Vitamin D: GP Tips

GP Tips: Vitamin D supplementation

Who needs what? When do they need it? Where do they get it?

We had lots of questions on the course, and have since, relating to Vitamin D. It’s fair to say that GPs have not really embraced (so far!) the official advice for supplementation to all children, pregnant and breast feeding women and all the over 65s. One of my colleagues with pre-school children recently discussed this in her GP study group, and none of the GPs who were pregnant or have children had embraced this advice for themselves and their own children.  Partly this is due to genuine scepticism about the need and or potential risks and benefits (the rationale is laid out here http://www.dh.gov.uk/health/2012/02/advice-vitamin-d/), but partly I think also because there has been so much confusion about who needs what, when they need it and where you get it. So, we just love to keep things really simple….

 ► What does the NHS actually recommend? And what preparations are available?

 http://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-D.aspx

 ‘Taking 25 mcg or less a day of Vitamin D is unlikely to cause harm’

Group	Recommended daily dose of supplementation	Example products
Pregnant and breast-feeding women	10 mcg ≡ 400 IU Daily	Healthy Start or Pregnacare vitamin tablets
Children aged 6 months to 5 years Breast-fed infants, from 1 month of age IF mother has not taken supplements in pregnancy Babies fed infant formula (which is fortified) do NOT need supplementation until receiving <500ml formula daily	7 – 8.5 mcg ≡ 300 IU	Healthy Start vitamin drops (contain 7.5 mcg per 5 drops) or Abidec drops (contain 10mcg per 0.6mls)
Adults Everyone aged over 65 Other adults who may be at risk e.g. darker skin, poor sun exposure, housebound etc	10 mcg ≡ 400 IU Daily	Standard combinations of calcium and vitamin D containing 10mcg ≡ 400 iu daily (see below) Vitamin D alone supplements available OTC e.g. from Boots, Holland and Barrett etc (10mcg/400 IU and 25 mcg/1,000 IU preparations available)

Note that the calcium component of preparations often leads to poor tolerability (they really do taste of chalk!). Furthermore there have been recent concerns possibly linking calcium supplements with raised MI risk. Vitamin D alone can easily be obtained OTC, for example

·         Boots offer a 12.5 mcg (500IU) and 25 mcg (1,000 IU) supplement

·         Holland and Barrett offer a 10 mcg (400 IU) and 25 mcg (1,000IU) supplement.

·         Sub-lingual sprays supplying 1,000IU daily are also available

And advise patients have a calcium-replete diet

http://www.nos.org.uk/~/document.doc?id=981

 For a full list of all available preparations, see

http://www.nelm.nhs.uk/en/NeLM-Area/Other-Lib-Updates/Drug-Discontinuation-And-Shortage/Vitamin-D---Available--products-for-DOH-recommendations/

►What about treating Vitamin D deficiency?

 This of course is a different issue, and requires treatment with high dose colecalciferol, as discussed by Zoe on the course (see Spring 2012 book for the guideline, p.245).  For example, adults with proven deficiency should have 20,000 IU units 3 per week (60,000IU weekly) for 8-12 weeks followed by 1-2,000 IU daily for 12 weeks.

 When I was a kid, our mothers gave us a tea spoon of cod liver oil (can still taste it – yuk!) and bundled us outside at 9am with instructions to ‘not come home until tea time’. We’d hang around the rec, smoke John Players No. 6 (aged 10…) and try to avoid being attacked by rival gangs. Being beaten up was a constant threat. We were about as relaxed as wilderbeest strolling across the Serengeti. But at least we’d make lots of vitamin D…

Simon

With thanks to Drs Zoe Ballantyne and Cathy Scott

Irritable Bowel Syndrome, GP Tips

GP Tips for IBS

Thanks to Dr Simon Travis, Consultant Gastroenterologist at the John Radcliffe Hospital in Oxford for his expert advice and the GPs of the19 Beaumont Street Journal Club.

 Symptoms and differentials

·         Mucus discharge is a benign symptom, common in IBS

·         Morning diarrhoea/bowel disturbance implies IBS but if diarrhoea persists throughout the day consider referral to exclude other pathology, such as microscopic colitis

·         Nocturnal diarrhoea is pathological until proved otherwise

·         Bacterial overgrowth is implied by previous bowel resection and/or underlying bowel disease and explosive, malodorous diarrhoea with gas and wind and normal CRP. Also seen in elderly and with autonomic neuropathy. A treatment trial with cipro or metronidazole is reasonable if clinical suspicion is strong

Tests

·         FBC, CRP and EMA only essentials. In active Crohn’s a CRP will be raised 90% of the time i.e. few false negatives. ESR is more expensive, and gives little extra value

