Spinal Cord Injury and Vitamin D:A Case for Testing and

Supplementation

Hannah CoakleyJanuary 23rd, 2014

What Does Vitamin D Do?

What Happens to Vitamin D in SCI Patients?

• 32% of SCI veterans are deficient in Vitamin D

• Persons with SCI have marked loss in bone mass over time, predisposing them to fractures

• Vitamin D deficiency can further accelerate bone loss among the SCI population

What Happens to Vitamin D in SCI Patients?

• Vitamin D plays a major role in the regulation of immune response systems

• Increasing circulating Vitamin D could decrease incidence of common SCI-related diseases:

diabetes, CVD, and pneumonia

Evaluating the Research: Vitamin D and Bone Density

ObjectiveExamine the efficacy of supplementing SCI

patients with Vitamin D at levels of 2000 IU/day this amount is higher than the IOM

recommendation of 600 IU/day

Vitamin D and Bone Density

Study PopulationSeven subjects with chronic SCI enrolled at the

Bronx VA: 6 male, 1 female. Four paraplegics and three tetraplegics.

Four complete injuries and three incomplete injuries

Patients had to be Vitamin D deficient w/o any history of kidney disorder

Vitamin D and Bone Density

MethodsBlood/urine tested at screening, baseline, month 1

and month 3.

Oral administration of 2000 IUs vitamin D3 daily and 3.25g calcium carbonate for 90 days

Levels of serum vitamin D were tested, as were iPTH levels and NTx levels

Vitamin D and Bone Density

Results

Vitamin D and Bone Density

LimitationsVery low sample size affects the significance of the

findings

Concerns regarding over-supplementation:could cause calcification of tissues and kidney stones

Did not test compliance, even in an in-patient setting

Evaluating the Research: Vitamin D Analog Supplementation

Objective To determine whether thesupplementation of syntheticVitamin D2 is effective in increasing bone mineral density (BMD) among SCI patients.

Vitamin D Analog Supplementation

Study Population• 40 subjects: 17 tetraplegics, 23 paraplegics

• Range of injury duration was 1 – 34 years.

• Mean age was 43 +/- 13 years

• 23 never smoked, 9 currently smoked

• Fracture histories were not obtained

Vitamin D Analog SupplementationMethods

Either 800 IU Vitamin D2 (n=21) or a placebo (n=19) was administered daily in a double blind study

Blinded DEXA scans were performed at baseline, 6, 8, 12, 18, and 24 months

Urine and serum Calcium and NTx were also measured to determine bone breakdown

Vitamin D Analog Supplementation

Results

Vitamin D Analog Supplementation

Limitations• History of bone fracture not obtained

• Small sample size

• Differences were significant, but also minimal

• Potential of confounding with other medicines

Comparison of NTx Levels

Duration Vit D2 (800 IU) PercentageChange

Vit D3 (1000 IU) Percentage Change

Baseline 30 nm BCE --- 11.7 nm BCE ----

6 months 16.2 nm BCE 46% decrease 8.4 nm BCE 32% decrease

12 months 17.5 nm BCE 8% increase from 6 months

42% decrease overall

8.5 nm BCE 1% increase

31% decrease overall

Interpretation/ Implications for Our Practice

• Advocating for the consistent measurement of Vitamin D levels among all SCI patients is essential

• There exists somewhat strong evidence that Vitamin D raises both circulating serum levels and overall bone mineral density in SCI patients.

Case Study, Mr. W

54 y/o white male• Problems: C3-6, ASIA D, Very Incomplete

Tetraplegia since fall in 2008, Hyperthyroid, A-fib, Hepatitis C, Hernia, Hypercholesterolemia, Anxiety disorder, Tobacco use

• Meds: Atenolol, Cyclobenzaprine, Alprazolam, Hydrocodone

Pertinent Lab Values/ Trends

Vitamin D (Serum) 27.4 (2/13), 23.5 (4/13), 30.8 (8/13)

Pertinent Lab Values/ Trends

Calcium (Plasma):8.4 (1/13), 9.5 (7/13), 9.2 (1/14)

Anthropometrics & Nutrition Diagnosis

Height: 74 in // Weight:241 lb %DBW: 121%Recent weight changes: 9lb weight gain over the past yearBMI: 31 on 01/21/14

“Overweight/obesity related to excessive calorie intake as evidenced by diet history and BMI of 31.”

Intervention

• Pt is not interested in Vitamin D supplementation

• RD and DI educated patient on importance of adequate sunlight exposure, drinking milk and consuming fatty fish whenever possible

• Consider a lower Vitamin D supplement dosage or synthetic D2 instead of D3

Prognosis

New vitamin D labs should be drawn as it has been nearly 6 months. Recent Ca WNL.

Fair patient’s eating habits are questionable

Additionally, adequate Vitamin D is very difficult to obtain from food alone during winter

References1) Bauman, Emmons, Cirnigliaro, Kirshblum & Spungen.

Vitamin D Replacement in SCI. Journal of Spinal Cord Medicine. Vol 34 Num 5, 2011.

2) Bauman, Spungen, Morrison, Zhang, and Schwartz. Effect of a vitamin D analog on leg bone mineral density in patients with chronic spinal cord injury. Journal of Rehabilitation Research & Development. Vol 42 Num 5, 2005.

3) Office of Dietary Supplements, NIH. Vitamin D – Health Professional Fact Sheet. Reviewed 24 Jun 2011.