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Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken?

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Endocrinologist
Practicing since : 2002
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Hi! Doctor, My father is 61 years old and is having around 60kg weight, he was feeling pain in his complete body since last December, we have gone for number of tests CT Abdominal, Ultrasound, sugar, Protein AG etc all tests were with good result. One of physian suggested to go for Vitamin D test and the result was 24.90nmo/l, calcium was 9.20 mg/dL, phosphorous serum was 3.90 mg/dl, so doctor advised him to take 0000IU XXXXXXX for 4 weeks with milk + 250 mg calcium carbonate and after 4weeks+10days we have again gone for test and the result was 99nmo/l, calcium 9.60mg/dL, phosphorous 3.90 mg/dl, I have a couple of questions: 1.) After taking XXXXXXX he feels pain in complete body and then feels good for next 2-3 days and then again starts feeling pain, is it normal or something more needs to be taken care? 2.) Looking at current Vit D level do he need to go for 2-3 weeks more with VitD 0000IU dosage? Please suggest
Posted Mon, 30 Jul 2012 in Thyroid Problem and Hormonal Problems
 
 
Answered by Dr. Anantharaman 42 minutes later
Hi,

Thanks for your query.

Your father did have a low vitamin D level and he has been treated appropriately for the same. The question that you have - whether it is vitamin D deficiency alone or there could be some other problem? Is a difficult one to answer.
Usually if the symptoms are because of vitamin D deficiency and osteomalacia the symptoms will take about 3-6 months to completely resolve. This is because the new healthy bone takes that many days to replace older unhealthy bone which is causing pain.

We have not reached that time point and we could wait and persist with our vitamin d treatment and look for improvement. It will be a good idea to check the phosphate level and the alkaline phosphatase level. The phosphate should increase slightly and the alkaline phosphatase should decrease. Since you are saying that he has been extensively evaluated for the bone pain it would seem a reasonable approach to me to wait. If after 4 months of treatment the symptoms worsen then there is definitely need to evaluate again

Usually vitamin D is given weekly for 6 weeks followed by fortnightly. The repeat levels of vitamin D that have been measured are in the healthy range and are not likely to go up very high. I think he should take 2-3 weeks more of vitamin D weekly and thereafter fortnightly once as suggested by your doctor.

I hope my advice was useful. Please do write back in case of further queries.

Regards
Anantharaman
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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 1 hour later
Thanks for your reply.. Alkaline phosphate was 55 u/l in first test and Phosphorous serum was 3.90 in 2nd time test Alkaline phosphate is 66U/L and phosphorous is the same. Please suggest as alkaline phosphate has increased but ref range is 30-120 which is well in limit..
 
 
Answered by Dr. Anantharaman 2 hours later
Hi,
Thanks for writing in.
If the alkaline phosphatase is normal, we go for a test known as bone specific alkaline phosphatase. Sometime this situation can happen because the alkaline phosphatase comes from two sources bone and liver which adds upto to total alkaline phosphatase level. Sometimes it may so happen that the bone component is more but the liver component is less making the total level normal. It will be a good idea to get the bone specific alkaline phosphatase level . It will also address your basic doubt whether the problem we are dealing with is a vitamin D deficiency bone disease. In case of vitamin D deficiency disease the bone specific alkaline phosphatase will always be high.
I would like to clarify my earlier response saying that the alkaline phosphatase may go down. It does go down but after an initial increase especially in the first month. The phosphate remaining the same is a bit unusual but may be there if the initial levels are normal. In any case, careful follow up with treatment of vitamin D levels is probably what we should pursue. I want to see any radiographs (Xrays) of his bones if they have been taken it may give me some clues regarding the bone disease.
Regards
Dr. Anantharaman



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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 56 minutes later
Thanks doctor for your responce, may be I sound stupid but please bare, as I am not a medico person infact working for Ranbaxy Labs Ltd. R&D Division for last 4 years, what I got is
1.) Alkaline phosphatase for bone needs to be done and it should come high if some bone desease is there I have a question but if decease is not there and Vit D was low because of mull nutrition(as my father is pure vegetarian and vit d is very rare in veg and exposer to sunlight is avoided now a days by all of us) then?
2.) In first month alkaline phosphatase will go up and then will come down in subsiquent months am I rite?
3.) Because the phosphate level was normal so may be the phosphate was same in both tests am I rite?
4.) If I need to share X-Ray how I need to do the same?