·         Fancy faecal tests

o   Faecal calprotectin levels. Marketed as a new test for intestinal inflammation, and thus to distinguish IBS from IBD. But at this stage probably not suitable for primary care

o   Faecal fats. Not very useful as false positive rate high. If negative can help rule out malabsorption, but a malabsorption syndrome is clinically diagnosed on basis of diarrhoea and weight loss

o   Faecal elastase (send to biochemistry) is a good test for pancreatic insufficiency

 Gut flora and IBS

·         Huge area of interest at present and highly significant in some types of IBS

·        we are 10% human and 90% gut bacteria…there are so many billions of bacteria in the gut a little pot of yoghurt or single course of antibiotics is unlikely to have much meaningful impact, hence the indifferent results in trials

·     What is more clinically relevant is the substrate the bacteria feed on. Bacteria in the gut ferment carbohydrate, which produces gas. Therefore if bloating is a problem…

 Bloating and IBS

·         Aim to alter the substrate the bacteria feed on, by reducing the amount of resistant starch

·        Resistant starch is more resistant to digestion, and hence will be more likely to be fermented in the colon producing bloating

·         Dietary manipulation therefore aims to reduce resistant starches

o   The longer the shelf-life of the food, the more resistant the starch! E.g. fresh egg pasta will have much less resistant starch than dried pasta, French white bread (goes stale quickly) will have much less than brown, granary bread etc

o   Simple tips: if bloating cut down on carbs, especially complex carbs and resistant starches e.g. low calorie sweeteners/diet drinks, have fresh new potatoes rather than old, eat ripe soft fruit, avoid seeds, avoid preserved and unripe fruit etc. Toasting and cooling carbs increases starch resistance.

o   This explains why some people feel they are gluten intolerant when they do not have coeliac; do not go gluten free, just cut down on complex carbs

·         Golden linseed is effective as it is water soluble fibre. Mix into foods.

Self-help and dietary manipulation

·         Read and recommend the excellent Irritable Bowel Solutions by Prof John Hunter

Simon Curtis

Why this blog?

We're working GPs just like you. We just take the time out each week that you don't have to trawl through all the literature, searching for the 'knowledge' we need to practise effectively, efficiently and enjoably. And we're also interested in 'out of the box' stuff, which relates to being a GP. So, when we come across some useful pearls and nit-bits we'll share them here, with some personal views and opinions. Let us know what you think!

Simon, Zoe, Neal and Michelle

Patient-Based Medicine

PBM: Patient-Based Medicine

"The art of medicine is a literary art. One that requires of the practitioner the ability to listen in a particular way, to empathise, but also to imagine. To try to feel what it must be like to be that other person lying in the sick bed, or sitting across the desk from you. To try to understand the storyteller, as well as the story." Cecil Helman, GP

'Clean clear water transformed health in 19thC; clean clear knowledge will transform health in the 21st Century', Sir Muir Gray

Inspired by both Helman and Gray we aim to practise, and teach, what we apologetically call Patient-Based Medicine. 

For those unfamiliar with it, Suburban Shaman is a wonderful book by the late great GP Cecil Helman (obituary, BMJ2009:339;b2904). He made his name with Culture, Health and Illness but Suburban Shaman is an autobiographical celebration and affirmation of General Practice, an entertaining and funny read. Helman firmly believes in a non-medicalised whole-person model of care, in which the patient’s unique cultural background and circumstances are inseparable from their experience of illness. He sees many similarities with the role we play in the community with that of healers, or shamans, in traditional cultures. He writes ‘beyond the disease is the person, but beyond the person are always the time and place and particular circumstances in which they live and die’.  

We mention this here because NB Medical’s Hot Topics course is all about helping GPs with keep up with ‘the knowledge’: clinical evidence, guidelines and all the other new developments that come our way. We agree with Muir Gray, and believe we really do need to be aware of this information so that we can offer our patients the best treatments available, but all has to be interpreted in the light of the unique circumstances in which we and our patient find yourself.  EBM is often criticized for being reductive, de-personalizing ‘cook book’ medicine but  this is not so as its definition makes clear: ‘EBM is the integration of the best available evidence with our clinical expertise and our patients’ unique values and circumstances’ (EBM2007:12:1). 

As patients we want our doctors to consider us as unique people, rather than conditions, and to try to understand us in our context. But at the same time we really do want them to know that if we turn up with Bell’s Palsy that 50mg of prednisolone for 10 days is an effective treatment. And, if we don’t know, where and how we can find the answer.

We at NB are passionate believers in Patient Based Medicine. This is personalised, patient-centred care based on the best available scientific evidence. Our role is to try to understand our patients, to help them to make sense of their problems and to empower them to make informed choices which are appropriate to them. These choices should be evidence-based, but ultimately it’s ALWAYS the patient’s call.

Simon