Vitamin D deficiency

Vitamin D is a fat soluble vitamin used by body for normal bone development and maintenance by increasing the absorption of Calcium , Magnesium and Phsophate
 ( Omeed Sizar , Swapnil Khare , Amy Gilver 2019 )

A UK survey ( BMJ 2010 ) showed that more than 50% of the adult population have 
insufficient levels of Vit D and that 16 % have severe deficiency during winter and spring

It is the most common nutritional deficiency in the world

Causes- Insufficient 
exposure to
 sunlight Inadequate 
dietary and supplemental
 vit D Impaired absorption eg
Malabsorption , obesity ,
 severe liver failure Impaired activation 
of Vit D eg
CKD , Liver disease , inherited enzyme disorders Nephrotic syndrome Drugs eg

Orlistat
Anticonvulsants – carbamazepine , phenobarbital , phenytoin
colestyramine , corticosteroids , 
HAART ( antiretroviral therapy )
rifampicin

Recommended test is
 to check circulating 25-hydroxyvitamin D – 
{25 (OH )D level }

Risk factors –Pigmented skin Limited sun exposure or atmospheric pollution
○ More than 90 % of Vit D is derived from UV B light
○ Winter months ( oct- april ) in most of Western world UV B is inadequate for Vit D synthesis
○ cultural reasons- covering skin
○ strict sunscreen use Dietary eg
○ strict vegans – who do not eat fish Pregnant or breast feeding○ Exclusive breast fed babies Multiple short interval pregnancies Ageing ( reduced ability of skin to produce vit D ) Obese – BMI > 30 ( inverse association of seum 25(OH)D and BMI
or had gastric bypass surgery Institutionalized or housebound Family h/o vit D deficiency

No evidence 
demonstrating benefits
 of screening for 
Vit D deficiency at a 
population level

Suspected Rickets-Deficient mineralisation at growth plate of long bones – particularly at sites of rapid bone growth Progressive bowing of legs
bowing of legs can also be a normal finding in toddlers Progressive knock knees Wrist swelling Rachitic rosary – swelling of the costochondral junctions Craniotabes- skull softening with frontal bossing and delayed fontanelle closure Delayed tooth eruption and enamel hypoplasia

Who to test

Long standing ( > 3 mts ) unexplained bone pain Proximal muscular weakness and pain Tetany due to low calcium Seizures due to low calcium
( usually in infancy ) Infantile cardiomayopathy Bone disease as osteomalacia , osteoporosis or Paget’s disease

Low Calcium or Phosphate High AlkPo4 -
more than 80 % adults with osteomalacia have ↑↑ AlkPo4 Radiographs showing osteopenia , rickets or pathological fractures Chronic renal disease Chronic liver disease Malabsorption syndromes
○ coeliac
○ Crohn’s
○ cystic fibrosis

Investigations- Bone profile Renal liver and thyroid function PTH FBC including Ferritin Malabsorption screen Rheumatoid and other autoimmune screening Inflammatory markers – ESR/ CRP

Treatment- Invita D3 oral solution ( plastic ampoules )
two oral ampoules ( 25000 Units each ) every week for 6 weeks Plenachol or Aviticol 20,000 Units , 3 caps weekly for 5 weeks Fultium -D3 3200 unit capsules – once / day for 12 weeks Hux D3 – 3 capsules once a week for 5 weeks supplements should be taken with food to aid absorption Ergocalciferol IM inj – 7.5 mg ( 300 , 000 IU ) in 1 , 2 ml ampoules Maintenance regimens may be considered 1 month after loading dose- given daily or intermittently. Maintenance – consider 1 month after loading dose and doses 800- 2000 units daily

Eg Fultium D-3 20 mcg
 ( 800 IU capsules )

Follow up-Calcium and renal profile – 1 month Check Vit D level atleast 3 months after initiating therapy Consider more regular calcium level checking in people receiving Ca supplements in addition to high dose vitamin

Lifestyle advice-Consider 400 IU of Vit D through the year- for all adults in UK including those at higher risk Fair skinned people 20-30 minutes of sunlight exposure on the face and forearms at midday can generate upto 2000 IU of Vit D two to three such exposure a week can be enough Sunbeds –> not effective emit high levels of UVA which do not contribute to Vit D synthesis Most important dietary source
○ oily fish- as salmon , mackerel , sardines
○ cod liver oil
○ Egg yolk , meat , offal , milk , mushrooms and fortified foods Also important to maintain dietary intake of calcium

Referral to secondary care- Malabsorption disorders – need higher doses Fragility fracture , documented osteoporosis or high risk fracture or is being treated with an antiresorptive drug Severe kidney disease People with conditions with ↑↑ sensitivity to Vit D –> higher risk of toxicity ( need lower doses ) Repeated low calcium with or without symptoms Children with suspected rickets Poor response to treatment ie
25(OH) D level < 50 8-12 weeks after treatment Persistent low serum phosphate or low/high alkaline phosphatase On anti-eplileptic medication or an oral corticosteroid or taking any other medication which can cause deficiency Unexplained deficiency

Pregnant and
 breastfeeding women 
should take 400 IU 
( 10 mcg ) of Vit D daily to prevent deficiency

LINKS AND RESOURCES

INFORMATION FOR PATIENTS

The patient can register and request Vit D Supply Health Start Vitamin Vouchers https://www.healthystart.nhs.uk/

How much calcium and Vitamin D- does a patient need ? Information from National Osteoporosis Foundation https://www.nof.org/patients/treatment/calciumvitamin-d/

A 2 page plain  pdf summary factsheet for patients from The Association of UK Dietitians on Vitamin D https://www.bda.uk.com/foodfacts/VitaminD.pdf

