. leads to approximately 330,000 deaths per year.

    For the scientific references and articles for the above statements, visit http://sunlightinstitute.org/

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