Episode 52 - Vitamin D Check - a podcast by Rio Bravo Family Medicine Residency Program

Vitamin D deficiency screening recommendations by USPSTF and other organizations is discussed. CDC announces “no masks required” for vaccinated people. Question of the month about fever and cough answered.

Introduction: Mask use no longer required for vaccinated people
By Hector Arreaza, MD

Today is May 17, 2021.

Did you receive your COVID-19 vaccine? If you did, we have good news for you, well, this may not be news for you anymore by the time you listen to this episode.

The CDC director, Rochelle Walensky, announced a few minutes ago that vaccinated people no longer need to wear masks indoors or outdoors and no longer need to keep social distance[1]. A person is considered fully vaccinated 2 weeks after one dose of J&J vaccine or two weeks after second dose of Moderna or Pfizer vaccines.

Fully vaccinated people are required to wear masks in airplanes, trains, buses, other public transportation, health-care settings, and where required by local authorities or businesses. These mask and social distancing guidelines may change in the future because we have seen the behavior of the coronavirus is unpredictable. These guidelines are dynamic.   

This announcement came one day after CDC endorsed administration of the Pfizer vaccine to persons between 12 and 15 years old. We do not know if this is the beginning of the end, but for sure we are starting to see a light at the end of the tunnel. 

As of today, about 117 million Americans are fully vaccinated (35% of the population). The effectivity of vaccination has been remarkable. The rate of breakthrough infections (it means infection after full vaccination) is rare, and severity of disease is mild after vaccination. For the record, the federal government has set a goal of vaccinating 70% of Americans by July 4th, 2021. 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.

Question of the Month: Fever and Cough
Written by Hector Arreaza, MD

This is a 69-year-old male patient, who comes to clinic for acute onset of fever (102 F), cough, and shortness of breath which has progressively worsened over the last 3 days. 

He does NOT smoke tobacco. He takes benazepril 10 mg daily. His immunizations are not up to date. Physical exam: Tachycardia of 110 bpm and fever of 101.5 F (38.6 C). He has bibasilar crackles, White count is elevated 13.5, and chest x-ray shows a right lower lobe consolidation. He has a negative rapid COVID-19 test. 

What are your top 3 differential diagnoses and what is the acute management of this patient’s condition?

First, we want to announce the winner. I am the winner [applause].

The top 3 differential diagnosis are: 1. Community acquired pneumonia, viral or bacterial (no surprises there, the symptoms are typical of CAP); 2. COVID-19 pneumonia (the rapid COVID-19 test was NEGATIVE, but the confirmatory test is pending, this patient may have COVID-19 until proven otherwise); and 3. My third DDX is pulmonary coccidio-idomycosis (also known as Valley Fever in California, or simply cocci). If you are not familiar with the diseases in the Central Valley of California, you may think this is a very unusual differential, but for us is not that uncommon. One day we will talk more about that disease.

Acute management:

The first decision you must make is where to treat this patient. Will you treat him at home or in the hospital? If sent to the hospital, can he be treated on the floor or requires ICU admission?

You have to determine is the patient is experiencing septic shock or respiratory failure. If septic shock and respiratory failure are not likely, and CURB-65 score is zero, then no hospital admission is needed. 

This patient meets SIRS criteria (systemic inflammatory response syndrome): temperature >38 C, HR > 90, and WBC >12,000. BP was not provided so it is not possible to determine if he has septic shock (BP <90/60).

Respiratory failure is suspected when pulse ox is below 92% on room air. That information is not provided in this case. Assuming Pulse ox is below 92% on room air, then you use an objective way to determine severity of pneumonia or guide your management. 

There are not enough elements to calculate the CURB-65 score: Confusion, BUN >20 mg/dL (>7 mmol/L), Respiratory rate ≥30 breaths/minute, Blood pressure (systolic <90 mmHg or diastolic <60 mmHg), Age ≥65 years. Further labs would be needed to determine the severity of this pneumonia. A CURB 65 above 2 points warrants hospital admission. CURB 3-5 may require ICU admission.

Based on my assessment, this patient meets admission criteria. Let’s assume patient’s blood pressure is below 90/60.

The priority is to start fluid resuscitation, Normal saline or LR 30 mL per kilo, in the first 3 hours, mean arterial pressure 60 mmHg to 70 mmHg and urine output >0.5 ml/kg/hour, lactic acid trending down. IF response is poor, consider ICU transfer.

Collect blood culture x2 before IV antibiotics. 

IV antibiotics: Ceftriaxone and Azithromycin IV.

Order labs CBC, CMP, D-dimer level, Lactate, procalcitonin, COVID-19 PCR, rapid influenza testing, urinary antigen testing (eg, pneumococcus, legionella), sputum culture: sputum of good quality, quantitative culture of protected brush or bronchoalveolar lavage; ABG to assess for respiratory failure, especially if patient’s pulse ox is low. In the Central Valley: Order Coccidio-iodomycosis (cocci) titers. Starting empiric fluconazole is an option when you have a high suspicion for pulmonary cocci. 

