Vitamin D Deficiency in adults

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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties

Vitamin D is an essential vitamin for musculoskeletal health as it promotes calcium absorption from the bowel and enables mineralisation of newly formed osteoid tissue in bone.

The main natural source of vitamin D is from skin synthesis following exposure to sunlight. In the UK, there is no ambient ultraviolet sunlight of appropriate wavelength from mid-October to early April, so the population has to rely on both body stores from the summer and dietary sources.

According to surveys, a significant portion of the UK population has low vitamin D levels, particularly in the winter months. Therefore, there is growing interest in the importance of vitamin D and correction of deficiency states.

The National Osteoporosis Society has issued a guide called Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management, upon which the guidance used in this pathway was largely based.

NICE have also issued  public health guidance 56, Vitamin D: increasing supplement use in at-risk groups.

There is still a need for local guidance to address inconsistencies in practice and practical issues

Patient Information Leaflet available from:

Vitamin D  Food Facts sheet

https://www.bda.uk.com/foodfacts/VitaminD

NSCCG Sign off form

 https://www.prescriber.org.uk/

Public Health England has issued new advice on vitamin D based on the recommendations of the Scientific Advisory Committee on Nutrition.

The advice notes that vitamin D is made in the skin on exposure to UVB in sunlight but since this is difficult to quantify a daily dietary intake of 10 micrograms is being recommended.

It is noted that in spring and summer the majority of the population get enough vitamin D through sunlight on the skin and a healthy, balanced diet. In autumn and winter months it is difficult for people to meet the 10 microgram recommendation from consuming foods naturally containing or fortified with vitamin D so people should consider taking a daily supplement containing 10 micrograms of vitamin D.

The advice also considers people whose skin has little or no exposure to the sun, like those in institutions such as care homes, or who always cover their skin when outside and recommends that they need to take a supplement throughout the year.

Ethnic minority groups with dark skin, from African, Afro-Caribbean and South Asian backgrounds, may not get enough vitamin D from sunlight in the summer and therefore should consider taking a supplement all year round.

Recommendations are also made for children under 5. Children from birth to 1 year old who are breast feed should be given a daily supplement containing 8.5 to 10 micrograms of vitamin D. Formula fed children of this age consuming 500ml or more each day do not require a daily supplement because infant formula is fortified with vitamin D. Children aged 1 to 4 years should be given a daily supplement containing 10 micrograms of vitamin D. It is noted that low-income families can access vitamin D free of charge via Healthy Start schemes.

Action: Clinicians should be aware of this new advice. The advice consistently refers to "dietary sources" of vitamin D including foods naturally containing or fortified with vitamin D and supplements. As such prescribing of vitamin D purely for supplementation following this advice should be resisted.

There is no level of 25(OH)-vitamin D below which symptoms are always present, and symptoms from vitamin D deficiency are very
rare in white individuals in the UK.

There is no indication to check vitamin D status, unless the person presents with signs or symptoms of vitamin D deficiency (see
editorial from The Lancet, January 2012 vitamin D testing and BMJ July 2012 vitamin D: some perspective please).

The potential musculoskeletal manifestations of vitamin D deficiency are:

• proximal muscle weakness
• bone pain
• bony deformity
• stress fractures or fragility fractures
• soft tissue pain (should only be considered in high risk groups with chronic soft tissue pain)

Investigations may show:

• low/ low-normal serum calcium
• normal/raised alkaline phosphatase
• normal/ raised PTH

The histological appearance in the bone is “osteomalacia”, where the protein matrix of the bone is normal, but is insufficiently
mineralised.
These are non-specific symptoms and are also a feature of other conditions such as polymyalgia rheumatica, inflammatory arthritis,
hypothyroidism and myeloma. Consider performing specific investigations for these conditions before considering Vitamin D
deficiency.

Vitamin D3 (colecalciferol) is made in the skin through the action of ultraviolet light. It then undergoes further changes in the liver abd kidney to become active. Some colecalciferol is obtained from the diet, such as fish, eggs and fortified foods.

Risk factors include:

• Lack of sun exposure, for example those who cover skin when outside, either for cultural/religious reasons or who habitually wear sunblock, patients with darker skin, housebound or elderly patients, residents in care homes, and patients who have recently been released from prison
• Malabsorption and dietary factors, including short bowel syndrome, cholestatic liver disease, coeliac disease, obesity or vegan/vegetarian diet
• Medications which can affect absorption of vitamin D, such as anticonvulsants, colestyramine, glucocorticoids, antiretrovirals, orlistat
• Age >65 years
• Concurrent conditions with a risk of vitamin D deficiency, for example

Vitamin D 400iu daily is recommended for ALL pregnant or breastfeeding women, until the child is 1 year of age.

