spring 2009

C L I N I C A L   P R A C T I C E
New utilization rules for vitamin D testing

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 Enforcement of strict utilization rules are necessary to control costs and ensure that 25 hydroxy-vitamin D remains available to patients for whom there is good evidence for a benefit.

By Dr. Edward Randell

Laboratories across the country have been experiencing increasing workloads for 25 hydroxy-vitamin D testing. This has mainly come from increased public interest in recent publications showing associations between vitamin D status and risk for various diseases ranging from multiple sclerosis to certain types of cancer. However, 25 hydroxy-vitamin D testing is very costly and there is no evidence to support widespread screening for vitamin D insufficiency. Therefore, enforcement of strict utilization rules has become necessary to control costs and to ensure that 25 hydroxy-vitamin D remains available to patients for whom there is good evidence for a benefit.

The role for vitamin D status testing in individuals at high risk for bone related disease is well established. Hence, measurement of serum 25 hydroxy-vitamin D levels is reserved for patients with clinical symptoms or who are at increased risk for developing osteoporosis or osteopenia. This includes patients with fat malabsorption syndromes, impaired liver function, or who are home-bound and institutionalized, and in whom supplementation with therapeutic doses of vitamin D is being considered and monitoring is required. The monitoring interval in such individuals should not be less than 3 months since achievement of stable blood levels typically requires several months of supplementation. Once stable and adequate blood levels are achieved in these patients, annual or less frequent monitoring is sufficient.

To get vitamin D status tested in patients where it is necessary the standard laboratory requisition must be completed. An acceptable reason for testing must also be included in the clinical diagnosis section of the requisition. The following are accepted responses: Ordered by an endocrinologist (with the name of the specialist indicated); Receiving daily vitamin D supplementation of >2000 IU for >6 months; at high risk or being treated for Osteomalacia/Rickets; at high risk or being treated for Osteoporosis/Osteopenia; or unexplained hyper/hypocalcemia. Patients presenting to blood collection sites without one of these indicated on the requisition will not have a sample collected for vitamin D testing.

Outright vitamin D deficiency resulting in osteomalacia and rickets is relatively rare, but usually occurs when blood levels of 25 hydroxy-vitamin D decrease to below 25 nmol/L. Recent studies, however, suggest that optimal supplementation and reduction of fracture risk may be indicated by serum 25 hydroxy-vitamin D levels greater than 90 nmol/L. Individuals living at higher latitudes generally have 25 hydroxy-vitamin D levels lower than this, unless they are receiving regular supplements of vitamin D (>1000 IU/day).

This is especially true during winter months when 25 hydroxy-vitamin D levels typically fall to about 15 nmol/L below peak summer levels. Not surprisingly, almost 80 per cent of the province’s population getting vitamin D status tested are insufficient during peak summer months compared with about 90% during winter months. Testing of vitamin D status is not necessary to determine the need for supplementation and a decision to supplement can be safely made without vitamin D status testing.

Edward Randell, Ph.D., DCC, FCACB is Chief of the Division of Biochemical Pathology at the Health Sciences Centre and is Associate Professor, Laboratory Medicine with the Faculty of Medicine at Memorial University. He may be reached at Ed.Randell@easternhealth.ca



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