Procalcitonin: Measure on admission and 1-2 days later. If <0.25 this may indicate a viral pneumonia but antibiotics still recommended based on your clinical judgment. If you suspect bacterial CAP, you can decide to discontinue antibiotics once the procalcitonin is below 0.25 or decreasing more than 80% from peak level.

Lactic acid: Use to guide fluid resuscitation. 

Follow your patient closely until you can tell objectively he is improving.

Vitamin D Check. 
With Yodaisy Rodriguez, MD, and Hector Arreaza, MD

What is Vitamin D?

Vitamin D is a fat-soluble vitamin that has an important function in calcium and bone metabolism. It stimulates absorption of calcium by the intestines, it inhibits excretion of calcium and phosphates by the kidneys, and it increases bone resorption. It also participates in many other cellular functions outside the skeletal system.

Metabolism: There are two kinds of exogenous vitamin D: Vitamin D3 is called cholecalciferol, Vitamin D2 is called ergocalciferol. The major source of natural vitamin D in our bodies is the skin. UV B light turns 7-de-hydro-cholesterol into Vitamin D3 (cholecalciferol) in the skin. Dietary sources of vitamin D can be Vitamin D2 or D3. Only a few foods contain vitamin D naturally. Fatty fish is the main food with vitamin D.

After Vitamin D gets activated by UV light, it gets activated in the liver and results in 25-hydroxyvitamin D, which is the most abundant circulating vitamin D in our bodies. After activation in the liver, 25-hydroxy-vitamin D is then metabolized by the kidney, resulting in 1,25-di-hydroxy-vitamin D, which is the most active form of vitamin D (also short-lived). 

Skin: 7-dehydrocholesterol -> UV Light -> Cholecalciferol (D3) -> LIVER -> 25-hydroxyvitamin-D -> KIDNEY -> 1,25 dihydroxyvitamin D (most active form of vitamin D)

Diet/Supplement: Vitamin D2 and D3 -> LIVER -> 25-hydroxyvitamin-D -> KIDNEY -> 1,25 dihydroxyvitamin D (most active form of vitamin D)

Screening for Vitamin D Deficiency in Adults.

Screening means to run tests before there is clinical evidence of a disease. 

41% of the adult US population has Vitamin D levels below 20, classified as subclinical Vitamin D deficiency, which may contribute to osteoporosis and traumatic fractures in older adults. Clinical vitamin D deficiency (hypocalcemia, hypophosphatemia and rickets and Osteomalacia) is uncommon in the US. 

The goal of screening for vitamin D deficiency would be to identify and treat it before any symptoms are present.

The best marker for detection of deficiency. 

Total 25 hydroxyvitamin D level is currently considered the best marker of vitamin D status. This is the result of the activation by the liver. However, precise measurement of levels is difficult because Vitamin D requirements may vary by individual, by testing method, and between laboratories.

According to the National Academy of Medicine: 97.5% of the population will have their vitamin D at a serum level of 20 ng/mL (49.9 nmol/L) and risk for deficiency. Bone health concerns start at levels less than 12 to 20 ng/mL (29.9- 49.9 nmol/L).

The 2014 National Health and Nutrition Examination Survey found that: 5% of the population 1 year or older had very low 25-hydroxyvitamin D (25[OH]D) levels <12 ng/mL, 18% had levels between 12 and 19 ng/mL.

Risk factors for low vitamin D levels. 

-Low dietary vitamin D intake.

-Little or no UV B light exposure (eg, because of winter season, high latitude, or sun avoidance – office jobs)

-Older age 

-Obesity: people with obesity have a 1.3- to 2-fold increased risk for low vitamin D level

-Patients taking medications that accelerate the metabolism of vitamin D (such as phenytoin)

-Hospitalized or institutionalized patients

-Patients with increased skin pigmentation

-Osteoporosis

-Malabsorption, including inflammatory bowel disease and celiac disease

Interesting fact: Prevalence of low vitamin D is 2 to 10 times higher in black persons than in non-Hispanic white persons.

 

Recommendations for screening for vitamin D deficiency. 

USPSTF: 2021 – All adults: Grade I (insufficient evidence) for screening for vitamin D deficiency in asymptomatic, community-dwelling, non-pregnant adults. 

USPSTF: 2018 – Elderly patients: Grade D (do not give) Vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older who are community-dwelling without evidence of osteoporosis or vitamin D deficiency.

USPSTF: 2018 – Postmenopausal women: Grade D (do not give) daily vitamin D (400 IU or less) and calcium (1000 mg or less) for the primary prevention of fractures in community-dwelling, postmenopausal women without osteoporotic fractures, increased risk for falls, or a diagnosis of osteoporosis or vitamin D deficiency. Grade I (Insufficient evidence) to recommend daily supplementation with more than 400 IU of vitamin D and more than 1000 mg of calcium to prevent fractures in community-dwelling, postmenopausal women.

USPSTF: 2018 – Men and premenopausal women: Grade I (insufficient evidence) for vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in community-dwelling, asymptomatic men and premenopausal women. 

Dr. Arreaza: Treatment and Interventions.

