Sir,
We read with great interest the report by Sarma et al. regarding the vitamin D toxicity and hypercalcaemia.[1] Considering that other causes of parathormone (PTH) independent hypercalcaemia are themselves not very common, vitamin D toxicity should figure high in the list of suspected causes.
However, we would like to point out that although the recommended daily allowance of vitamin D is 800 IU/day, the tolerable upper intake level of vitamin D is 4000 IU/day as endorsed by the Institute of Medicine and the Endocrine Practice Committee guidelines.[2] Hence, we suspect that additional intake of vitamin D must be present in the case mentioned by Sarma et al. who reported that the patient was on 2400 IU of vitamin D daily.[1] Since oral vitamin D preparations available in the country exist in strengths of 1000/2000 IU (intended for daily use) as well as 60000 IU (intended for weekly/monthly use in Vitamin D deficiency), such errors in dosing are not uncommon. Further, several physicians still use the 6 lakh units intramuscular injections of vitamin D, ostensibly to eliminate compliance issues.
Further, we would like to mention that vitamin D toxicity responds better to high doses of glucocorticoids (100 mg/day hydrocortisone or equivalent) rather than low dose glucocorticoids.[3] While severe hypercalcaemia may require bisphosphonate therapy, considering the gastrointestinal side effects and slower onset of action of oral bisphosphonates, intravenous bisphosphonates are preferred agents for use in hypercalcaemia.[4]
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REFERENCES
- 1.Sarma A. Vitamin D toxicity presenting with altered sensorium and hypercalcaemia. Indian J Anaesth. 2020;64:909–11. doi: 10.4103/ija.IJA_166_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of vitamin D deficiency: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911–30. doi: 10.1210/jc.2011-0385. [DOI] [PubMed] [Google Scholar]
- 3.Marcinowska-Suchowierska E, Kupisz-Urbańska M, Łukaszkiewicz J, P łudowski P, Jones G. Vitamin D toxicity–A clinical perspective. Front Endocrinol. 2018;9:550–7. doi: 10.3389/fendo.2018.00550. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Turner JJO. Hypercalcaemia – presentation and management. Clin Med. 2017;17:270–3. doi: 10.7861/clinmedicine.17-3-270. [DOI] [PMC free article] [PubMed] [Google Scholar]