Thanks & Regards XXXXXXX
 
 
Answered by Dr. Anantharaman 2 hours later
Hi,
You are welcome to clarify your doubts-that's the whole point of this forum. I’ll give answers question wise
1. You can do a bone alkaline phosphatase that will help us in finding out if there is bone disease or not. The levels of vitamin D your father is not rare in the general population. About 50 percent will have levels like these. Even if you do take non vegetarian diet, there is no vitamin D in that as well. The main source for vitamin D is sunlight and vitamin D added to food as fortification.
2.and 3 Yes you have understood me correctly
4. You can scan the X-rays and send if you have digital X-rays you can send them directly as file attachment. You can directly upload the reports using ‘Upload your reports’ section on the right. Or you can send them to me at YYYY@YYYY . In the subject line, please write Attention to Dr Anantharaman

Regards
Anantharaman
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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 11 days later
Hi Doctor,
I have two query actually after 8-9days of taking 0000IU XXXXXXX dad feels weakness and losness on his body is that normal or some side affect?
As he has now taken XXXXXXX for 6 weeks and we are giving a break 4 a month is a maintenance dose required?
please suggest
regards XXXXXXX
 
 
Answered by Dr. Anantharaman 8 hours later
Hi XXXXXXX

Thanks for writing in your doubt.

Weekly once dose of 0000 units if taken for 6-8 weeks does not produce any side effects, the repeat vitamin D that you have done is normal.

The weakness and fatigue your father is feeling is not probably related to vit D dose.

Answer to second question:

Yes he does require a maintenance dose usually 0000 IU taken once every 15 days.

I again want to reiterate that if symptoms don't improve by this month end he requires a re-evaluation by the endocrinologist to see if there is any other problem.

Regards
Anantharaman
Above answer was peer-reviewed by
 
Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 3 hours later
Dear Doctor,
Thanks for your response.
Greeting’s of the Day.
Yes as per your earlier advice he should start feeling better after first 3 months, we have been monitoring him closely for that, as it has been only 1.5 months now and he says that he has been bit relived with pain not much what he is complaining of weakness and looseness.
What he claims is that he feels better after taking the dosage for 8-10 days and start feeling weakness and looseness once he stops taking dosage. As we have given a 15 days gaps after 4 weeks and he was feeling the same at that time now we have again been giving a break of 15 days he has started feeling the same. Please suggest do these symptoms come after taking such a high dosage and may disappear in day or two, as it would have pushed a lot of energy in your bones muscles and gets relaxed after that , may be not side effects but general symptoms.
As I have read this at a number of places one of the symptoms after 10-11 days of taking high dosage is constipation for a day and two and then gets regularized after that, and we have experienced the same that he gets constipated for a day or two and then starts passing the motin normally.

Please suggest .
Regards XXXXXXX
 
 
Answered by Dr. Anantharaman 20 hours later
Hi,
Thanks for writing in detail about your fathers symptoms. There can be a waxing and waning(increase and decrease) of symptoms in any long standing problem. The vitamin D levels achieved after treatment are in normal range. Like you have observed closely the weakness may be related to fluctuating levels of phosphate or calcium which can cause such symptoms. Over a period of three months I expect even these symptoms to improve. Continue the fortnightly vitamin D till that time. You don't have to worry about any significant problem because of these symptoms
Regards
Anantharaman
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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 9 days later
Dear Doctor,
Greetings of the day, I have some queries as we have again gone for all tests in this month (It has been 2 months now) and have the following result:
1.) Alkaline phosphate has gone down from 66 U/L to 63 U/L this month.
2.) Phosphorous has gone up from 3.90 mg/dl to 4.0 mg/dl this month.
3.) Vitamin D has gone up from 99 nmo/l to 101 nmo/l this month.
4.) Calcium has gone down from 9.60 mg/dl to 9.40 mg/dl this month.
4.) We have gone for other tests like HBA1C which was 5.5 and Thyroid Profile/Urine/Testosterone etc and all are well within range.

I have few queries regarding the same
1.) As now he is taking Vitamin D 2000IU per day and 1 gm of calcium, is it the right amount or he needs to add on more into Vitamin D?
2.) As taking more calcium (1gm) and he is bit worried about his health, he is a bit constipated(It’s not choked completely but he complains that he feels a bit constipated), so should he take something parallel to calcium so that he be relieved from constipation completely?
3.) He is still feeling more week what should he do get relived and if he feels a bit of pain what should he be taking for that?

