Guidance On Vitamin D Deficiency/insufficiency (Page 3 of 9) in pdf

Investigation and treatment of Vitamin D deficiency / insufficiency in adults

Does the patient have ≥1 CLINICAL or BIOCHEMICAL FEATURE of vitamin D deficiency?

Vitamin D

• widespread bone pain or tenderness or myalgia

testing not

• proximal muscle weakness

required at

• tenderness over pseudo fractures

this stage

• Insufficiency fractures

• low serum calcium or high ALP

Yes

Give

Lifestyle

Does the patient have ≥1 RISK FACTOR for vitamin D deficiency?

advice

• elderly and housebound

• pregnancy & breast feeding

• darker skinned people

• low sun exposure (e.g. habitual skin covering, housebound, skin conditions)

• vegan/vegetarian

• liver/renal disease

• malabsorption

• anticonvulsants, glucocoticoids, cholestyramine, rifampicin or anti-retrovirals

• obesity

• Known disorder of calcium metabolism

Exclude other

Yes

causes of

symptoms

Have other causes for symptoms been excluded?

then restart

pathway

Yes

Carry out tests for suspected vitamin D deficiency: 25-OHD, Ca

, ALP, PO

, also U+Es, LFTs, FBC. PTH is elevated in vitamin D deficient states but routine

measurement not indicated.

Do any of the following apply?

Refer to appropriate secondary care specialist(s).

• focal bone pain

• skeletal deformity

If patient referred and treatment is necessary then 1st

Yes

• malabsorption

treatment course initiated by secondary care.

• renal stones

• chronic renal disease, severe liver disease, lymphoma, metastatic cancer, parathyroid

Patient should only be transferred back to primary care with

disorders, sarcoidosis, TB

a treatment plan.

• Atypical biochemistry (e.g. low vit D and hypercalcaemia)

• Pregnancy or breastfeeding

Assess need for treatment based on total serum 25-OHD level

25-OHD < 25nmol/L

25-OHD 25 - 49nmol/L

25-OHD 50 - 75nmol/L

Maintenance of 800-1000 IU/day (*)

Loading/ Treatment dose required (*)

Lifestyle

(Doses of up to 2000 IU may be required)

advice

1st line: Colecalciferol 20,000 IU capsule: 5 capsules a day for 3

•

OTC high strength vitamin D preparation providing 800-

days (total dose of 300,000 IU).

2,000 IU/day + Lifestyle advice

2nd line: Colecalciferol 20,000 IU capsule: 3 capsules (60,000 IU)

weekly for 8-12 weeks.

•

Consider Adcal D3 - 2 daily (containing 400 IU

3rd line: Colecalciferol 300,000 IU IM injection: single dose where

colecalciferol per tablet) for 65 and over due to evidence of

oral therapy cannot be tolerated or concordance is poor.

reduced fall and fracture risk + Lifestyle advice

4th Line: Ergocalciferol 300,000 IU IM injection: single dose where

oral therapy cannot be tolerated or concordance is poor and

Routine monitoring of 25-OHD not necessary

colecalciferol injection is unavailable.

Calcium levels may need to be checked 3-6 monthly in

patients on doses higher than 1,000 IU/Day

See Monitoring below

- Check Ca & Vitamin D levels after 8- 12 weeks

Repeat loading dose

Refer to appropriate

Has patient responded to treatment?

specialist in secondary care

- Consider non-compliance

Yes

MAINTENANCE

Once 25-OHD levels are optimal give lifestyle advice and advise on maintenance treatment. See Maintenance box above.

•

MONITORING

Check serum calcium levels 4 weekly and 25-OHD levels 8-12 weekly for patients on high (treatment) dose of vitamin D.

•

Check for allergies (some products may contain peanut (arachis) oil, sunflower oil or soya oil.

•

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.

Patients should be advised of the symptoms of hypercalcaemia (nausea, abdominal pain, thirst, polyuria etc) and advised to stop taking vitamin D

•

supplements and seek medical advice if these occur.

Page 3 of 9

Guidance On Vitamin D Deficiency/insufficiency Page 3

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