Vitamin D deficiency as a cause of chronic pain in the palliative medicine clinic: two case reports

Vitamin D Deficiency and Unclear Abdominal Pain in Patients from Low- and Middle-Income Countries

Background: Abdominal pain is one of the commonest symptoms in emergency departments (EDs). Diagnosis demands full attention and critical thinking, since many diseases manifest atypically and the consequences of overlooking the symptoms may be disastrous. Despite intensive diagnostic procedures, some cases remain elusive and unclear abdominal pain (UAP) is not infrequent. Emerging evidence supports the hypothesis that functional pain might be attributed to vitamin D deficiency (VDD). People with darker or covered skin are predisposed to developing VDD. Patients in Switzerland stemming from low- and middle-income countries (LMIC) are such a population. Aim: To identify cases with UAP in LMIC patients and to compare vitamin D status with a control group. Methods: A retrospective single-center case-control study was carried out from 1 January 2013 to 31 August 2016 in all adult patients (more than 16 years old) stemming from LMIC and presenting at the university ED of Bern with abdominal pain. Vitamin D status was retrieved from these cases when available. The control group consisted of patients without abdominal pain or metabolic diseases and was matched (1:1) to the cases for age, gender, body mass index, geographic distribution, and season of vitamin D estimation. Results: A total of 10,308 cases from LMIC were reported to the ED. In total, 223 cases were identified with UAP. The status of vitamin D was available for 27 patients; 27 matched individuals were subsequently retrieved for the control group. Women made up 56.7% of the UAP group and 43.3% of the control group. The most common origin of the LMIC subjects was southern Europe (20.4%), followed by southern Asia (16.7%) and Eastern Europe (13%). Fourteen UAP patients exhibited severe VDD (<25 nmol/L) versus one in the control group (p = 0.001). The difference remained significant if the patients were identified as having VDD (<50 nmol/L) or not (p = 0.024). Comparison of the means indicated that the UAP group had lower vitamin D levels than the control group (41.3 vs. 53.7 nmol/L, respectively), but this difference was marginal (p = 0.060) and not statistically significant. After adjustment for potential confounders, including gender, mean vitamin D levels remained non-significantly different between groups. In the sub-group analysis, vitamin D levels were lower in women than in men (p = 0.037), compared to the respective controls. Conclusion: This study showed for the first time that patients from LMIC who presented to ED with UAP displayed VDD. Validation from larger studies is warranted to evaluate the linkage of VDD with UAP.

Blood concentrations of vitamins B1, B6, B12, C and D and folate in palliative care patients: Results of a cross-sectional study

Objective

The main purpose of palliative care is symptom relief. Frequently, the symptoms of patients requiring palliative care are the same as common symptoms of vitamin deficiency (e.g. pain, weakness, fatigue, depression). The study aim was to investigate whether patients in palliative care are vitamin deficient.

Method

This was a monocentre cross-sectional study. Patients attending the palliative care unit of a general hospital in Germany from October 2015 to April 2016 were examined for vitamin blood concentrations and symptoms. Data were analysed using univariate analysis and bivariate correlations.

Results

Data were available from 31 patients. Vitamin D3 deficiency (<62.5 nmol/L) affected 93.5% of patients, vitamin B6 deficiency (<4.1 ng/mL) 48.4%, vitamin C deficiency (<4.5 mg/L) 45.2%, vitamin B1 deficiency (<35 µg/L) 25.8% and vitamin B12 deficiency (<193 pg/mL) 12.9%. There was a significant negative correlation between vitamin B1 ranges and pain (r = −0.384) and depression (r = −0.439) symptoms.

Conclusion

All patients showed a deficiency in at least one of the measured vitamins; 68% had concurrent deficiencies in >1 vitamin. A follow-up study using validated questionnaires and a larger sample is needed to investigate the effects of targeted vitamin supplementation on quality of life and symptom burden.

Treating Vitamin D Deficiency and Insufficiency in Chronic Neck and Back Pain and Muscle Spasm: A Case Series

INTRODUCTION

The association between vitamin D deficiency or insufficiency and pain in the musculoskeletal system, especially in the neck and/or back regions, and/or muscle spasm is not well studied. The results of the limited studies have been mixed.

