It is better intramuscular as we can calculate the ideal dose

Would go for oral. Higher patients´compliance due to easier intake.

Dear Ali and Nils,

Tnx.

- There is a negative correlation between the number of consumed pills per day and treatment adherence in IBD patients. Thus, forgetting to consume the vitamin D supplement pills as prescribed is possible.

- On the other hand, vitamin D toxicity is less likely with low doses of vitamin D. Monitoring adverse events is easier with vitamin D pills as they are in dosages of 400 IU to 50,000 IU, while injection dosage is available in 300,000 and 600,000 IU forms.

Therefore, several factors including the patient's preference, patient's treatment adherence, severity of deficiency, and etc. should be consider in this regard.

Try oral treatment first and measure the vitamin D level; if that does not work, use the parenteral route. Since vitamin D is lipid soluble, uptake depends on bile acid mizelles and in Crohns disease there could be a bile acid deficiency. syndrom due to bile acid malabsorption in the terminal ileum.

Intramuscular therapy is better for this patient.

I would also go with oral first. Intersestingly in stable remission IBD the effect of oral D is better during the non sunny months. Measuring vitamin D lvels would help to guide dose and route

Dear Andrew and Harald,

Would you place IBD patients on maintenance D after the treatment of D deficiency? if yes, by which dose?

Although there is controversy about optimum serum 25(OH) D3 levels for non skeletal

diseases, the value of 75nmol/L seems to be desirable for autoimmune diseases. As always there is discussion how best to achieve this. For example patients with severe deficiency may require large Im doses but the majority may achieve this level with 1200 to 4000 IU/d(30-100micrograms/d). Again if possible dosage ideally would be guided by blood levels.

Thank you Andrew

The Hopkins lupus cohort use 40 ng/mL (100 nmol/L) as the target 25(OH)D level for routine clinical care of patients with SLE based on prospective data of 1000 SLE patients, and as you stated and based on the study by Yang et al. (Clin Transl Gastroenterol 2013;4:e33), a dose of up to 5000 IU/d may be required in most of IBD patients to reach and maintain this level.

I think injection is better than oral therapy

Dear Hossein,

We also have a concern with oral therapy as IBD patients consume lots of pills a day and also Crohn's patients has a 30% decreased absorption. But head to head studies shows that the area under the curve for serum 25[OH]D is greater for oral therapy than injection therapy with the same total dose which may be important for IBD patients, though the final level would be the same after about six months. So, we are going to compare oral with injection therapy in a trial this year. If proved to be the same, treatment adherence and patient's preferences should be considered.

Andrew,

Would you monitor the patients during D supplementation with serum Ca or you would check them for urinary Ca as well?

IM, but you can always try mecury lamp.

Check 25OHD for treatment efficiency

For practical reasons I prefer i.m. injections of 100.000 UI Vit.D every 3-4 months since this approach avoids daily administration and ameliarates patient compliance

In my opinion, I.M injection of vit D followed by oral therapy will be more useful to subside patients complaint of body-ache and keep them healthy in the long run. I would also advise to check Vit D level every 6 to 12 months.

There are forms of oral vitamin D designed for those with poorly functioning guts.

Example: Bio-D-Mulsion Forte by Bioteic-Research. Very low cost.

Details are at http://is.gd/gutvitd

I aggree to Andrew`s comments.

Maintainance D-supplementation in IBD patients seems resonable as long as there is active disaese.

I aggree to Andrew`s comments.

Maintainance D-supplementation in IBD patients seems resonable as long as there is active disaese.

I aggree to Andrew`s comments.

Maintainance D-supplementation in IBD patients seems resonable as long as there is active disaese.

Vitamin D for intramuscular administration is not commercially available in the United States.

Major source of vitamin D is sunlight, but we are living in the era of limited sun exposure. Adequate bioavailability of vitamin D from food is very less unless consumption of vit D rich food ( salmon etc). With malabsorption due to concurrent calcium malabsorption--> hyperparathyriodism exacerbate vitamin D deficiency. These patients need higher dose of D2 or D3 daily doses, 25(OH) D level should be checked to evaluate the response of treatment, aiming level > 30ng/ml, followed by maintenance dose. Along with ViT D, calcium supplementation should be done that too may be required in higher doses.

Dear Harald,

Although few studies are conducted on the subject, maintenance vit D is not only benefit for those with active disease but for prevention of relapse in those in remission:

http://www.ncbi.nlm.nih.gov/pubmed/24236989

Also, I guess that vit D supplementation can improve sleep disturbance and psychological distress which are highly frequent in IBD patients:

http://www.ncbi.nlm.nih.gov/pubmed/24494848

According to clinicaltrials.gov there are several active trials on maintenance vit D for IBD and we should wait for the results.

Dear Bandana,

It seems that IBD patients require higher dose of vit D and higher level for optimum benefits than non-patient population not only due to less dietary intake and less absorption but also according to the pathophysiology of the disease. The 2013 Hopkins Lupus Cohort Report recommended 40 ng/ml as the appropriate level for vit D in patients with lupus which is an autoimmune disease somehow like IBD.

http://www.ncbi.nlm.nih.gov/pubmed/23888367

Hope that future studies can determine the optimum serum level of vit D in IBD patients.

As there is no IM form of vitamin D in the United States (?elsewhere) oral vitamin D in appropriate doses should be given. The dose depends on a variety of factors including baseline serum 25OHD, body weight and degree of malabsorption. The latter factor is not accurately measureable.. In general the lower the serum level and the higher the weight the greater the dose will be needed. If necessary a starting dose as high as 50,000 units daily for several weeks could be used followed by serum levels to determine when the level is at least 30 ng/ml. Then a maintenance dose should be chosen to maintain the serum 25OHD above 30 ng/ml. Lower doses would be used in patients with a mild deficit and normal weight. There can be no rigid recommendation because of the great variability between patients.

I agreed with Dr. Mansoor ul Haq.

I don't see UVB lamps as answer in the above discussion. For those of us with long winters there are "tanning salons" where UVB lamps are available commercially and cost is not so high. Concern is that some establishments have switched to UVA-only.

Also, what is known about sub-lingual absorption of vitamin D?