Vitamin D Deficiency or Insufficiency in Primary and Secondary Care - Advice on the Management of Adults over 18 years with

Publication: 23/08/2013  --
Last review: 01/02/2016  
Next review: 01/02/2019  
Clinical Guideline
CURRENT 
ID: 3399 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Advice on the Management of Adults over 18 years with Vitamin D Deficiency or Insufficiency in Primary and Secondary Care

This pathway is intended for use by healthcare professionals who see patients at risk of vitamin D deficiency. It is not a screening pathway and Vitamin D testing is not a screening tool. The aim of this guidance is to give recommendations on when measuring of vitamin D levels may be appropriate and how to proceed when abnormal vitamin D levels are seen.

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Summary

Vitamin D is essential for good bone health but there is still uncertainty around its role in other diseases such as cancer, heart disease and diabetes1.

Vitamin status is monitored by measuring serum 25-hyroxyvitamin D (25(OH)D) concentration. Leeds Hospitals endocrinologists use a level of < 30nmol/l to define deficiency in adults.

Serum 25(OH)D conc

Vitamin D status

Manifestation

<30 nmol/l

Deficient

Osteomalacia, usually presenting as musculoskeletal pain + weakness in adults.

30 – 75 nmol/l

Insufficient

Possibly associated with increased risk of disease

75 – 125 nmol/l

Sufficient

Healthy

Please note: Vitamin D levels used to define deficient, insufficient and sufficient in the adult guidelines differ from those in the Leeds children’s guidelines.

Recent information from the UK has indicated that around 50% of the adult population may have vitamin D insufficiency in winter and spring, with the prevalence of vitamin D deficiency at around 16%2. People who achieve an adequate level of vitamin D during the summer should have sufficient levels in the winter without supplementation but in some people supplementation may be necessary.1

There is currently a lack of evidence to support routine screening of vitamin D levels in general practice1.

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Lifestyle Advice

90% of the body’s vitamin D requirement is obtained from ultraviolet B sunlight exposure, with only a minimal amount obtainable from food. It follows that adequate exposure to sunlight is essential for good health.
During the summer two or three exposures of 20 minutes (of at least the face and arms without sunscreen and not behind glass) each week should provide adequate amounts of vitamin D for most fair skinned individuals.2 In the UK, from October to April sun exposure is not adequate for synthesis of vitamin D and levels must be maintained by using tissue stores and dietary sources.

NB. Patients with melanoma should seek specialist advice.

Food sources which can contribute to vitamin D status are:

  1. Oily fish such as herring, sardines, mackerel, salmon and tuna.
  2. Eggs and meat contain small amounts.
  3. Vitamin D fortified foods such as margarines and cereals & powdered milk (check product labels).

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Department of Health recommendations

The DOH advice is that the following adults and children are at risk of deficiency: pregnant and breastfeeding women, people aged over 65, people with low or no sun exposure and those with darker skin.

They recommend supplementation in the following:3

Supplements are recommended for following people:

Daily vitamin D supplement
  • All pregnant + breastfeeding women

10mcg (400 units) /day
  • All infants and children from 6 months to 5 years, unless they are drinking 500ml or more of infant formula a day at any time during this age range. (Infants aged 0-6 months may not need supplements as they should get adequate amounts from breast milk or infant formula milk. If there is any doubt about the mother’s use of vitamin supplements during pregnancy and/or breast feeding, breastfed infants will benefit from vitamin D supplements from 1 month)

6 months to 5 years: 7 to 8.5mcg (280-340units) per day
  • People with little sun exposure, e.g. people confined indoors for long periods and those who cover their skin for cultural reasons.

10mcg (400units)/day
  • People aged 65 years and over

10mcg (400units) /day

Lifestyle advice should be reinforced with people at risk of deficiency.

Suitable supplements are available to buy from pharmacies, health food shops and supermarkets. Patients should consult their community pharmacist if they are unsure which product to buy.

