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Evaluation and use of vitamin D on respiratory symptoms

Posted on: March 23, 2018   by  John Cannell, MD

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In 2014, a patient wrote to me,

Dear Dr. Cannell:

As a way of introducing myself, I have moderate to severe COPD. I quit smoking after my first “exacerbation.” I was in hospital for over a week with intravenous antibiotics etc. Finally released and thought I would be miserable for the rest of my life. Was doing research on Crohn’s disease for my boss and discovered the miracle that is Vitamin D. Needless to say my lifestyle and latitude guaranteed that I was “D”ficient . I began supplementing using the Stoss method for 3 days, 50,000 IU/day of D3, and then 10,000-20,000 daily and I haven’t had a serious exacerbation since then! The last one was in 2007. Yes, I’ve had colds but not something that wasn’t easily remedied with a little more vitamin D, some OC meds and bed rest.

I also get plenty of sunshine in the summer time. Vitamin D has changed my life. Is it a cure for COPD? No, but it is a treatment that all pulmonary specialists should prescribe.

Sincerely,

Robert, McDowell County, West Virginia


Dear Robert,

My father once wrote a poem dedicated to anyone who has gone into McDowell County twice.  I went into it hundreds of times. I never got used to the slag piles, which looked to me like bombed out WW2 cities.

When I was a ER doc and family practitioner in the coal fields of Southern West Virginia, I saw one patient after another with adult asthma and/or chronic bronchitis (COPD), not to mention Black Lung. They complained of almost constant shortness of breath, like they were drowning; I remember thinking, I don’t want to ever feel like I’m constantly drowning.  COPD gets worse over time. I treated them with bronchodilators, and occasionally steroids but such treatment does not change the unrelenting progression towards a terrible death.

Eventually everyday activities, such as walking or getting dressed, become difficult. It affects almost 5% of the world’s population and, in the US, is associated with smoking; in the developing world it is also associated with breathing the smoke of indoor cooking stoves. In the developing world air pollution is a major cause of COPD but, since President John Kennedy’s Clean Air Act, that association in the USA has weakened.

What has not weakened is the association between urban residence and COPD. In the world, urban dwellers have a COPD prevalence of 13% and among rural dwellers the prevalence is about 9%. Why has the urban/rural difference not changed during the time air pollution in the USA lessened? Perhaps because the urban/rural differences in COPD were not due to air pollution, but another risk factor.

A recent large study from Australia found most adult COPD (chronic bronchitis and asthma) is highly associated with vitamin D levels.

Mulrennan S, Knuiman M, Walsh JP, Hui J, Hunter M, Divitini M, Zhu K, Cooke BR, Musk AWB, James A. Vitamin D and respiratory health in the Busselton Healthy Ageing Study. Respirology. 2018 Jan 24. 

Overall, mean vitamin D level of these COPD (chronic obstructive pulmonary disease) was 24 ng/m; 8% had vitamin D level <20 ng/ml; 73% had level 20-40 ng/ml and almost 20% had levels above 40 ng/ml. This study was conducted in Australia, which is closer to the equator than the US, but levels above 40 ng/ml due to incidental sun exposure are not common; indeed 12% of these COPD patients were taking supplemental vitamin D.  This means 20% of COPD patients have adequate levels of vitamin D (>40ng/ml). While 12% or 20% may not sound like a lot, fifteen years ago, before the Vitamin D Council was formed, it may have been < 5%.

This study found low level of vitamin D were significantly associated with asthma (Odds Ratio: OR: 1.54), bronchitis (OR: 1.68), sleep apnea (OR: 1.57), wheezing (OR: 1.57), shortness of breath (OR: 1.45), and chest tightness (OR: 1.52). The tests of lung function showed that levels < 40 ng/ml) were associated with significantly higher FEV1 and FVC (tests of lung function).

The authors wrote,

“Assessment of the relationship between vitamin D and respiratory outcomes demonstrated a clear association between lower vitamin D levels and rates of reported asthma, bronchitis and respiratory symptoms, irrespective of smoking status.”

The mean FVC (how much air one can blow out) was higher in those with a vitamin D level >40 ng/ml as compared to those with vitamin D levels between 20 and 40 ng/ml. Even after adjusting for a number of conditions that are associated both with both COPD and vitamin D, the OR remained high. One test of lung function showed an association of -1.83; much worse results in subjects with 25(OH)D <20 ng/ml but much better (coefficient: 2.64) in subjects with 25(OH)D > 40 ng/ml, the minimum vitamin D level the American Endocrine Society and we recommend.

(As an aside, all readers who think the Endocrine Society only recommended levels > 30 ng/ml, out to beware.  They said > 30 ng/ml in their abstract but the body of the paper recommended levels above 40 ng/ml. So, if you say >30/ng/ml, you appear to have only read the abstract.)

I could find a number of controlled trials of using vitamin D in COPD patients. All the ones I could find showed vitamin D helps various symptoms associated with COPD.  I have blogged on several of those in the past:

https://www.vitamindcouncil.org/rct-vitamin-d-improves-exercise-tolerance-in-copd-patients/

We know COPD patients with lower baseline 25(OH)D levels deteriorate quicker:

Persson LJ, Aanerud M, Hiemstra PS, Michelsen AE, Ueland T, Hardie JA, Aukrust P, Bakke PS, Eagan TM. Vitamin D, Vitamin D Binding Protein, and Longitudinal Outcomes in COPD. PLoS One. 2015 Mar 24;10(3):e0121622.

What do these numbers mean? In our opinion, patients with COPD should walk as fast as they can (not run) to their nearest drug store or internet supplier and take 10,000 IU (250 mcg)/day. Recent studies show 5,000 IU (125 mcg)/ day) is often not enough to get 25(OH)D above 40 ng/ml. While it is true that no study using 250 mcg/day have been done on COPD, that fact should only be important to scientists, not physicians.

Scientists are dedicated to finding the truth, not treating patients, and often give terrible advice to physicians, who care for COPD patients. The scientists often say or imply that vitamin D should not be given until science (beyond a reasonable doubt) that it helps. If physicians listen to that advice, they are violating the tenants of Evidence Based Medicine, which clearly state physicians are obligated to act using the “best available evidence.” Physicians cannot afford the luxury of waiting until scientists prove something beyond a reasonable doubt. We (physicians) are charged with treating patients based on what is known now, using the “potential benefit vs. potential risk,” the equation we have used for centuries.

As 10,000 IU (250 mcg)/day has never been shown to cause harm, has been used in a number of studies without harm and was the now defunct Food and Nutrition Board’s NOAEL (the dose has never been associated with harm), we believe physicians are obligated, both ethically, legally and using the tenants of Evidence Based Medicine, to recommend and use 10,000 IU (250 mcg)/day on their COPD patients.

Since I stopped smoking as a young man, I don’t have symptoms of COPD as I age. But I remember COPD patients pleading for help, pleading for me to stop that constant feeling of drowning.  I could help acutely but I couldn’t do anything to help the unrelenting disease process. Perhaps that’s because I didn’t put them on higher doses of vitamin D?

 

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