#549 - More on Vitamin D, Doxy PEP for STI Prevention, I’m Out To Get You

From the Endocrine Society of America

1)  (More) Guidelines on Vitamin Supplementation and Testing

The US Preventive Services Task Force (USPSTF) does not recommend screening for vitamin D levels routinely (Insufficient evidence). For fracture prevention, the USPTSF recommends against supplementing Vitamin D with less than 400 mcg per day and has no recommendation (insufficient evidence) for any other supplementation. The Institute of Medicine (now National Academy of Medicine) in 2007 similarly found no evidence for routine screening for Vitamin D, and instead suggested age-based routine supplementation for everyone.

Vitamin D has held a bright spot on stage for over 20 years. In 2000, only 0.3% of people used vitamin D supplements; in 2014, it was almost 20%. This surge has been due to a combination of expert opinion recommendations and lots of research revealing associations between vitamin D and several disease states. Randomized trials have mostly failed to demonstrate benefits from screening or supplementation. The Endocrine Society – one of three endocrinology specialty societies – has recently produced their own guideline on Vitamin D supplementation and testing attempting to summarize this trial data. The goal of this Guideline Development Panel was to establish clinical guidelines for the use of vitamin D to lower the risk of disease in individuals without established indications for vitamin D treatment or 25(OH)D testing.

This guideline used the GRADE system for appraising and grading evidence. Patients and general internists were represented on the guideline group, but not other primary care physicians. The Mayo clinic evidence-based practice center performed the systematic review for the guideline group’s questions. The guideline was posted for peer and public review before final publication.

The authors looked at specific outcomes for pediatric (1-18), young adult, older adult and elderly population. They regarded the question of vitamin D supplementation for infants (through formula or supplementation for breast-fed infants) as a settled question (recommended).

A quick summary of their recommendations:

The society recommends against routine screening for vit D, even in populations such as: those with “dark complexions” and those who are obese (all weak recs, very low evid).

For supplementation, the society recommends daily, low-dose vitamin D (400-800 mcg/day) over the non-daily, high-dose forms (e.g., 50,000 units weekly) when needed for people ages 50 years and higher. (weak rec, low evid).

John’s Comments:

I was primed to react strongly to this guideline, given the pro-vitamin D stances of the other endocrinology organizations in the past (yes, this is known as “bias”), but this group had a robust, transparent guideline process. When they exercised judgement to make recommendations based on, at most, moderate evidence, they at least labelled the recommendations appropriately as “weak.” These recommendations are pretty close to the IOM’s recommendations from 2007, so it’s nice to see that when there is a robust evidence-based process for guidelines, we can get consistent recommendations across groups.

References:

• Demay MB, Pittas AG, Bikle DD, et al. Vitamin D for the Prevention of Disease: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. Published online June 3, 2024: dgae290.  Link
• Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, et al., editors. Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011. Link

From the Literature and the CDC

2)  STI Prevention After Unprotected Sex

The incidence of sexually transmitted infections (STIs) caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum has continued to increase in the US, with certain populations disproportionately affected.  Postexposure prophylaxis (PEP) involves taking a medication to prevent an infection after a possible exposure and is a common strategy for prevention of HIV and other infections. PEP is distinct from pre-exposure prophylaxis (PrEP), which involves taking a medication before exposure occurs.  

Doxycycline is used as PrEP or PEP to prevent infections such as malaria and Lyme disease but, until recently, has not been used to prevent STIs.  The CDC recently published a recommendation for the use of doxycycline postexposure prophylaxis (doxy PEP) as a way to prevent some bacterial STIs in certain higher-risk populations.  The CDC specifically recommends that clinicians should counsel all gay, bisexual, and other men who have sex with men (MSM) and transgender women (TGW) who have a history of at least one bacterial sexually transmitted infection (STI) (specifically, syphilis, chlamydia or gonorrhea) during the past 12 months about the benefits and harms of using doxycycline (any formulation) 200 mg once within 72 hours (not to exceed 200 mg per 24 hours) of oral, vaginal, or anal sex (not to exceed one dose/24 hours).  This should be offered through a shared decision-making process.

In three large randomized controlled trials, 200 mg of doxycycline taken within 72 hours after sex has been shown to reduce syphilis and chlamydia infections by >70% and gonococcal infections by approximately 50% in higher risk groups including gay, bisexual, and other men who have sex with men and transgender women.  