In the mother Vitamin D deficiency leads to an increased risk of calcium malabsorption, bone density loss, poor weight gain, myopathy, and higher parathyroid hormone levels.

In the infant there is a risk of neonatal hypocalcaemia, hypocalcaemic seizures, infantile heart failure, enamel defects, large fontanelle,reduced bone mineral density or congenital rickets (or rickets of infancy if breastfed).

Those at higher risk of vitamin D deficiency in pregnancy include:

• women who are not exposed to much sun, for example those who cover their skin for cultural reasons, who are housebound or
  confined indoors for long periods
• women from ethnic minorities who have darker skin, because their bodies are less able to produce vitamin D. Clinical deficiency has been most reported among children of African-Caribbean and South Asian origin
• multiple pregnancies within a short time frame
• women on certain anticonvulsant medication
• women with BMI >30

There is no need to routinely monitor vitamin D levels, however, serum calcium levels should be checked one month and three months after starting pharmacological doses of vitamin D in a pregnant patient to avoid the risk of maternal and foetal hypercalcaemia.

More information on vitamin D deficiency in pregnancy can be found at: https://www.sps.nhs.uk/articles/which-oral-vitamin-d-dosing-regimens-correct-deficiency-in-pregnancy/

• Gradual onset and persistent bone pain without preceding mechanical injury (frequently in back or lower limb)
• General musculoskeletal pain
• Bone pains
• Proximal muscle weakness (difficulty with stairs, getting up off the floor or standing after sitting in a low chair)
• Waddling gait or change in gait

Some patients may complain of general tiredness, which should only be considered in combination with other symptoms which may be attributed to vitamin D deficiency. Tiredness alone is not an indication of vitamin D deficiency.

Consider specialist referral at diagnosis if any of the following are present:

• renal impairment (eGFR <30mL/min, CKD stages 4-5)
• renal stones
• hypercalcaemia (Ca²⁺ >2.6mmol/L)
• liver function tests abnormal across the range (note raised alkaline phosphatase is common in vitamin D deficiency)
• hyperparathyroidism
• iron deficiency should be investigated in the context of the patient's individual circumstances
• sarcoidosis
• active tuberculosis
• malabsorption, e.g. coeliac disease
• chronic liver disease
• patients with lymphoma or metastatic cancer
• patients who fail to respond to treatment despite good compliance with supplementation for six months
• pregnant patients presenting with vitamin D deficiency

These conditions are those where calcium level may be adversely affected by treatment or the absorption or conversion of 25(OH)vitamin D to 1,25(OH) Vitamin D is affected and therefore specialist involvement may be required.

 
 
Depending on outcome, the patient may still require vitamin D treatment in primary care, but with support from a specialist

Information and advice should be given, including safe exposure to sunlight as well as advice on diet and supplements. The following leaflets may be printed out and given to patients.

Public Health England - Vitamin D: All you need to know

British Dietetic Association: Vitamin D food fact sheet

NOTE: Patients with current bone disease could be considered for testing prior to corrective treatment

Dietary intake delivers around 2-4mcg (80-160 iu ) of vitamin D per day:

• oily fish (canned or fresh) is the best source of vitamin D
• small quantities of vitamin D are found naturally in:
• egg yolk
• liver
• meat
• dairy products
• vitamin D fortification is mandatory in margarine and formula milk
• many breakfast cereals are fortified with vitamin D
• vitamin D fortification is mandatory in margarine and formula milk
• many breakfast cereals are fortified with vitamin D

90% of daily vitamin D requirement is obtained by the action of UVB sunlight on the skin. For most adults who do not fall within the risk groups, 2-3 exposures of sunlight per week during April to September are enough to achieve healthy vitamin D levels. Length of exposure is dependent on skin type and a common sense approach is needed. Typically up to 20-30 minutes per exposure is sufficient, avoiding high factor sunscreen for short exposures. This is not advice to get a suntan and sunburn should be avoided at all costs.