(I would also like to bring to your notice we have taken CT and Ultrasound in month of XXXXXXX 2012 for Whole Abdominal and the result was normal, as well as for prostate the tests were normal, So we don’t have any doubts about any form of malignancy)

Please suggest

Regards XXXXXXX
 
 
Answered by Dr. Anantharaman 43 minutes later
Hi XXXXXXX

Thanks for writing back.

1) Regarding vitamin D deficiency and calcium induced constipation: his Vitamin D deficiency seems to have resolved as all the changes that we predicted are happening including the increase in vitamin D level (which is now in the normal range). He now needs to take vitamin D 60,000 IU once every 15 days. You can reduce the calcium dose to 500 mg per day and increase calcium XXXXXXX foods in the diet- yoghurt, paneer, raagi, fruits etc. In addition, a diet XXXXXXX in fiber will normalize the motions. The changes in the dosages need to be made after consulting and discussing with the treating doctor.

2) Regarding his feeling of weakness, it is very non-specific. Kindly upload all the reports you have so that I can have a look at them.

You have a feature to upload the reports / image by yourself at the right side of the query page, please utilize that so that I can answer your queries better.

If I am not able to find any significant problem, then you will have to consult your physician again who has to review the history and re-examine him.

Regards
Anantharaman
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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 3 hours later
Dear Doctor,

Thanks for your responce, I have uploaded the reports for last 6-7 months since he has started feeling more pain, the details of reports are:
Dec2011-Jan2012 : BloodTest/Ultrasound Abdomen/HBA1C/ABG/BariumSwallow/CT Abdomen
May2012: Alkaline Phosphate/Calcium/Phosphorous/Vitamin D/HBA1C
Jun2012 : Hemoglobin/Glucose, Fasting/ Uric Acid/Alkaline Phosphate/ALP, Protein/Calcium/Phosphorous/Vitamin D
Jul2012: Alkaline Phosphate/ALP/Calcium Serum/Phosphorous/Testosterone/Vitamin D/Thyroid/Urine

As the vitamin D was pointed out by doctor in month of May2012 and then since we are on that treatment earlier we were just looking on for something or the other.
As he was taking 450 mg calcium only upto 4-5 days back but my doctor placed him on daily calcium and vitamin with a capsule twice a day which is having 500mg Calcium and 1000IU VitD3.
1.) As per your suggestion should I make it once a day and VitD 1000IU alone in place of second after consulting my doctor?
2.) As he is very poor with his eating habbits, so is there any medicine for Fibers which can be taken on daily basis till the time calcium is been taken in such amount..

Regards XXXXXXX
 
 
Answered by Dr. Anantharaman 18 hours later
Hi XXXXXXX

I went through all the reports in detail.

1) Based on his symptoms I suggest you get a prostatic specific antigen (PSA) test in view of age and mildly enlarged prostate. Also a serum protein Electrophoresis to look for any multiple myeloma and thyroid function test (T3, T4, and TSH) may be needed.

2) I suggest you review with your treating doctor and see if he can take only one tablet of calcium 500 + vitamin D 1000 IU because of constipation

3) You can ask your doctor regarding Isaphgul husk for treatment of constipation.

Hope I have answered your query.

Regards
Anantharaman
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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 6 hours later
Dear Doctor,
Thanks for your reply.
We have done PSA and it was nomal, Thyroid test is also there in July 2012 report that to was in normal range, serum protein was also tested in XXXXXXX report which was normal.
I had a word with my doctor he has changed a dose with VitD and Methylcolbamin in place of calcium. What do u say about this change?
Any other sugestions,Plz share. If we are missing out smthng.

Regards XXXXXXX
 
 
Answered by Dr. Anantharaman 17 hours later
Hi,

Thanks for writing in.

I noticed the TSH report now it's normal.

I would like a serum protein electrophoresis - which is different from serum protein. It's done to rule out multiple myeloma which can be a cause of bone pains.

As far as B12 is concerned you can take it as advised by your doctor.

I'm reassured by the normal PSA report.

