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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