Vitamin D deficiency - clinical guidelines for adults
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Vitamin D deficiency — clinical guidelines for adults
Importance of vitamin D
A significant proportion of the UK population have low vitamin D levels, which has resulted in a
rising number of reported cases of rickets in children and osteomalacia in adults. This is of
particular concern for all pregnant and breastfeeding women, young children, older people, black
and ethnic minority groups, and those at risk of inadequate sunshine exposure. Pregnant women
especially need to ensure their own requirement for vitamin D is met and to build adequate fetal
stores for early infancy.
Vitamin D deficiency impairs the absorption of dietary calcium and phosphorus, which can give
rise to bone deformities in children, and bone pain and tenderness as a result of osteomalacia in
adults. It is essential that everyone, especially those people most at risk, are aware of the
implications of vitamin D deficiency and most importantly what they can do to prevent it.
Risk factors for vitamin D insufficiency and deficiency
Pigmented skin (non-white ethnicity)
Lack of sunlight exposure
Skin concealing garments or strict sunscreen use
Multiple, short interval pregnancies
Elderly or housebound
Vegan / vegetarian or high phytate consumption such as in chapatis
Malabsorption (e.g., inflammatory bowel disease, coeliac disease, pancreatic
insufficiency)
Use of anticonvulsants, rifampicin, cholestyramine, anti-retrovirals
Sources of vitamin D
The sun: Our body creates most of our vitamin D from modest exposure to direct UVB sunlight.
Regular, short periods of UVB exposure without sunscreen during the summer months are
enough for most people. However, some groups (see risk factors listed above) may not be able to
get enough vitamin D in this way. In addition, those living at above 52° N latitude (the UK is at
latitude of 50–60° N) may not get enough vitamin D during the winter months.
Diet: Food in the diet can also contribute to vitamin D levels, but the average daily intake is just
2–4 micrograms, and it is difficult to obtain enough vitamin D from diet alone. Food sources
include:
Oily fish (such as salmon, mackerel and sardines)
Cod liver oil and other fish oils
Eggs
Meat
Mushrooms
Manufacturers also have to add it to all margarine and infant formula milk. Other manufacturers
add it voluntarily to some breakfast cereals, soya products, some dairy products, powdered milks
and low-fat spreads; however, this is often a minimal amount.
Breastfed babies get their vitamin D from their mother’s breast milk, which is one reason why it is
important for pregnant and breastfeeding mothers to have adequate vitamin D levels of their own.
Vitamin D deficiency – clinical guideline for adults v2.0 Uploaded by: Kathryn Rawson, June 2015
Approved by: Area Prescribing Committee Date: 07/05/2015 Review by: June 2017
Page 1 of 6Prevention of vitamin D deficiency and insufficiency
It is important that people who find it hard to get enough vitamin D from the sun and their diet take
a vitamin D supplement. Specific groups who may benefit from vitamin D supplementation are
listed in the table below (Department of Health recommendations):
People at risk of vitamin D deficiency Daily vitamin D supplement
All pregnant and breastfeeding women 400 IU (10 micrograms) / day
People who are not exposed to much sun (e.g., people 400 IU (10 micrograms) / day
confined indoors for long periods and those who cover their
skin for cultural reasons)
People aged 65 years and over (see elderly patients section) 400 IU (10 micrograms) / day
********* 1 microgram is equivalent to 40 International Units ***********
Patients can be advised to buy over the counter (OTC) vitamin supplements or signposted to
Healthy Start Clinics where Healthy Start Women’s vitamins are available. These contain folic
acid 400 micrograms, vitamin D 10 micrograms [400 IU] and vitamin C 70 mg, and are suitable for
vegetarians, free from milk, egg, gluten, soya and peanut residues. For more details of the
scheme see: www.healthystart.nhs.uk
Clinical features of vitamin D deficiency
Muscle pain
Proximal muscle weakness
Rib, hip, pelvis, thigh and foot pain are typical
Fractures
Assessing the patient
Patient characteristics Advice and management
Healthy, no risk factors, symptom free No investigations required
Lifestyle advice
Risk factors only Lifestyle advice
Consider long term preventative therapies
Risk factors AND clinical features (see Lifestyle advice
management flowchart - Appendix 1) Investigations
Therapeutic intervention
Long term preventative treatment
Investigations
Test Reason
Renal function tests (U&E, eGFR) To exclude renal failure. See note below on renal
patients.
Liver function tests (including ALP) To exclude hepatic failure.
FBC Anaemia may be present if there is malabsorption.
TFTs To exclude primary hyperparathyroidism.
Calcium To exclude hypercalcaemia and provide a baseline for
monitoring. Hypocalcaemia may indicate long standing
vitamin D deficiency.