Regards
Anantharaman
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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 2 days later
Dear Doctor,
Thanks for reply.
Actually my Dad is complaining not of only bone pain he is complaining weakness in muscles and pain in body and he was also found with insufficent VitD level for a period of time. I think is it OSTHOMALASIA because of Vit D deficiancy, what do u say about it? He feels initial pain when he takes high dosage of Vit D then he feels relaxed for a period of time but again feels weakness and losness after sometime. Please suggest
And needs to be consulted with Ortho.

As he is not having any fever or he feels tired(he complaints of weakness but don't feel tiredness when he goes for a walk of 1km or so) nor weight loss nor Nausea or constipation or Frequent urination and he is having good protein level and platlet count and normal level of calcium so I think we XXXXXXX need to go for unnecessary testing of protein electrophoresis at this level, and should concentrate on the Ortho side for that, as the same is view of my physian and coleage doctors(at Ranbaxy R&D), what do u suggest?

Regards XXXXXXX

 
 
Answered by Dr. Anantharaman 28 minutes later
Hi,

Thanks for writing in.

As the symptoms are persisting many months after starting treatment, I felt that we needed to do some evaluation. I respect your physician’s judgment because he is the one who has actually seen the patient.

I really have no explanation at this point for fluctuation in his bone pain symptoms with worsening immediately after taking the vitamin D. Daily vitamin D 1000 IU with calcium is a good option as suggested by your physician. If on treatment there is a worsening then we can look at other causes, as your physician has suggested.

Regards
Anantharaman
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Follow-up: Having body pain. Vitamin D test done. Getting on and off pain while on medicine. What care should be taken? 1 hour later
Dear Doctor,
Thanks for your prompt response, I really feel good about your approach and vision of looking into things
I have some more questions to follow:
1.)     Is it Osteomalacia ? In case of osteomalacia TSH should get deviated?
2.)     As the phosphorous level were seen rising up and alkaline phosphate going down as per your expectations gives you strength that we are in rite direction of treatment and would experience the same more in future.
3.)     I am still not able to find an answer to my problem from anyone that why he starts fealing weakness and looseness after 10-12 days of taking 0000IU. Why is he relived for 10-12 days from that if it’s not working, does it work as Steroid?
4.)     As he feels pain when he takes XXXXXXX dosage at initial level(Pain may be due to repair system of rachets ?) and taking daily dosage may be adding that pain to him on daily basis. Should I ask my doctor for 0000IU dosage for every week. Current Vit D level is 101 nmo/l, many white paper suggest that this level should be 150 nmo/l for aged people?
5.)      I respect your suggestion going for more evaluation but when I also look for all reports which you can also see in last 6 months we are not finding deviation in base reports eg Urine report, Potein serum, other blood test etc which is holding me back in going for Elect Protein. As he is 61 and we should avoid going for more-2 tests also.
6.)     As we have started treatment in second week of May is it has been a long time of treatment and we should be having some good results in hand? Please suggest
Regards XXXXXXX
 
 
Answered by Dr. Anantharaman 17 hours later
Hi,
Thanks for the compliments. I'll try and answer all your queries point wise.
1) The diagnosis of osteomalacia is presumptive we actually need a bone biopsy or at least a bone specific alkaline phosphatase in this particular case. But in actual practice these are not done. we give vitamin D and wait for improvement in symptoms. The fact that all the biochemistry changed the way we wanted supports a diagnosis of vitD deficiency bone disease.TSH was asked to rule out hypothyroidism which can also present like this.
2) All the biochemistry is already near normal it's unlikely that it will improve much more .if it stays the same that's enough.
3) I'm not able to understand this symptom of your father that it causes weakness 10-15 days after a dose and feels better after a dose.
4) vitamin D levels do not fluctuate too much whether you give the vit D daily or monthly .the dose of 1000-2000 iu daily should theoretically cause less fluctuation than a weekly dose. I don't feel the healing osteomalacia is the cause of pain. A level of above 30 ng/ml or 100 nmol/ l is what is considered healthy. There might be some literature saying that a higher level is needed but that is not universally accepted.
5 and 6) if your physician feels that he is fine we can wait one or two more months if there is improvement or stabilisation of symptoms we can avoid further tests. If it worsens, we should look for other causes . Serum total protein cannot be used to see if there is a multiple myeloma- we need a serum electrophoresis.
Regards
Anantharaman
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