In general, patients with serum 25(OH)D levels <12 ng/mL are at risk for developing osteomalacia. 

Work up: In patients with Vitamin D <12, measure serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH), electrolytes, blood urea nitrogen (BUN), creatinine, and tissue transglutaminase antibodies (to assess for celiac disease). Radiographs in case of bone pain. 

PTH should be high in low vitamin D. You can use PTH as an indirect indicator of appropriate level of Vitamin D when it normalizes after adequate repletion. Fracture prevention is accomplished when Vitamin D level is between 28-40 ng/mL (70 to 99 nmol/L).

Yodaisy: Prevention and optimal intake: 

The Institute of Medicine (IOM) in 2010 posted the Recommended Dietary Allowance (RDA) of vitamin D for children 1 to 18 years, pregnant women, and nonpregnant adults younger than age 70 years is 600 international units, and 800 international units for patients older than 70 years. To re

Arreaza: The American Geriatrics Society (AGS) and the National Osteoporosis Foundation (NOF) recommend a slightly higher dose of vitamin D supplementation (at least 1000 international units [25 micrograms], and 800 to 1000 international units daily, respectively) to older adults (≥65 years) to reduce the risk of fractures and falls. Note we are citing different organizations. 

Yodaisy: When a real vitamin D deficiency is diagnosed, it is usually treated with oral vitamin D prescriptions. It can be vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol). Toxicity is rare, which is characterized by marked hypercalcemia, hyperphosphatemia and hypercalciuria. Toxicity is rare (typically >150 ng/mL), and PO vitamin D supplementation has not been associated with serious harms. 

Vitamin D and COVID-19.

There is growing interest as a facilitator of innate immune response during COVID-19 infection. Vitamin D supplementation may be needed to meet recommended intake or treat deficiency, however, exceeding the upper level intake is not recommended. No evidence in reducing the risk of severity, length of hospital stay, or mortality. 

 

Summary.

USPSTF - Do not give: 

1. Vitamin D to elderly patients to prevent falls. 

2. Vitamin D (<400) and calcium (<1000) to asymptomatic postmenopausal women to prevent fractures.

USPSTF - Insufficient evidence to recommend for or against: 

1. Screening for Vitamin D deficiency in adults.

2. Supplementation with Vitamin D (>400) and calcium (>1000) in asymptomatic postmenopausal women to prevent fractures.

3. Supplementation with Vitamin D and calcium, alone or combined, for the primary prevention of fractures in asymptomatic men and premenopausal women.   

Vitamin D deficiency screening recommendations by other organizations: 

-Against screening: The American Society for Clinical Pathology (ASCP). 

-Insufficient: The American Academy of Family Physicians. 

-Screen in individuals at risk: The Endocrine Society and the American Association of Clinical Endocrinologists.

Prevention of deficiency: Recommended Dietary Allowance: Vitamin D 600 international units until age 70, then 800 units a day. Other organizations (American Geriatrics Society and the National Osteoporosis Foundation) recommend a higher RDA of 800 to 1000 for persons older than 65 who are at risk for vitamin D deficiency.

 

Now we conclude our episode number 52 “Vitamin D Checks”. Dr Rodriguez explained that the USPSTF gave a grade I recommendation for Vitamin D deficiency screening in asymptomatic adults. Grade I means “insufficient” evidence. The endocrinologists recommend screening those who are at risk for vitamin D deficiency. According to the USPSTF, Vitamin D supplementation in older adults do not prevent falls and do not prevent fractures in postmenopausal women without deficiency or osteoporosis. Make sure you stay up-to-date with any changes in the future. And congratulations to Dr Arreaza for answering the Question of the month. Stay tuned for another question in the future. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, and Yodaisy Rodriguez. Audio edition: Suraj Amrutia. See you next week! 

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References:

CDC says fully vaccinated Americans no longer need masks indoors or outdoors in most cases, The Washington Post, May 13, 2021.  https://www.washingtonpost.com/health/2021/05/13/cdc-says-fully-vaccinated-americans-no-longer-need-masks-indoors-or-outdoors-most-cases/

 

U.S. Preventive Services Task Force. Screening for Vitamin D Deficiency in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(14):1436–1442. doi:10.1001/jama.2021.3069. https://jamanetwork.com/journals/jama/fullarticle/2778487. 

 

Dawson-Hughes, Bess, MD. Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment. Up to Date, last updated: May 03, 2021. Accessed on May 5, 2021. https://www.uptodate.com/contents/vitamin-d-deficiency-in-adults-definition-clinical-manifestations-and-treatment?search=vitamin%20d&source=search_result&selectedTitle=2~146&usage_type=default&display_rank=1

 

LeClair BM, Si C, Solomon J. Vitamin D Supplementation and All-Cause Mortality. Am Fam Physician. 2020 Jul 1;102(1): Online. PMID: 32603077. https://www.aafp.org/afp/2020/0701/od1.html#:~:text=In%20summary%2C%20high%2Dquality%20evidence,%3D%20274%20for%201.2%20years).

 

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