Phosphate Hypophosphataemia may indicate long standing
vitamin D deficiency.
25-OH Vitamin D levels* To determine vitamin D status
* Only measure if patient is symptomatic and has risk factors for Vitamin D deficiency.
Vitamin D deficiency – clinical guideline for adults v2.0 Uploaded by: Kathryn Rawson, June 2015
Approved by: Area Prescribing Committee Date: 07/05/2015 Review by: June 2017
Page 2 of 6Measurement, status and management (see Appendix 1 for flowchart)
Vitamin D level Vitamin D status Health effect Management
75 nmol/L Optimal Healthy None
Diagnosis and coding
If deficiency diagnosed use the Read code .C28 Vitamin D deficiency (for audit purposes)
Contraindications for vitamin D
Patients with hypercalcaemia or metastatic calcification.
When to refer to secondary care
All children under 1 year
Atypical biochemistry
Atypical clinical manifestations or biochemistry
Deficiency due to malabsorption
Failure to respond to treatment after 3 months
Focal bone pain
Liver disease
Lymphoma
Metastatic cancer
Parathyroid disorders
Renal disease
Renal stones
Sarcoidosis
Short stature and skeletal deformity
Tuberculosis
Unexplained deficiency
Unexplained weight loss
Monitoring
Adjusted serum calcium should be checked 1 month after completing the loading regimen
or after starting vitamin D supplementation (if baseline calcium level is >2.45 mmol/L) in
case primary hyperparathyroidism has been unmasked.
Routine monitoring of vitamin D levels is generally unnecessary for patients on long term
maintenance vitamin D doses of up to 2,000 IU/day.
Whilst on maintenance vitamin D doses recheck bone profile and vitamin D levels if
symptoms suggestive of vitamin D toxicosis or hypercalcaemia (confusion, polyuria,
polydipsia, anorexia, vomiting or muscle weakness).
For patients on potent antiresorptive agent (e.g., denosumab or zoledronic acid) check
vitamin D levels annually as per protocol.
Duration of treatment
For osteoporosis: consider indefinite therapy.
For symptomatic vitamin D deficiency: consider discontinuation if symptoms resolved and
optimal vitamin D levels achieved (>75 nmol/L). Recheck vitamin D levels if symptoms
return then maintain indefinite supplementation.
Vitamin D deficiency – clinical guideline for adults v2.0 Uploaded by: Kathryn Rawson, June 2015
Approved by: Area Prescribing Committee Date: 07/05/2015 Review by: June 2017
Page 3 of 6Treatment regimes
1. Treatment of deficiency (25-OHDA recent meta-analysis has raised concerns about a possible modest increase in the risk of some
cardiovascular events in postmenopausal women who use calcium and vitamin D supplements to
prevent osteoporotic fractures. However, there are limitations to the data and no change to
prescribing practice is currently recommended.
Prescribers should consider the potential benefits and risks of using calcium and vitamin D for
prevention of osteoporotic fractures on an individual basis in line with NICE guidance. Prescribers
should consider offering these supplements to patients who receive treatment for osteoporosis
(e.g., with bisphosphonates), unless they are confident that the patient has an adequate calcium
intake and is vitamin D replete.
Renal Patients
NICE clinical guideline CG182 on chronic kidney disease, published in 2014, advises on which
vitamin D preparations should be used and when, according to the stage of renal impairment.
Available at http://www.nice.org.uk/guidance/CG182
Intestinal Malabsorption
These patients should be referred to secondary care. Vitamin D deficiency caused by intestinal
malabsorption or chronic liver disease usually requires vitamin D in pharmacological doses. A
suggested regime for adult patients would be to use ergocalciferol 300,000 IU by intramuscular
injection monthly for 3 months, followed by 300,000 IU by intramuscular injection once or twice a
year.
Patients on Anti-epileptic medication
The available data suggest that long-term use of anti-epileptic drugs (in particular carbamazepine,
phenytoin, phenobarbital, primidone and sodium valproate)9 is associated with decreased bone
mineral density that may lead to osteopenia, osteoporosis, and increased fractures in at-risk
patients. Vitamin D status should be assessed for at-risk patients who are taking these medicines
long term, and patients treated according to their level (see Appendix 1). NICE clinical guideline
CG137 on epilepsy, published in 2012, advises full blood count, electrolytes, liver enzymes,
vitamin D levels, and other tests of bone metabolism (e.g., serum calcium and alkaline
phosphatase) every 2–5 years for adults taking enzyme-inducing drugs.