A very useful 3 page pdf  summary from National Institutes of Health–https://ods.od.nih.gov/pdf/factsheets/VitaminD-Consumer.pdf

A page on Vitamin D from the British Association of Dermatologists http://www.bad.org.uk/skin-cancer/vitamin-d

An authoritative information resource for patients from the National Osteoporosis Society https://theros.org.uk/media/98141/vitamin-d-supplements-and-tests.pdf

A paper on Vitamin D –  particularly written for patients from The Journal of Clinical Endocrinology and Metabolism https://academic.oup.com/jcem/article/96/7/1/2833362

Medline Plus information for patients- a comprehensive patient resource https://medlineplus.gov/vitamind.html

Rickets information for parents from The Royal Free London https://www.rcpch.ac.uk/sites/default/files/BPSU_Rickets_Public_information_leaflet_v6-02082016.pdf

Rickets information from Rare Diseases Database https://rarediseases.org/rare-diseases/rickets-vitamin-d-deficiency/

INFORMATION FOR CLINICIANS

NICE Vitamin D supplement use in specific population groups https://www.nice.org.uk/guidance/ph56

Scientific Advisory Committee on Nutrition – Vitamin D and health 2016 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/537616/SACN_Vitamin_D_and_Health_report.pdf 

National Institute of Health – Information for clinicians https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

National Osteoporosis Society – Vitamin D and Bone Health https://theros.org.uk/media/100233/nos_vitamin_d_and_bone_health_in_children_web.pdf

Royal Osteoporosis Society– a quick treatment summary for GPs https://theros.org.uk/healthcare-professionals/courses-and-cpd/osteoporosis-resources-for-primary-care/investigation/how-should-gps-assess-vitamin-d-deficiency/

European Society of Endocrinology – Vitamin D testing and treatment: a narrative review of current evidence in Endocrine Connections – Open access an excellent comprehensive review https://ec.bioscientifica.com/view/journals/ec/8/2/EC-18-0432.xml

References

1. NOGG 2017 Clinical guideline for the prevention and treatment of osteoporosis National Osteoporosis Guideline Group on behalf of: Bone Research Society British Geriatrics Society
   British Orthopaedic Association British Orthopaedic Research Society International Osteoporosis Foundation Osteoporosis 2000 Osteoporosis Dorset Primary Care Rheumatology Society Royal College of General Practitioners Royal Osteoporosis Society
   Royal Pharmaceutical Society Society for Endocrinology Updated July 2019
   www.shef.ac.uk/NOGG
2. Vitamin D and bone health: A practical clinical guideline for patient management – National Osteoporosis Society Guideline 30 MAY 2013 Dr Terence Ong is a Research Fellow at Nottingham University Hospitals NHS Trust.Professor Opinder Sahota is Professor of Orthogeriatric Medicine and Consultant Physician at Nottingham University Hospitals NHS Trust https://www.bgs.org.uk/blog/vitamin-d-and-bone-health-a-practical-clinical-guideline-for-patient-management-%E2%80%93-national
3. Vitamin D and bone health : a practical clinical guideline for management in children and young people Diagnosis and management of vitamin D deficiency BMJ 2010 ;340: b5664
4. What dose of vitamin D should be prescribed for the treatment of vitamin D deficiency?Published 16th February 2017, updated 9th April 2020
5. Coventry & Warwickshire Area Prescribing Committee Clinical guideline – CG019 Vitamin D Prescribing Guidelines- Adults June 2017
6. Michael F. Holick, Neil C. Binkley, Heike A. Bischoff-Ferrari, Catherine M. Gordon, David A. Hanley, Robert P. Heaney, M. Hassan Murad, Connie M. Weaver, Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 96, Issue 7, 1 July 2011, Pages 1911–1930, https://doi.org/10.1210/jc.2011-0385
7. CKS NICE Vitamin D deficiency in adults- treatment and prevention November 2016 https://cks.nice.org.uk/vitamin-d-deficiency-in-adults-treatment-and-prevention
8. Vitamin D Deficiency BMJ Best practice https://bestpractice.bmj.com/topics/en-gb/641
9. Braegger, Christian^*; Campoy, Cristina^†; Colomb, Virginie^‡; Decsi, Tamas^§; Domellof, Magnus^||; Fewtrell, Mary^¶; Hojsak, Iva^#; Mihatsch, Walter^**,1; Molgaard, Christian^††; Shamir, Raanan^‡‡; Turck, Dominique^§§; van Goudoever, Johannes^||||,2on Behalf of the ESPGHAN Committee on Nutrition Vitamin D in the Healthy European Paediatric Population, Journal of Pediatric Gastroenterology and Nutrition: June 2013 – Volume 56 – Issue 6 – p 692-701 doi: 10.1097/MPG.0b013e31828f3c05
10. NHS Wales ( 2014) Diagnosis and management of vitamin D deficiency in adults
11. PHE guidance on Vit D accessed via https://www.gov.uk/government/news/phe-publishes-new-advice-on-vitamin-d
12. Sizar O, Khare S, Goyal A, et al. Vitamin D Deficiency. [Updated 2020 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532266/
13. Rusińska, Agnieszka et al. “Vitamin D Supplementation Guidelines for General Population and Groups at Risk of Vitamin D Deficiency in Poland-Recommendations of the Polish Society of Pediatric Endocrinology and Diabetes and the Expert Panel With Participation of National Specialist Consultants and Representatives of Scientific Societies-2018 Update.” Frontiers in endocrinology vol. 9 246. 31 May. 2018, doi:10.3389/fendo.2018.00246