Question

A 32-year old male patient walks into your endocrinology clinic complaining of fatigue, muscle weakness,, and bone and back pain. He is a very active and generally healthy athlete and said all these symptoms have only appeared in the last two weeks.

After checking his prior medical history, you noticed that he went to his primary care physician a month ago to get treatment for high cholesterol levels. His physician prescribed he take oral Cholestyramine daily for the next month.

Based on his symptoms, you run a general blood test checking for levels of thyroid hormones, blood calcium, metabolic markers, alkaline phosphatase, a lipid profile, vitamin D panel, etc. Results show that his levels of Vitamin D3 are low as well as low blood calcium levels. Looking at his past chart, you noticed that his primary care doctor did a general blood test a month ago and his Vitamin D3 and blood calcium levels were normal.

The mechanism of action of Cholestyramine is to bind to bile acids in the intestine, preventing their absorption. You do some research, and find that there is a possible side effect of Cholestyramine affecting the intestinal absorption of fat-soluble vitamins, including Vitamin D.

You are deciding how best to treat him based on the current information, and with his need to also take a cholesterol-lowering drug. How would you treat him? Include all treatment possibilities (both pharmaceutical and lifestyle changes) and include your reasoning for each one.

Answer 1

Bile salts are very important in absorption of digested fats and fat soluble vitamins. Digested fats, fat soluble vitamins form a complex with bile salts called micelle which help in transporting digested fats to the intestinal epithelium for their absorption. Cholestyramine attaches to the bile acids and prevents its absorption. This is affecting the absorption of the digested fat and also fat soluble vitamins like vitamin D.

Excess cholecterol is also harmful to the person as it can cause, cardio vascular disorders.

At the same time vitamin D is also very important for absorption of Ca in to the body from the gut.

Cholestyramine should not be taken along with other medications. It might interfere with their absorption in to the body. It is best taken along with a meal.

Person should take cholesterol lowering medication and also Vitamin D. he should avoid taking the medications together. Life style changes like less intake of fats in the diet, good and regular exercise also are must to control cholesterol. Regular exercise will use up the fat present in the body and hence reduce cholesterol levels in the body. Vitamin D can be synthesized in the skin by standing in the sun every day for some time. Exposure to sun to prevent vitamin D deficiency is best way to Vitamin D deficiency management.

In extreme cases administering vitamin D intravenously is another option.

So by taking these measures, deficiency of vitamin D and control of cholesterol can be managed.