Guidance On Vitamin D Deficiency/insufficiency (Page 2 of 9) in pdf

• older people (65 years and over)

• darker-skinned people

• low sun exposure (those who avoid the sun, wear whole-body coverings, live in institutions or are

housebound, skin conditions e.g. skin cancer, habitual sunscreen use)

• obese individuals

• malabsorption or other dietary problems

• vegetarian or fish free diet

• severe liver disease

• chronic kidney disease and nephrotic syndrome

• certain medicines e.g. use of anticonvulsants (e.g. carbamazipine, phenobarbital, phenytoin,

primidone), rifampicin, cholestyramine, glucocorticoids, highly active antiretroviral treatment.

Investigation and Treatment of Vitamin D deficiency and insufficiency

For guidance on investigation and treatment of vitamin D deficiency and insufficiency:

• in adults - refer to the flowchart on page 3

• in children - refer to the flowchart on page 4

Further Considerations

The regimes recommended in the flowchart have taken into account potential costs and availability

(see product availability tables on page 7-8).

Loading/treatment dose

• Currently there are no suitable licensed medicinal products containing just colecalciferol, available

in the UK. This is an important determinant for clinicians to note when considering product selection

for the treatment of vitamin D deficiency.

• There is a licensed ergocalciferol injection but there are often availability issues with this.

• As with all unlicensed specials, all clinical and legal responsibility lies with the prescriber rather

than the manufacturer (unless it can be proven that the product was faulty). Informed consent

should always be obtained from patients before prescribing in these circumstances.

Maintenance Treatment

All patients, where appropriate, should receive lifestyle advice to help to meet their vitamin D

requirements (see Lifestyle Advice section page 5).

• Patients requiring ongoing oral maintenance treatment should be encouraged to take over

the counter (OTC) vitamin D supplements (a variety of preparations are available to buy

commercially; refer to page 8) unless Adcal D3 or Calceos is indicated (see flowchart page 3

and pages 6 & 7).

• Patients should be advised if there are any restrictions to the type of vitamin D preparation they

should take (e.g. vegan, allergy or calcium restrictions).

Safety Considerations

• High doses of vitamin D can be toxic (resulting in hypercalcaemia and renal failure). This is most

likely to occur if high doses (used as initial treatment loading doses) are taken over a prolonged

period of time, or if alfacalcidol or calcitriol are given in error.

• Vitamin D treatment doses are contraindicated in patients with hypercalcaemia or metastatic

calcification, or where there may be significant interactions with other medications.

• Supplements of vitamin D containing vitamin A should not be taken in pregnancy as excessive

vitamin A doses are associated with foetal CNS malformations.

• Alfacalcidol & calcitrol should only be used in patients who cannot activate vitamin D and should

therefore not be used for the routine treatment of primary vitamin D deficiency/insufficiency, as they

carry a higher risk of toxicity and require long-term monitoring.

• There is a small risk of hypercalcaemia developing in the presence of undiagnosed sarcoidosis or

primary hyperparathyroidism in patients taking vitamin D.

• Some products may contain peanut (arachis) oil, sunflower oil or soya oil. Allergy to these may lead

to severe allergic reactions including anaphylaxis. Healthcare professionals should check for

allergies before prescribing or when recommending supplements. Patients should also be advised

to raise allergies at the point of dispensing or purchase to ensure the content of the product is safe

to take. Current status of the product ingredients should be obtained from the manufacturer as

formulation may change. Refer to UKMI document on suitable products for patients with peanut or

soya allergies in references section on page 9.

Page 2 of 9

Guidance On Vitamin D Deficiency/insufficiency Page 2

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