Doxy PEP, when offered, should be implemented in the context of a comprehensive sexual health approach, including risk reduction counseling, STI screening and treatment, recommended vaccination and linkage to HIV PrEP, HIV care, or other services as appropriate.  Persons who are prescribed doxy PEP for self-administration should undergo bacterial STI testing at anatomic sites of exposure at baseline and every 3–6 months thereafter.  Ongoing need for doxy PEP should be assessed every 3–6 months as well. HIV screening should be performed for HIV-negative MSM and TGW according to current recommendations. 

The recommendation notes that although not directly assessed in the trials included in these guidelines, doxy PEP could be discussed with MSM and TGW who have not had a bacterial STI diagnosed during the previous year but will be participating in sexual activities that are known to increase likelihood of exposure to STIs.

The CDC noted that no recommendation can be given at this time on the use of doxy PEP for cisgender women, cisgender heterosexual men, transgender men, and other queer and nonbinary persons as the evidence is insufficient to assess the balance of benefits and harms in these groups. 

Mark’s Comments:

I’ve already had a patient from one of these high-risk groups ask about this, so thought it important to get the word out.  Don’t be surprised if you have patients asking about Doxy PEP who are not in one of these high-risk groups, “but will be participating in sexual activities that are known to increase likelihood of exposure to STIs.”  Should you decide to prescribe it to them (which may be quite reasonable under certain circumstances), be sure to follow the guidance above regarding testing, education, counseling (including contraception counseling), screening, and follow-up.

Reference:

US Centers for Disease Control and Prevention.  CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024.  Morbidity and Mortality Weekly Report. June 6, 2024.  Vol. 73, No. 2.  Link

From PeerRxMed ( www.PeerRxMed.org )

3) Let’s Be Out to “Get” Each Other

“You know what everybody needs?… Everybody needs to be understood.”   Sherwin Nuland, MD, surgeon, author, bioethicist

When my children were younger, we used to regularly play a game in which I would say to them in a scary voice “I’m out to get you!” and then a chase would ensue, usually starting with screams and ending with us in a pile on the floor laughing.   At a recent gathering, those now grown children were recalling with fondness how much they loved that game.  Which has left me wondering what the adult version of being “out to get you” looks like (certainly without the scary voice) given our very human desire to be better understood, or “gotten.” 

Over the 4+ years since the PeerRx process was started, I’ve heard from numerous colleagues as to the power of regular peer connection, and the importance of having established an increased level of familiarity and comfort with each other.  Here are two stories that have been shared that clearly demonstrate the importance of our creating space to understand and be understood.  I suspect each of these stories will resonate with something similar to what you have experienced.     

The first colleague shared a story about the power of creating a space to allow another to feel heard: “I really didn’t want to check in even though I know it doesn’t have to take long.  There was just too much going on in my week.  If it hadn’t been for your ‘nudge’ e-mail, I wouldn’t have done it.  When I texted my PeerRx buddy and asked, ‘How are you?,’ they texted back that they were so glad I reached out – that they really needed to talk with someone about a struggle they were having, and they didn’t know who else to talk with about it.  What resulted was an important phone call where they opened-up about something quite serious they had been grappling with and we talked through it together.  I don’t think any of that would have happened had I not reached out.  It felt really good to be able to help them.”   And I suspect it felt even better to be the colleague who was helped. 

The second story was equally powerful about our need to feel understood.  “I had a close friend who had unexpectedly died recently, and I was feeling quite sad about it.  When I checked in with my buddy (FaceTime), they asked how I was doing.  I initially said that I was ‘fine,’ and then realized I was falling into a default pattern for me around stuffing ‘negative emotions.’  In the spirit of your encouragement to ‘feel what you feel,’ I interrupted that default mode and shared that I was actually not doing fine and was feeling profound sadness over the recent loss of someone whom I loved dearly.  What followed was an incredible sharing about how death had impacted each of our lives, and we both found ourselves crying, which I rarely do and never in front of a colleague.  We only talked for 20 minutes, but at the end I felt both comforted and so much more deeply connected with them.”  Wow ….

Yes, the need to feel understood is an essential part of who we are.  There is incredible power when we connect around those things that most deeply matter to us.  This week, when someone asks, “How are you?”, allow yourself to be “gotten” a little more by sharing something from your sacred “this is really important to me” space, and take a moment to appreciate the gift of having someone in your life who cares enough to be “out to get you.”  The chasing, screaming, and scary voice are, of course, optional …

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org