CASE PRESENTATION

The goal of this report is to examine the association between vitamin D deficiency and insufficiency and chronic neck and back pain and muscle spasm and the role of correction of vitamin D deficiency and insufficiency in the treatment of chronic pain and muscle spasm, especially in the neck and back regions. This case series reviewed medical records to identify patients with chronic pain (lasting from 6 months to 1 year) in the neck and back regions that improved significantly through the correction of the vitamin D deficiency or insufficiency. Patients were referred to the spine clinic of a tertiary hospital in a major metropolitan area in the Northwest by their primary care physicians after physical therapy and after first-tier pain medications, including nonsteroidal anti-inflammatory drugs, had failed. Some of the patients had epidural steroid injections without significant relief. The blood vitamin D level was tested at the clinical laboratory, and patients were given 50,000 IU of oral vitamin D once a week for 12 weeks. The main outcome measures were patient self-reported visual analog scale score and degree of muscle spasm. The 4 patients included in this series all had more than 70% improvement in their symptoms after taking 50,000 IU of vitamin D once a week for 12 weeks.

DISCUSSION

Vitamin D deficiency and insufficiency can cause or worsen neck and back pain and muscle spasm. The correction of vitamin D deficiency and insufficiency plays an important role in the treatment of chronic neck and back pain and muscle spasm among patients having concurrent vitamin D deficiency and insufficiency because it can be prevented and treated easily.Given the high health care expenditure on the treatment of chronic neck and back pain, prompt and accurate diagnosis and treatment of vitamin D deficiency and insufficiency not only increase the quality of care but also reduce the cost.

Vitamin D deficiency is associated with tibial bone pain and tenderness. A possible contributive role

BACKGROUND

Vitamin D deficiency is associated with osteomalacia and a variety of musculoskeletal pain. This study aimed to determine the association of vitamin D deficiency with tibial bone pain and tenderness.

METHODS

Patients with leg pain, defined as local pain and tenderness over tibial bones for ≥ 6 weeks were consecutively selected. Secondary causes of pain were excluded by appropriate clinical, radiological and laboratory examinations. Serum 25-hydroxyvitamin D (25-OHD) was assessed by enzyme-linked immunosorbent assay method and levels < 20 ng/mL were considered as deficiency. Age- and sex-matched subjects without leg pain served as controls. Multiple logistic regression analysis was used to determine associations.

RESULTS

One hundred and eighteen patients and 114 controls aged 46.8 ± 14.8 and 44.6 ± 14.1 years, respectively (P = 0.93) were analyzed. Mean 25-OHD level was significantly lower (P = 0.001) and the prevalence of 25-OHD deficiency was significantly higher in the patients as compared with the controls (75.4% vs. 23.6%), odds ratio (OR) = 9.54 (95% CI, 5.22-17.45, P = 0.001). There was a negative dose-response relationship between serum 25-OHD and tibial bone pain by OR = 17.33 (95% CI, 6.48-46.3) in subjects with 25-OHD < 10 ng/mL, and OR = 14.7 (95% CI, 6.35-34.6) in serum 25-OHD levels at 10-19.9 ng/mL, and OR = 2.58 (95% CI, 1.08-6.1) in those with 25-OHD at 20-29.9 ng/mL as compared with 25-OHD ≥ 30 ng/mL. After controlling for demographic and biochemical factors, the association reached a stronger level of 19.8 (6.9-56.3) in subjects with serum 25-OHD < 10 ng/mL and 14.4 (5.8-34.6) in those with serum 25-OHD at levels of 10-19.9 ng/mL and 1.85 (0.73-4.6) in 20-29 ng/mL.

CONCLUSION

These findings indicate a possible contributive role for serum 25-OHD deficiency in the development of pain and tenderness over the tibial bone.

Vitamin D in Pain Management

Vitamin D is a hormone synthesized in the skin in the presence of sunlight. Like other hormones, vitamin D plays a role in a wide range of processes in the body. Here we review the possible role of vitamin D in nociceptive and inflammatory pain. In observational studies, low vitamin D levels have been associated with increased pain and higher opioid doses. Recent interventional studies have shown promising effects of vitamin D supplementation on cancer pain and muscular pain-but only in patients with insufficient levels of vitamin D when starting intervention. Possible mechanisms for vitamin D in pain management are the anti-inflammatory effects mediated by reduced cytokine and prostaglandin release and effects on T-cell responses. The recent finding of vitamin D-mediated inhibition of Prostaglandin E2 (PGE2) is especially interesting and exhibits a credible mechanistic explanation. Having reviewed current literature, we suggest that patients with deficient levels defined as 25-hydroxyvitamin D (25-OHD) levels <30 nmol/L are most likely to benefit from supplementation, while individuals with 25-OHD >50 nmol/L probably have little benefit from supplementation. Our conclusion is that vitamin D may constitute a safe, simple and potentially beneficial way to reduce pain among patients with vitamin D deficiency, but that more randomized and placebo-controlled studies are needed before any firm conclusions can be drawn.