Those most at risk who should take a daily dietary supplement of 10mcg (400iu), as follows:

• all pregnant and breast-feeding women, especially teenagers and young women
• infants and young children under 5 years of age (7-8.5 mcg daily)
• older people aged 65 and over
• people who are not exposed to much sun for cultural reasons, or those that are housebound
• people with dark skin, for example of African, African-Caribbean and South Asian origin, whose bodies are not able to make as much vitamin D

Vitamin D daily supplementation can be delivered in doses of 400 iu daily in adults. Most OTC multi-vitamin preparations contain
adequate doses of 200-400iu daily (5-10mcg) and supplementation doses are not usually required in patients who are not in the risk
groups listed above.

Encourage self-care where appropriate

Supplements for use in pregnancy and in young children may be accessed through the national Healthy Start Vitamins scheme.

http://www.healthystart.nhs.uk/for-health-professionals/vitamins/vitamins-in-england/

Daily supplements can also be purchased over the counter (OTC) from pharmacies or health food shops. Relatively inexpensive examples include;

• Superdrug Pregnancy Care multivitamins
• The Haliborange baby and toddler multivitamin range
• Boots D3 400iu
• Tesco Vitamin D 10mcg
• Holland and Barrett D3 colecalciferol 400iu capsules or tablets
• HealthSpan multivitamin 50+

Serum vitamin D levels should not be checked routinely, and clinicians should actively avoid costly measurement of vitamin D levels in asymptomatic patients who are not suspected to have bone disease.

Vitamin D levels should only be checked when a patient has both risk factors for vitamin D deficiency and symptoms which could be attributed to vitamin D deficient. Patients with current bone disease may also be considered for testing.

Once clinicians have decided which patients need to be tested for vitamin D deficiency, they should request a test for 25-hydroxyvitamin D (which represents serum concentration of vitamins D2 and D3)

 Clinicians should also review the following test results to aid with diagnosis;

• Serum calcium to exclude hypercalcaemia and provide a baseline. If low vitamin D is confirmed and calcium raised, parathyroid hormone should always be checked. Do not check parathyroid hormone routinely. Serum phosphate may also be useful
• Liver function test to exclude hepatic dysfunction. Raised alkaline phosphatase is common in vitamin D deficiency.
• Urea and electrolytes to assess and exclude renal disease
• Full blood count may be useful to exclude alternative diagnoses in some patients. If there is low ferritin with low 25-OH vitamin D, consider malabsorption, e.g Coeliac disease.

In primary hyperparathyroidism, vitamin D deficiency should be ruled out in all patients as it increases the severity of the disease, can mask hypercalcaemia, increases the risk of parathyroid tumorigenesis and leads to higher post-operative risk.

If vitamin D is less than 50nmol/L in patients with primary hyperparathyroidism, they should be supplemented with vitamin D.

In patients with an established diagnosis of primary hyperparathyroidism who require supplementation, calcium should be checked within two weeks of starting vitamin D to check for worsening of hypercalcaemia.

 
 
When interpreting vitamin D levels, consider if the deficiency result is due to a potentially reversible cause, or if it is likely to be a permanent cause, e.g. the time of year that the sample has been taken.

Aim for cumulative dose of 300,000 units per treatment course.

Offer information and advice

Options for oral high dose loading regimen

• 20,000 unit capsule, e.g. Fultium D3, 2 capsules weekly for 7 weeks
• 25,000 unit ampoules (InVita D3), 2 ampoules weekly for 6 weeks
• Fultium D3 3200 unit capsules, one capsule daily for 12 weeks

Adjusted serum calcium should be checked one month after completion of the loading regimen, or after starting supplementation with vitamin D in case primary hyperparathyroidism has been unmasked.

Following completion of a loading regimen, a daily maintenance dose of  should be prescribed, usually doses of 800 units to 2000 units are used, e.g. Fultium D3 capsules 1 or 2 daily.

There is no clear consensus on how long this supplementation should last.

There is no need to routinely check vitamin D levels unless the patient remains symptomatic following compliance with supplementation for at least six months.

 It may also be considered appropriate in patients with malabsorption, or where poor compliance is suspected.

 Always assess patient compliance with prescribed drug regimen.

Evidence suggests that patients on oral supplementation may take at least 6-8 months to reach a steady state on supplementation, so it is best to check levels at 8-12 months. if vitamin D levels are optimal (>75nmol/L), it is not recommended to retest unless indicated.

