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Response to Tkachuk and Colleagues

the effect of vitamin D supplementation on the risk of falls in elderly institutionalized adults, was examined, the following was found. A Cochrane review from 2012 that included studies of elderly institutionalized adults showed that vitamin D supplementation alone had no significant effect on rate of falls (rate ratio = 0.55, 95% confidence interval (CI) = 0.19–1.64) or the risk of experiencing a fall (risk ratio = 0.80, 95% CI = 0.38–1.71). The addition of vitamin D to calcium supplementation only reduced the rate of falling (rate ratio = 0.71 95% CI = 0.56–0.90) but had no effect on the risk of experiencing a fall (risk ratio = 0.85 95% CI 0.69–1.05) or fracture. A recent systematic review published in the British Medical Journal found that there was no significant effect of vitamin D supplementation on the odds of falling (odds ratio = 0.97 95% CI = 0.84–1.11) or the rate of falls in older adults (rate ratio = 0.55 95% CI = 0.19– 1.64). A meta-analysis of randomized controlled trials found no significant difference in falls for vitamin D monotherapy (relative risk = 0.95, 95% CI = 0.89–1.02) or vitamin D plus calcium (relative risk = 0.95, 95% CI = 0.89–1.03). Feldman et al. conclude that high doses of vitamin D may not be safe given the vitamin D levels achieved and will consider lower doses in the future. This is troubling. Regardless of the dose, the evidence does not support the use of vitamin D monotherapy for reduction of clinical outcomes. The protocol at Feldman et al.’s institution has recently been revised to reduce the dose to 10,000 IU of vitamin D weekly. What is the scientific basis for the new recommended dose? Several contradictory statements were also made in the article. Specifically, it mentions that, in previous studies, mortality tended to increase with higher serum 25OHD levels—with a need for randomized controlled trials to demonstrate this causality—and that “collectively, these studies suggest that high 25OHD concentrations are not beneficial and could have adverse effects. The relevance of this in residential care needs to be established.” But in the conclusion, they state that the “Fraser Health Protocol of giving 20,000 IU of vitamin D weekly to older adults living in residential care facilities is feasible and safe and appears to have virtually eliminated vitamin D insufficiency. Serum 25OHD concentrations were higher than expected, with more than half the residents surveyed having a 25OHD concentration >100 nmol/L.” If someone were to read just the abstract or conclusion, they might miss the crucial point related to the known safety concerns regarding high 25OHD serum concentrations. The use of this protocol should be reconsidered, or at the very least, residents and clinicians should be informed that the efficacy and safety of high-dose vitamin D supplementation in terms of falls and fractures is unknown.