AP, a 65-year-old woman, presents to your pharmacy with a question regarding adequate vitamin D ingestion. Upon questioning by the pharmacist, AP admits she spends the majority of her day at work at her desk and does not maintain a well-balanced diet. At her last doctor’s appointment, AP had a low serum 25-OH vitamin D level (<30 ng/ mL). She is concerned that her vitamin D deficiency could lead to osteoporosis and perhaps other negative health consequences. AP is not currently taking any vitamin supplements and would like a recommendation for a product.
As her pharmacist, what advice would you give AP?
CJ, a 78-year-old man, presents to your pharmacy complaining of a rapid heart rate, insomnia, and gradual weight loss. He has been experiencing these symptoms for several weeks, but believed it was related to increased anxiety over his grandson joining the military. You review his medication profile and discover that the patient is currently taking fluoxetine 20 mg, atorvastatin 10 mg, aspirin 81 mg, levothyroxine 150 mcg, and hydrochlorothiazide 25 mg.
Which medication do you believe is the most likely cause of CJ’s recent symptoms?
Case 1: There are many different sources of vitamin D that can be utilized to meet the daily requirements. Vitamin D can be synthesized in the skin after exposure to sunlight. Ten to 15 minutes of midday sun exposure (11 am to 3 pm) is often sufficient; however, synthesis of vitamin D by the skin can vary somewhat based on skin pigmentation, geographic location, and season. Vitamin D can also be absorbed from dietary sources, including fish (salmon, mackerel, sardines), cod liver oil, liver and organ meats, egg yolks, and other foods “fortified” with vitamin D, such as dairy products, orange juice, breads, and cereals. The pharmacist might suggest a vitamin D supplement for patients that have or are concerned about a deficiency. The 2 most commonly available forms are vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol). The Recommended Dietary Allowance of vitamin D, according to the National Osteoporosis Foundation, is 800 to 1000 IU per day for patients 50 years and older. The currently accepted safe maximum dose is 2000 IU per day. This should be taken along with calcium, at a total daily dose of 1200 mg. Guidelines also recommend patients have their vitamin D levels rechecked 3 to 4 months after initiation of therapy.
Case 2: Common signs and symptoms associated with hyperthyroidism or overtreatment with thyroid hormone are nervousness, irritability, palpitations and tachycardia, tremor, weight loss, and insomnia. Thus, CJ’s symptoms are most consistent with drug-induced hyperthyroidism. Elderly patients should typically be started on lower doses of levothyroxine (12.5-25 mcg once daily). The elderly not only have declining endogenous hormone production, but declining drug metabolism and secretion as well. Furthermore, the elderly typically need decreased levothyroxine doses based on their weight, cardiac comorbidities, and the severity and duration of their hypothyroidism. CJ should have a TSH and T4 level drawn to confirm and ensure proper levothyroxine dosing. The dose should be adjusted so serum TSH values range from 0.3 to 3.0 mcIU/mL and a normal free T4 value. Although CJ is a potential candidate for a dose decrease, further evaluation is required due to his history and the range of symptoms. The pharmacist should also suggest CJ speak with his physician about his anxiety, as it cannot be ruled out as a cause of his symptoms.
Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy. Mr. Calamari is a PharmD candidate from the University of Connecticut School of Pharmacy.
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