Check compliance and consider referral if symptoms of vitamin D deficiency are still present following a 3 month treatment course and the 25 (OH) vitamin D level is still <50 nmol/L after six months.
If not already ruled out then consider alternate diagnoses e.g polymyalgia rheumatica, inflammatory arthritis, hypothyroidism and myeloma:

• muscle weakness
• bone pain
• chronic soft tissue pain in high risk groups
• bony deformity
• fractures

If vitamin D level is only partly corrected at 6 months, consider repeating a loading dose and /or subsequent higher maintenance dose and/or specialist referral.

Local administrative information

Overt vitamin D toxicity manifests itself through chronic hypercalcaemia and is rarely seen. 

An oral loading regimen of vitamin D  is unlikely to cause hypercalcaemia, but clinicians should consider checking calcium as they are a more appropriate indicator of toxicity than vitamin D levels.

 Should unexplained nausea and/or vomiting occur in a patient taking pharmacological doses of vitamin D, consider checking calcium levels.  

 Vitamin D excess if serum 25-OHD >250 nmol/L:

• if asymptomatic and serum calcium <3.5mmol/L, stop the vitamin D supplementation - no need for referral. If serum calcium raised, re-check with vitamin D estimation after 1 month
• if symptomatic hypercalcaemia or serum calcium >3.5mmol/L this needs acute medical advice/ admission

A vitamin D level of 30-50nmol/L may be adequate in some people; however, in patients presenting with symptoms, treatment is advised.

More information is available in the NOS guide Vitamin D and Bone Health: A Practical Clinical Guideline for Patient

A supplementation regimen without a loading dose is recommended for the treatment of vitamin D insufficiency

• 20,000 unit capsules, e.g. Aviticol, Fultium D3 or Plenachol, or other licensed alternatives, one capsule monthly
• InVita D3 solution, 25,000 unit ampoule, one ampoule monthly
• Fultium D3 800 unit capsules, one or two (800-1600units) daily
• Desunin 800 unit tablets, one or two (800-1600units) daily
• Accrete D3 or Calceos tablets (or suitable alternative) - 1 tablet twice a day (note: contains calcium)

A vitamin D level of greater than 50nmol/L is sufficient for almost the whole population but information and lifestyle advice may be beneficial

Dietary intake delivers around 2-4mcg (80-160 iu ) of vitamin D per day:

• oily fish (canned or fresh) is the best source of vitamin D
• small quantities of vitamin D are found naturally in:
  • egg yolk
  • liver
  • meat
  • dairy products
• vitamin D fortification is mandatory in margarine and formula milk
• many breakfast cereals are fortified with vitamin D

90% of daily vitamin D requirement is obtained by the action of UVB sunlight on the skin. For most adults who do not fall within the risk groups, 2-3 exposures of sunlight per week during April to September are enough to achieve healthy vitamin D levels. Length of exposure is dependent on skin type and a common sense approach is needed. Typically up to 20-30 minutes per exposure is sufficient, avoiding high factor sunscreen for short exposures. This is not advice to get a suntan and sunburn should be
avoided at all costs.

The CMO letter (Feb 2012) restated messages around healthy diet and lifestyle in the prevention of vitamin D deficiency and
rickets, and highlighted those most at risk who should take a daily dietary supplement of 10mcg (400iu), as follows:

• all pregnant and breast-feeding women, especially teenagers and young women
• infants and young children under 5 years of age (7-8.5 mcg daily)
• older people aged 65 and over
• people who are not exposed to much sun for cultural reasons, or those that are housebound
• people with dark skin, for example of African, African-Caribbean and South Asian origin, whose bodies are not able to make as much vitamin D

Vitamin D daily supplementation can be delivered in doses of 400 iu daily in adults. Most OTC multi-vitamin preparations contain
adequate doses of 200-400iu daily (5-10mcg) and supplementation doses are not usually required in patients who are not in the risk
groups listed above.

Encourage self-care where appropriate

Supplements for use in pregnancy and in young children may be accessed through the national Healthy Start Vitamins scheme.

http://www.healthystart.nhs.uk/for-health-professionals/vitamins/vitamins-in-england/

Daily supplements can also be purchased over the counter (OTC) from pharmacies or health food shops. Relatively inexpensive examples include;

• Superdrug Pregnancy Care multivitamins
• The Haliborange baby and toddler multivitamin range
• Boots D3 400iu
• Tesco Vitamin D 10mcg
• Holland and Barrett D3 colecalciferol 400iu capsules or tablets
• HealthSpan multivitamin 50+