Available at http://www.nice.org.uk/guidance/CG137
Vegetarians and vegans
Ergocalciferol is derived from a common plant steroid, whereas colecalciferol is most commonly
derived from an animal source such as sheep’s wool fat. Colecalciferol products derived from
wool fat are not acceptable to vegans and may also be unacceptable to vegetarians.10
References
1. National Osteoporosis Society. Vitamin D and Bone Health: A practical clinical guideline for patient management. April 2013.
http://www.nos.org.uk/document.doc?id=1352
2. Pearce SHS, Cheetham TD. Diagnosis and management of vitamin D deficiency. BMJ 2010; 340: 142‐147.
3. Department of Health Information Leaflet. Vitamin D an essential nutrient for all… but who is at risk of vitamin D deficiency?
Important information for healthcare professionals. 2007.
4. UK Chief Medical Officers Communication. Vitamin D advice on supplements for at risk groups, 2 Feb 2012. Accessed via
https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=101726 on 07.02.12
5. Consensus vitamin D position statement, Dec 2010. Accessed via http://www.cancerresearchuk.org/cancer-
info/prod_consump/groups/cr_common/@nre/@sun/documents/generalcontent/cr_052628.pdf on 16.02.15
6. Vitamin D deficiency and insufficiency – using appropriate available products – Updated document (August 2014).
http://www.medicinesresources.nhs.uk/en/Download/?file=MDs3OTA0MDg7L3VwbG9hZC9WaXRhbWluIEQgcHJvZHVjdCB
hdmFpbGFiaWxpdHkgQXVnIDIwMTRbMV0ucGRm.pdf Accessed 16.02.15
7. British National Formulary, February 2015 update. Accessed via https://www.medicinescomplete.com/mc/bnf/current/ on
16.02.15
8. Drug Safety Update April 2009; vol 2, issue 9
9. Drug Safety Update Oct 2011; vol 5, issue 3
Acknowledgements
Adapted, with permission, from guideline developed by Wirral University Teaching Hospital NHS Foundation Trust and NHS Wirral.
Vitamin D deficiency – clinical guideline for adults v2.0 Uploaded by: Kathryn Rawson, June 2015
Approved by: Area Prescribing Committee Date: 07/05/2015 Review by: June 2017
Page 5 of 6Appendix 1: Quick guide to vitamin D levels and management
(for patients with risk factors AND clinical features)
Clinical features of vitamin D deficiency
Muscle pain
Proximal muscle weakness
Rib, hip, pelvis, thigh and foot pain are typical
Fractures
Investigations
including 25-OH Vitamin D levels
75 nmol/L
Deficient Insufficient Adequate Optimum
High dose colecalciferol If fractures are the presenting If pain, weakness and Lifestyle No
(280,000 to 300,000 IU) feature: fatigue are the presenting advice intervention
see Table 1 symptoms required
High dose colecalciferol
Check calcium 1 month (280,000 to 300,000 IU) Maintenance vitamin D
after completing loading see Table 1 supplements
regimen (800 to 2,000 IU/day)
Check calcium 1 month after see Table 2
Maintenance vitamin D completing loading regimen
supplements if calcium Check calcium 1 month
normal Maintenance vitamin D after starting
(800 to 2,000 IU/day) supplements if calcium normal supplementation ONLY if
see Table 2 (800 to 2,000 IU/day) baseline calcium level
see Table 2 >2.45 mmol/L
Hypercalcaemia
If calcium levels are elevated:
1. Stop any calcium containing vitamin D supplements.
2. Delay further vitamin D loading, and repeat calcium levels 2 weekly until normalises.
3. Continue loading and check calcium levels every 4 weeks until loading completed.
4. If calcium levels are persistently elevated despite stopping calcium containing supplements check
PTH and refer to endocrinology (possibly unmasked primary hyperparathyroidism).
Table 1
Colecalciferol Route Length of Total Preparation
dose course loading
dose
®
First line 40,000 IU Oral 7 weeks 28,0000 IU Aviticol 20,000 IU capsules
weekly (N.B. contains gelatin)
®
Second 50,000 IU Oral 6 weeks 30,0000 IU InVita D3 oral solution 25,000 IU/ml
line weekly (suitable for vegetarians and patients
with swallowing difficulties)
®
Third 4,000 IU daily Oral 10 weeks 28,0000 IU Desunin 800 IU tablets
line (Gelatin free)
Table 2
Colecalciferol Dose Route Duration of Treatment Preparations
®
800 – 2,000 IU daily Oral See page 3 Desunin tablets (colecalciferol 800 IU)
(occasionally up to £3.60 for 30 tablets.
1
4,000 IU daily)
OR advise to purchase OTC vitamin D
treatments.
Vitamin D deficiency – clinical guideline for adults v2.0 Uploaded by: Kathryn Rawson, June 2015
Approved by: Area Prescribing Committee Date: 07/05/2015 Review by: June 2017
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