Supplements are available free of charge to qualifying women and children via the Healthy Start scheme – see website for eligibility criteria http://www.healthystart.nhs.uk/

No licensed medicines are currently available to prescribe for these groups. Healthy Start Vitamins are not available on prescription.

Prescribing of nutritional supplements on the NHS to these groups is not recommended.

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Who should we test?

Vitamin D levels should be checked in all people with confirmed or suspected bone disease/ low bone mineral density i.e osteomalacia, osteoporosis, Paget’s disease of bone, hyperparathyroidism and osteopenia; regardless of symptoms or risk factors.

In all other people vitamin D deficiency should be considered and checked for only if:

Patient has one or more of the following symptoms:

  • Unexplained widespread or localised bone pain and tenderness
  • Unexplained muscle weakness and pain.

Exclude other causes e.g. rheumatoid arthritis, polymyalgia rheumatica or hypothyroidism.

AND
One or more of the following risk factors:

  • Reduced exposure to sunlight e.g. due to being housebound, having skin covered when outside or routine use of high factor sunscreen.
  • Dark skin.
  • Over 65s, (particularly with a history of falls or in care home not already prescribed Ca + Vit D)
  • Pregnant + breastfeeding women
  • Obese people i.e. BMI>30.
  • Those who may have fat malabsorption e.g. CF, Crohns or bariatric patients.
  • Those taking medication that may increase vitamin D catabolism e.g. anti-epilepsy drugs, glucocorticoids, systemic anti-fungal drugs such as ketoconazole, cholestryramine, rifampicin, HIV drugs.

Patients with the following conditions would normally be managed by secondary care or should be referred to secondary care for treatment if abnormal vitamin D level is discovered:

Refer to secondary care if:

  • Chronic liver or kidney disease (CKD 4 or above)   
  • Primary hyperparathyroidism
  • History of renal stones
  • Hypercalcaemia
  • Metastatic calcification
  • Patient with chronic granuloma forming disorders (sarcoidosis or TB), chronic fungal infections or lymphoma.
  • Pregnant

It is worthwhile encouraging all patients with risk factors – even those not exhibiting symptoms – to make lifestyle changes in order to achieve adequate amounts of vitamin D, but it is not necessary to measure their levels, e.g. patients over 65years in care homes should be encouraged to go or be taken outdoors regularly.

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What baseline tests are required?

  • 25(OH)vitamin D
  • Bone profile (to exclude hypercalcaemia and provide a baseline for monitoring)
  • U+Es,

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Safety Issues

The Food Standards Agency advises that doses of up to 1000 units daily of vitamin D are not known to cause adverse effects in the general adult population1. Research suggests up to 10,000 units can be taken daily by healthy people for up to 16 weeks without toxicity. Excessive intake can rarely lead to hypercalcaemia; symptoms include muscle weakness, apathy, headache, anorexia, nausea and vomiting.4

Notes
Nomenclature: The term vitamin D is used for a range of compounds. Vitamin D2 is known as ergocalciferol. Vitamin D3 is known as colecalciferol.
1mcg colecalciferol / ergocalciferol are equivalent to 40units.

Colecalciferol (vitamin D3) is considered the preferred form of vitamin D for treatment. It has been reported that colecalciferol raises vitamin D levels more effectively than ergocalciferol (vitaminD2), and has a longer duration of action.4

Treatment Regimes for Adults  

SAFETY NOTE: Errors have occurred due to confusion between monthly, weekly and daily regimes and also high dose supplements being left on repeat prescription. Loading doses for treatment of deficiency or insufficiency should not be added to repeat and stop dates should be added to prescriptions where appropriate.

Dosing recommendations do not apply in pregnancy: refer to endocrinology for advice

Box 1
Treatment of Deficiency - WEEKLY REGIME (SERUM 25(OH)VitD conc < 30nmol/L)

Colecalciferol capsules: 40,000 units once weekly for 7 weeks

If liquid required prescribe:
Colecalciferol 25,000units/1ml oral solution unit dose ampoules sugar free, 2 ampoules once a week for 6 weeks.