Vitamin D supplementation to palliative cancer patients shows positive effects on pain and infections-Results from a matched case-control study

BACKGROUND

We previously showed an association between low vitamin D levels and high opioid doses to alleviate pain in palliative cancer patients. The aim of this case-controlled study was to investigate if vitamin D supplementation could improve pain management, quality of life (QoL) and decrease infections in palliative cancer patients.

METHODS

Thirty-nine palliative cancer patients with levels of 25-hydroxyvitamin D < 75 nmol/L were supplemented with vitamin D 4000 IE/day, and were compared to 39 untreated, matched "control"-patients from a previous study at the same ward. Opioid doses, antibiotic consumption and QoL-scores measured with the Edmonton Symptom Assessment Scale (ESAS) were monitored. The primary endpoint was the change from baseline after 1 and 3 months compared between the groups using linear regression with adjustment for a potential cofounding factor.

RESULTS

After 1 month the vitamin D treated group had a significantly decreased fentanyl dose compared to the untreated group with a difference of 46 μg/h; 95% CI 24-78, which increased further at 3 months to 91 μg/h; 95% CI 56-140 μg/h. The ESAS QoL-score improved in the Vitamin D group the first month; -1.4; 95% CI -2.6 - (-0.21). The vitamin D-treated group had significantly lower consumption of antibiotics after 3 months compared to the untreated group, the difference was -26%; 95%CI -0.41%-(-0.12%). Vitamin D was well tolerated by all patients and no adverse events were reported.

CONCLUSION

Vitamin D supplementation to palliative cancer patients is safe and improvement in pain management is noted as early as 1 month after treatment. Decreased infections are noted 3 months after vitamin D treatment. The results from this pilot-study have been used for the power-calculation of a future randomized, placebo-controlled, double-blind study called "Palliative-D" that will start in Nov 2017 and will include 254 palliative cancer patients.

Vitamin D and patients with palliative cancer

Vitamin D is a hormone that is synthesised in the skin in the presence of sunlight. Sufficient vitamin D levels are important-not only for a healthy skeleton-but also for a healthy immune system. Many patients with cancer have insufficient vitamin D levels, and low vitamin D levels are associated with increased 'all-cause mortality' and especially mortality due to cancer. Low vitamin D levels have also been associated with increased risk of infections, increased pain, depressive disorders and impaired quality of life. We review the role of vitamin D in the immune system, in relation to cancer disease, pain and depression. We have recently performed an observational study in 100 patients with palliative cancer in Sweden. The main result was that low vitamin D levels were associated with higher opioid dose, that is, more pain. We also describe a case report where vitamin D supplementation resulted in radically decreased opioid dose, less pain and better well-being. Vitamin D supplementation is not connected with any adverse side effects and is easy to administrate. Thus, we hypothesise that vitamin D-supplementation to patients with palliative cancer might be beneficial and could improve their well-being, decrease pain and reduce susceptibility to infections. However, more clinical studies in this field are needed before firm conclusions can be drawn.

Low vitamin D levels are associated with higher opioid dose in palliative cancer patients--results from an observational study in Sweden

Background

Vitamin D deficiency is common among palliative cancer patients and has been connected to an increased risk for pain, depressions and infections. Therefore we wanted to test the hypothesis that low 25-hydroxyvitamin D (25OHD) levels are associated with higher opioid dose, higher infectious burden and impaired quality of life in palliative cancer patients. The secondary aim was to investigate the association between 25OHD-levels and survival time.

Method

In this prospective, observational study in palliative cancer-patients (n = 100) we performed univariate and multiple linear regression analysis to assess the association of 25OHD levels with opioid dose, infectious burden (antibiotic consumption), quality of life (Edmonton Symptom Assessment Scale, ESAS) and survival time, controlling for potential confounding factors.

Results

The median 25OHD level was 40 nmol/L (range 8-154 nmol/L). There was a significant association between 25OHD levels and opioid dose, beta coefficient -0.67; p=0.02; i.e. a low 25OHD level was associated with a higher opioid dose. This association remained significant after adjustment for stage of the cancer disease in a multivariate analysis, beta coefficient -0.66; p = 0.04. There was no association between 25OHD levels and antibiotic use or quality of life. Univariate cox regression analysis showed a weak correlation between survival time and 25OHD levels (p<0.05). However, decreased albumin levels and increased CRP levels were superior markers to predict survival time; p<0.001 for both analyses.

Conclusion

Low 25OHD-levels are associated with increased opioid consumption in palliative cancer patients. Future interventional studies are needed to investigate if pain can be reduced by vitamin D supplementation in these patients. In addition, this study confirms previous findings that low albumin and increased CRP levels are useful markers for survival time in palliative cancer patients.