Tools for Practice


#12 What is the Benefit of Vitamin D: Trend or Treat?


CLINICAL QUESTION
In patients >50 years old, what are the benefits of Vitamin D treatment on falls, fractures and mortality?

BOTTOM LINE
Present evidence supports the use of Vitamin D around 800–1000 IU to reduce fractures, falls and overall mortality in older patients (likely ≥50 years old). There is currently no high level evidence to support regularly testing older patients for Vitamin D insufficiency.


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EVIDENCE
Numerous meta-analyses outline what the benefits of Vitamin D are:
  • Falls:
    • Cochrane review of falls and fallers (four and five Randomized Controlled Trials (RCTs) respectively) in hospitals/continuing care settings.1
      • Rate ratio for falls vs. control 0.72 (95% Confidence Interval 0.55–0.95).
      • No significant effect for fallers.
    • Cochrane review in community dwelling elderly found no benefit.2
      • Post-hoc subgroup analysis of three RCTs in those with low Vitamin D levels.
        • Risk ratio for fallers 0.65 (0.46–0.91), Number Needed to Treat (NNT) for ten months 11.
    • Other meta-analyses had mixed results, but most found benefit.3-8
  • Fractures:
    • Meta-analysis of 11 RCTs with patient-level data from 31,022 people.9
      • Benefit only with doses ≥800 IU/day.
      • Rate ratio 0.86 (0.76–0.96) for non-vertebral fracture.
      • If fracture risk is 15% over ten years, NNT 48
    • Other meta-analyses also found decreased risk.10-12
  • Mortality:
    • Cochrane review of 50 RCTs, 94,148 patients over median two years.13
      • In higher quality studies, rate ratio 0.95 (0.91–0.99), NNT 223.
    • Other meta-analyses have similar results.14,15
Context:
  • Many falls studies only found significant effects on the total number of falls, as opposed to the less biased number of people who fell (fallers).
  • Only high Vitamin D doses provide benefit for fractures (≥800 IU/day).9,12
    • Concurrent calcium is likely required (perhaps 500mg).
  • Mortality was secondary outcome in most studies.
    • Dose and Vitamin D status do not appear to matter for mortality.13
  • Indirectly, Vitamin D3 (cholecalciferol) may be better than D2 (ergocalciferol) for preventing mortality.13
  • Although Vitamin D has not demonstrated increased adverse events, most trials were not adequately designed to assess long-term harms.16
  • Vitamin D testing is not necessary: treating on spec is beneficial and trials did not modify treatment based on levels.1-15
October 16, 2009

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Author(s):

  • Christina Korownyk MD CCFP
  • G. Michael Allan MD CCFP

1. Cameron ID, Murray GR, Gillespie LD, et al. Cochrane Database System Rev. 2010; 1:CD005465.

2. Gillespie LD, Robertson MC, Gillespie WJ, et al. Cochrane Database System Rev. 2009; 2:CD007146.

3. Chua GT, Wong RY. Can Geriatr J. 2011; 14(4):93–9.

4. Bischoff-Ferrari HA, Dawson-Highes B, Staehelin HB, et al. BMJ. 2009; 339:b3692.

5. Kalyani RR, Steain B, Valiyil R, et al. J Am Geriatr Soc. 2010; 58(7):1299–1310.

6. Michael YL, Whitlock EP, Lin JS, et al. Ann Intern Med. 2010; 153:815–25.

7. Murad MH, Elamin KB, Abu Elnour NO, et al. J Clin Endocrinol. 2011; 96:2297–3006.

8. Bischoff-Ferrari HA, Dawson-Highes B, Willett WC, et al. JAMA. 2004; 291(16):1999–2006.

9. Bischoff-Ferrari HA, Willett WC, Orav EJ, et al. New Engl J Med. 2012; 367:40–9.

10. Avenell A, Gillespie WJ, Gillespie LD, et al. Cochrane Database System Rev. 2009; 2:CD000227.

11. Chung M, Lee J, Terasawa T, et al. Ann Intern Med. 2011; 155:827–38.

12. Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Arch Intern Med. 2009; 169(6):551– 61.

13. Bjelakovic G, Gluud LL, Nikolova D, et al. Cochrane Database System Rev. 2011; 7:CD007470.

14. Autier P, Gandini S. Arch Intern Med. 2007; 167(16):1730–7.

15. Rejnmark L, Avenell A, Masud T, et al. J Clin Endocrinol Metab. 2012; 97:2670–81.

16. Cranney A, Horsley T, O’Donnell S, et al. Evid Rep Technol Assess (Full Rep). 2007; (158):1–235.

Authors do not have any conflicts of interest to declare.