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The recommendation for 200 to 800 IU daily is for people who already have normal vitamin D levels. To correct vitamin D deficiency, modern sources recommend a m

The recommendation for 200 to 800 IU daily is for people who already have normal vitamin D levels. To correct vitamin D deficiency, modern sources recommend a minimum of 1,500 to 2,000 IU daily [1]. The Endocrine Society even recommends 6,000 IU daily [2], so 5,000 IU is not crazy by any means. There is also nothing crazy about five years of supplementation: Many people won't maintain normal vitamin D levels even after five years of 2,000+ IU (unless they make lifestyle changes like being deliberate about spending more time in the sunlight) and they may need to continue vitamin D repletion indefinitely [2, 3]. 5,000 IU is probably a bit much to give without rechecking the vitamin D level at least once a year or so, but at least to me it's not obviously medical malpractice. If there is medical error here, it's ignoring calcium levels higher than 11 mg/dl for months and the fact that the patient had to refer herself to an endocrinologist because her PCP did nothing about it. Overall, I really don't like this article. The author is generalizing based on outlier cases. She even admits this: "Of course, there is a selection bias in who comes to me. There are people out there doing just fine on 5000 units of Vitamin D daily. I only see the ones who develop high calcium levels." She uses "hormone" as a sort of scare word, kind of how "chemical" is used in other contexts. Sure, there are some hormones that can be very harmful, but there is nothing inherently wrong about taking hormone supplements, even for an extended period of time, just like there is nothing inherently wrong about consuming "chemicals." I strongly disagree about restricting over the counter vitamin D. Tylenol and ibuprofen lead to thousands of hospital admissions and hundreds of deaths per year, and yet we freely give them over the counter. If vitamin D doesn't meet the threshold for OTC, then basically nothing does. Parts 1 and 3 of the series are better. I agree that the evidence on vitamin D for most things other bone growth in children and osteoporosis is weak. [1] https://www.ccjm.org/content/89/3/154 https://www.ccjm.org/content/89/3/154 ("Increasing and maintaining the 25(OH)D level consistently above 30 ng/mL may require at least 1,500–2,000 IU/day") [2] https://academic.oup.com/jcem/article/96/7/1911/2833671 https://academic.oup.com/jcem/article/96/7/1911/2833671 ("We suggest that all adults who are vitamin D deficient be treated with 50,000 IU of vitamin D2 or vitamin D3 once a week for 8 wk or its equivalent of 6000 IU of vitamin D2 or vitamin D3 daily to achieve a blood level of 25(OH)D above 30 ng/ml, followed by maintenance therapy of 1500–2000 IU/d") [3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912737/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912737/ ("Regardless of initial vitamin D therapy, and assuming no change in lifestyle or diet, a maintenance/prevention daily dose of 800 to 2000 IU or more will be needed to avoid recurrent deficiency")

devaboone 3y ago
I wrote the article because I see cases like hers pretty frequently. She is an outlier in the severity of her symptoms, but not an outlier in getting Vitamin D toxicity from 5,000 units daily. I get at least one patient a week contacting me about their high calcium levels - and when I get into their medical history it is clear that Vitamin D is the cause of the high calcium. In most cases, they are on 5,000 units daily. Some people need higher doses of Vitamin D because they have problems with Vitamin D metabolism. Those people are outliers as well. And there are people who can take 5,000 units of Vitamin D over a prolonged period and still have normal calcium levels. The key here is that they are checking calcium and Vitamin D levels. For most people who need Vitamin D, a dose of 1,000 to 2,000 units daily is more than enough. None of your articles contradict that, and actually that is the dose they are recommending.
- Calavar 3y ago
  I think we're on the same page that this is ultimately an issue of not following up the levels. Actually, it seems that it was worse than that - multiple physicians over a span of four months saw the calcium level > 11 and didn't act on it. (Imagine if it was a hypercalcemia of malignancy with that much diagnostic delay.) I guess your argument is that a medication that requires a provider to order follow up labs shouldn't be OTC. My counter is that there are probably at least one to two orders of magnitude more people hospitalized for NSAID induced renal injury annually than there are people hospitalized for vitamin D induced hypercalcemia. Maybe those people could be saved from renal injury if their PCP followed their creatinine, but if we set the bar at that level than virtually no medication would qualify for OTC. This is an era where patients expect more autonomy, including the ability to self direct treatment with lower risk medications. You're absolutely right that vitamin D shouldn't be billed as zero risk, but it's certainly low risk. As to vitamin D being a hormone, I think that's neither here nor there, especially if the question is whether vitamin D should be available OTC. I think patients tend to mentally translate "hormone" to steroid sex hormones or HGH, since those are the ones that they read and hear about in the media. Those have a lower therapeutic index and broader constellation of side effects than vitamin D does. So even though it is completely accurate to call vitamin D a hormone, it's a term that is overloaded with so much baggage that I don't think it's useful for communicating with laypeople. Anyway, I disagree with those points, but I do think parts 1 and 3 of your article series were quite good. I have to admit that I didn't realize some labs set the upper limit of normal for 25(OH) that high, so part 2 was a learning point for me as well.

devaboone 3y ago

I wrote the article because I see cases like hers pretty frequently. She is an outlier in the severity of her symptoms, but not an outlier in getting Vitamin D toxicity from 5,000 units daily. I get at least one patient a week contacting me about their high calcium levels - and when I get into their medical history it is clear that Vitamin D is the cause of the high calcium. In most cases, they are on 5,000 units daily. Some people need higher doses of Vitamin D because they have problems with Vitamin D metabolism. Those people are outliers as well. And there are people who can take 5,000 units of Vitamin D over a prolonged period and still have normal calcium levels. The key here is that they are checking calcium and Vitamin D levels. For most people who need Vitamin D, a dose of 1,000 to 2,000 units daily is more than enough. None of your articles contradict that, and actually that is the dose they are recommending.

Calavar 3y ago
I think we're on the same page that this is ultimately an issue of not following up the levels. Actually, it seems that it was worse than that - multiple physicians over a span of four months saw the calcium level > 11 and didn't act on it. (Imagine if it was a hypercalcemia of malignancy with that much diagnostic delay.) I guess your argument is that a medication that requires a provider to order follow up labs shouldn't be OTC. My counter is that there are probably at least one to two orders of magnitude more people hospitalized for NSAID induced renal injury annually than there are people hospitalized for vitamin D induced hypercalcemia. Maybe those people could be saved from renal injury if their PCP followed their creatinine, but if we set the bar at that level than virtually no medication would qualify for OTC. This is an era where patients expect more autonomy, including the ability to self direct treatment with lower risk medications. You're absolutely right that vitamin D shouldn't be billed as zero risk, but it's certainly low risk. As to vitamin D being a hormone, I think that's neither here nor there, especially if the question is whether vitamin D should be available OTC. I think patients tend to mentally translate "hormone" to steroid sex hormones or HGH, since those are the ones that they read and hear about in the media. Those have a lower therapeutic index and broader constellation of side effects than vitamin D does. So even though it is completely accurate to call vitamin D a hormone, it's a term that is overloaded with so much baggage that I don't think it's useful for communicating with laypeople. Anyway, I disagree with those points, but I do think parts 1 and 3 of your article series were quite good. I have to admit that I didn't realize some labs set the upper limit of normal for 25(OH) that high, so part 2 was a learning point for me as well.