Patients with diseases that may be improved with treatment e.g. confirmed osteomalacia, osteoporosis (testing not needed if prescribing calcium/vitamin D and bisphosphonate).

Patients with musculoskeletal symptoms that could be attributed to deficiency e.g. suspected osteomalacia, chronic widespread pain.

Do not test: Asymptomatic individuals at risk of deficiency (treat as per

DH guidance). Universal population screening of asymptomatic healthy

individuals is not recommended.

Regular but sensible exposure to sunlight - 20-30 minutes around midday on the face and forearms 2-3 times a week during the months of April-October. Exposure may need to be longer in darker skinned people.

Dietary source: principally found in oily fish / fish oils – 2-3 portions a week. Also in egg yolk and some breakfast cereals.

References and further reading: Diagnosis and Management of Vitamin D Deficiency.

BMJ 2010;340:142 East & South East England Specialist Pharmacy

Service. Vitamin D Deficiency and insufficiency; using appropriate products. April 2012

Vitamin D deficiency Other treatment regimes have been used and the following is only a guide.

Vitamin D insufficiencyMost people may have adequate calcium absorption.

Vitamin D replete

serum 25-OHD concentrations

< 30 nmol/L

30-50nmol/LPotentially at risk

>50nmol/L

Recommended treatment and duration

PRO D3® capsules20 000 IU three times a week for 8-12 weeks OR60 000 IU once a week for 8-12 weeksMaintenance: Desunin® 800 IU take 1-2 tablets daily

Desunin® 800 IU take 1 - 2 tablets daily

Vitamin D supplementation with 10 micrograms (400 IU) is recommended for those considered “as risk” as per DH Guidance

Prescriber

GP’s or Hospital Consultants

GP to maintain

GPs or hospital

GPs, hospital or over the counter supply

Drug status

Unlicensed – food supplement

Licensed

Licensed

Licensed

Who to Test (£19 per test)

In patients with primary hyperparathyroidism the low vitamin D level can be a compensatory change. Check serum calcium and in patients with high serum calcium and normal or high parathyroid hormone, discuss their case with an endocrinologist before initiating treatment. In all patients with deficiency, 25 OHD levels should be re-checked after 4 weeks and treatment amended to a maintenance rate if level is greater than 50ng/ml. Further high dose courses may be prescribed by the specialist if targets have not been achieved.Some drug treatments represent an additional risk factor for lowering vitamin D levels, these include; some anticonvulsants, corticosteroids, rifampicin and antiretrovirals. Vitamin D supplements (+/- calcium) should be considered for these patients.For others at risk where calcium and vitamin D supplements may be appropriate, see the DH correspondence “Vitamin D – advise on supplements for at risk groups.

Additional Notes

Desunin® tablets are licensed for treatment and do not contain peanut oil. Pro D3®, classed as a food supplement, does not contain peanut oil, is Halal, Kosher and gelatine free. The product has a

wide range of strengths including; 400; 1000; 2500; 10,000; 20,000 and 30,000IU. Both Desunin® and Pro D3® are readily available from wholesalers. Ergocalciferol in doses of up to 300,000 IU is available for injection preparation. It should be considered for patients with

severe malabsorption and will need discussion with a specialist. 400 IU vitamin D = 10 micrograms. Calceos®, Adcal D3® or Calcichew D3 Forte® may be prescribed in supplementation therapy when additional calcium is

required. These all provide 400 IU of Vitamin D.

Vitamin D products: as colecalciferol or ergocalciferol

Recommendations to patients

UK Medicines information (UKMi). What Dose of Vitamin D. October 2010 CMO letter to GPs. Vitamin D – vitamin D supplements for at risk groups National Osteoporosis Society. Vitamin D and Bone Health. April 2013 DOH. Vitamin D – advice on supplements for at risk groups –

correspondence

Management of Vitamin D Deficiency and Insufficiency in Adults

Version: 1 Authors: John Hampton Issue Date: December 2013 Review Date December 2015, Diane Tomlinson