Improving vitamin D management in an adult cystic fibrosis program.
Maine Medical Center, Medical Education, Maine Medical Center Research Institute
Adult, Vitamin D, Cystic Fibrosis, Vitamins, Cholestanes
BACKGROUND Gastrointestinal manifestations of cystic fibrosis (CF), including pancreatic insufficiency, cause nutrient malabsorption. Patients with CF, especially those with pancreatic insufficiency, have difficulty absorbing fat-soluble vitamins A, D, E and K. A common problem in CF clinics is adequately managing vitamin D deficiency. A multidisciplinary team conducted a quality improvement project to monitor and improve vitamin D levels in these patients with protocolized management independent of physicians.
METHODS Our Adult CF Program includes 111 patients (57 female) with an average age of 33 and an average BMI of 23.59kg/m2. 84% of our patients are pancreatic insufficient. Established patients who had a vitamin D level drawn were included in data collection. Interventions and responses were recorded during the same period. The team developed a protocol for managing vitamin levels with repletion guidelines based on a modified version of the CF Foundation’s Vitamin D Deficiency Clinical Care Guidelines. Low vitamin D was defined as less than 25ng/mL of 25-hydroxy vitamin D (25-OH-D). Patients with low 25-OH-D were counseled by the dietitian and/or pharmacist on adherence to their prescribed regimen, or prescribed a new regimen with a higher dose of 25-OH-D with the intent to recheck vitamin levels after 3 months. All abnormal lab values and vitamin regimens, as well as results from subsequent lab draws were tracked in a patient-specific database maintained by the team.
RESULTS 25-OH-D levels were drawn in 80 clinic patients, 28 of which had low 25-OH-D at initial lab draw. The majority of low 25-OH-D patients were younger females, had low BMI, and were on pancreatic enzyme replacement therapy. One quarter of them were on tube feeds. Of these, 2 patients had no prescribed vitamin supplementation prior to initial lab draw. CF-specific multivitamins were prescribed for 19 patients and 9 were prescribed additional 25-OH-D supplementation. Seven patients with low 25-OH-D were not included in the protocol for various reasons, including critical illness. Interventions made by the team after initial lab draws included initiation or increased dosage of 25-OH-D supplements (14 patients), and counseling on adherence to the currently prescribed regimen (3 patients). Ten patients with low 25-OH-D levels on screening had follow-up lab draws as part of the protocol and all showed improvement. Of these, 70% had normal levels on retesting. Five patients were not yet due for follow up labs at the end of the project period and 6 were overdue. There were no new cases of 25-OH-D deficiency. Over the course of one year, the average 25-OH-D level in our patients increased from 30.2ng/dL to 33.4ng/dL.
CONCLUSIONS Preliminary findings from the first year of data collection demonstrate a positive impact on 25-OH-D levels in patients with CF when independently managed by nursing, pharmacy, and nutrition following a standardized protocol. Going forward, limitations of the protocol will be addressed to further improve vitamin replacement in high-risk patients, and further data on outcomes will be collected.
DiLoretor, Stefanie; Murry, Alicia; Smith, Tegan; and Tate, Lauren, "Improving vitamin D management in an adult cystic fibrosis program." (2020). Costas T. Lambrew Research Retreat 2020. 6.
Award for Excellence in Quality Improvement Research: Faculty/Staff Award - Scientific Talk Lauren Tate, RD, Clinical Dietician, Nutrition Services, Maine Medical Center: Improving vitamin D management in an adult CF program. 2020 Costas T. Lambrew Research Retreat.