1. Spinal Cord Injury and Vitamin D: A Case for Testing and Supplementation Hannah Coakley January 23 rd, 2014

2. What Does Vitamin D Do?

3. 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

4. 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

5. Evaluating the Research: Vitamin D and Bone Density Objective Examine 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

6. Vitamin D and Bone Density Study Population Seven 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

7. Vitamin D and Bone Density Methods Blood/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

8. Vitamin D and Bone Density Results

9. Vitamin D and Bone Density Limitations Very 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

10. Evaluating the Research: Vitamin D Analog Supplementation Objective To determine whether the supplementation of synthetic Vitamin D2 is effective in increasing bone mineral density (BMD) among SCI patients.

11. 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

12. Vitamin D Analog Supplementation Methods 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

13. Vitamin D Analog Supplementation Results

14. 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

15. Comparison of NTx Levels DurationVit D2 (800 IU)Percentage Change Vit D3 (1000 IU)Percentage Change Baseline30 nm BCE---11.7 nm BCE---- 6 months16.2 nm BCE46% decrease8.4 nm BCE32% decrease 12 months17.5 nm BCE8% increase from 6 months 42% decrease overall 8.5 nm BCE1% increase 31% decrease overall

16. 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.

17. 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

18. Pertinent Lab Values/ Trends Vitamin D (Serum) 27.4 (2/13), 23.5 (4/13), 30.8 (8/13)

19. Pertinent Lab Values/ Trends Calcium (Plasma): 8.4 (1/13), 9.5 (7/13), 9.2 (1/14)

20. Anthropometrics & Nutrition Diagnosis Height: 74 in // Weight:241 lb %DBW: 121% Recent weight changes: 9lb weight gain over the past year BMI: 31 on 01/21/14 “Overweight/obesity related to excessive calorie intake as evidenced by diet history and BMI of 31.”

21. 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

22. 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

23. References 1)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.