  • Monitor Calcium, 25(OH)Vit D, U+Es and ALP six weeks after completing course
  • If levels still < 30nmol/L a second course may be given.
  • If levels still < 30mmol/L after 2 attempts at loading and compliance confirmed refer to secondary care.

Within LTH and for people receiving Denosumab or IV bisphosphonate treatment a more rapid loading regime may be required. See Protocol for Rapid Vitamin D replacement on Leeds Health Pathways for dosage. If DAILY dosing preferred to aid compliance see Licensed Presentations below*.

Box 2
Treatment of Insufficiency - MONTHLY REGIME (SERUM 25(OH)VitD conc 30 - 75nmol/L)

Colecalciferol capsules 40,000 units once a month for 3 months

If liquid required prescribe:
Colecalciferol 25,000units/1ml oral solution unit dose ampoules sugar free, 2 ampoules once a month for 3 months

  • Monitor Calcium, 25(OH)Vit D, U+Es and ALP six weeks after completing course.
  • If levels still < 75nmol/L a second course may be given.
  • If levels still <75nmol/L after 2 attempts at loading and compliance confirmed consider referral to secondary care.

Box 3
Maintenance Treatment following correction of Deficiency or Insufficiency combined with food and lifestyle advice

 PRESCRIPTION ONLY TREATMENT:

  • Colecalciferol 800units tablets or capsules ONCE or TWICE daily, or
  • Colecalciferol 40 – 50,000 units once per month (October to March inclusive) and 20 – 25,000 units once per month (April to September inclusive), using any of the licensed products available. This is an empirical regimen used by LTH Endocrinologists.
  • Calcium + vitamin D 800units per day for elderly, institutionalised people to prevent falls and for those with osteoporosis/osteopenia if daily recommended intake of calcium not met. 

OVER THE COUNTER TREATMENT:

  • Suitable supplements are available to buy, ask community pharmacist for latest advice.

Monitoring of vitamin D levels is not required at these dosages unless on- going low BMD, bone problems, poor absorption or symptomatic of vitamin D deficiency.

LICENSED PRESENTATIONS AVAILABLE FOR COLECALCIFEROL PRESCRIBING

The following preparations are listed in the Drug Tariff Part VIIIA (Basic Prices of Drugs) Jan 16 and are suitable for generic prescribing:

  • Colecalciferol 20,000unit capsules
  • Colecalciferol 25,000units/1ml oral solution unit dose ampoules sugar free
  • Colecalciferol 40,000unit capsules( Currently the most cost effective preparation for treating deficiency (January 16).
  • *Colecalciferol 3200 unit capsules (suitable for daily dosing deficiency treatment: 1 DAILY for 12 weeks)
  • Colecalcoferol 800 unit tablets and capsules
  • Colecalciferol 15,000 units/5ml oral solution (more expensive than unit dose ampoules)

 

 

Provenance

Record: 3399
Objective:
Clinical condition:

Vitamin D Deficiency or Insufficiency
Target patient group:
Target professional group(s): Primary Care Doctors
Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

References:

  1. Consensus Vitamin D position statement. http://www.cancerresearchuk.org/cancer-info/prod_consump/groups/cr_common/@nre/@sun/documents/generalcontent/cr_052628.pdf
  2. Pearce SHS, Cheetham TD. Diagnosis and management of vitamin D. BMJ 2010; 340: 142‐147.
  3. DOH . http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_132508.pdf
  4. UKMI Q+A What dose of Vitamin D should be prescribed for the treatment of vitamin D deficiency? http://www.evidence.nhs.uk/search?q=%22What+dose+of+vitamin+D+should+be+prescribed+for+the+treatment+of+vitamin+D+deficiency%22

Grateful thanks to Dr S Orme, Dr A Abbas and Nicola Butler at Leeds Teaching Hospitals for their invaluable help writing this guideline.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

 

 

 

 

 

 

 

Leeds Health Pathways