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Vitamin D Deficiency

  

Vitamin D blood levels should only be tested with symptoms indicative of rickets, osteomalacia or symptomatic hypocalcaemia. If deficiency is found with these symptoms, a course of high dose replacement therapy should be prescribed


Diagnosis of low vitamin D levels (deciding which patients to test)

Serum vitamin D levels should NOT be checked routinely

Testing of serum vitamin D levels in winter months (October to March) will result in naturally lower levels due to seasonal variation.

Levels should only be checked when a patient has symptoms that suggest rickets, osteomalacia, or symptomatic hypocalcaemia

Specific SYMPTOMS which may lead to testing of vitamin D levels if clinically appropriate

  • Severe aching in bone and muscles
  • Proximal muscle weakness making standing up and walking difficult and painful.
  • Marked waddling gait
  • In all other cases with risk factors for deficiency lifestyle advice should be provided.
Testing for vitamin D deficiency

Test for 25-hydroxyvitamin D (25-OHD) levels which represent serum concentration of vitamin D3.

Clinicians may also choose to test serum calcium, phosphate, alkaline phosphatase and parathyroid hormone levels (bone profile) when clinically appropriate.

Interpreting vitamin D levels

Deficient:       < 25nmol/l
Insufficient:    = 25-50nmol/l
Adequate:      > 50nmol/L
*Levels represent serum concentration of 25-hydroxyvitamin D (25-OHD)

Treatment of symptomatic vitamin D deficiency in adults

The primary aim of treatment is to replenish vitamin D stores then continue with a lower maintenance dose of vitamin D.

Oral loading regimen of vitamin D3 (colecalciferol) up to a total of approximately 300,000 units vitamin D given either as weekly or daily split doses.

Followed with a maintenance dose of 800 to 2000 units of oral vitamin D3 (colecalciferol) daily or larger doses at less frequent intervals (over the counter)

Monitoring vitamin D levels during treatment

Vitamin D levels do not need to be checked routinely, and can take 3-6 months to reach a steady state after treatment has started.

Local specialists recommend re-checking vitamin D levels 6 months after a loading regimen of vitamin D has been given.

If levels are still sub-optimal, compliance with medication should be discussed. Alternatively, consider referral to an appropriate specialist.

Calcium levels should be checked 1 month after the final loading dose of vitamin D to detect patients with sub-clinical primary hyperparathyroidism.

Providing an oral loading regimen of vitamin D is unlikely to cause hypercalcaemia but if concerned, clinicians should consider checking calcium levels as they are a more appropriate indicator of toxic levels of vitamin D.

Where unexplained nausea and / or vomiting in a patient taking pharmacological doses of vitamin D consider checking calcium levels

Choice of vitamin D products

MHRA guidance advise that prescribers use licensed products wherever possible.

Table 1: Coventry and Warwickshire treatment guidelines, based on expert consensus:

 

Summary of Treatment of Symptomatic Vitamin D Deficiency

Click link here or on right for full document

Choice of vitamin D products

MHRA guidance advise that prescribers use licensed products wherever possible.

Coventry and Warwickshire treatment guidelines, based on expert consensus:

Referral to UHCW Metabolic Bone and Osteoporosis Service

The service led by Dr Randeva, Consultant Endocrinologist, sees a wide range of patients with calcium disorders, Vitamin D deficiency and Primary Hyperparathyroidism.

Severe Vitamin D deficiency is rapidly becoming a serious health issue in the UK and world-wide.

We have well established expertise in treatment of parathyroid disease and parathyroid adenomas. We work closely with our endocrine surgical colleagues (Prof. Mehana, ENT) to manage patients who require parathyroidectomy.

University Hospital in Coventry is one of the handful of centres that offer minimally invasive parathyroid surgery.

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