Treatment of Vitamin D Deficiency

Patient identification

The Royal Osteoporosis Society (ROS) has categorised the population into 4 groups based on their differing health needs.1 This categorisation helps to identify the increasing prevalence of vitamin D deficiency within each patient group.

Plasma 25(OH)D

The Royal Osteoporosis Society advises that in those patients where 25(OH)D is tested, the results be acted upon as follows:¹

Plasma 25(OH)D < 25 nmol/L - treatment recommended.
Plasma 25(OH)D 25–50 nmol/L - treatment is recommended in patients with the following:

Fragility fracture, documented osteoporosis or high fracture risk.
Treatment with antiresorptive medication for bone disease.
Symptoms suggestive of vitamin D deficiency.
Increased risk of developing vitamin D deficiency in the future because of reduced exposure to sunlight, religious/cultural dress code, dark skin, etc.
Raised PTH.
Medication with antiepileptic drugs or oral glucocorticoids.

Treatment recommendations

The Royal Osteoporosis Society recommends:¹

Vitamin D3 is recommended as the vitamin D preparation of choice.
Oral administration of vitamin D is recommended.
Recommended treatment based on fixed-loading doses and maintenance therapy.
Where correction of vitamin D deficiency is less urgent and when co-prescribing vitamin D supplements with an oral antiresorptive agent, maintenance therapy may be started without the use of loading doses.
Where rapid correction of vitamin D deficiency is required, such as in patients with symptomatic disease or about to start treatment with a potent antiresorptive agent (zoledronate or denosumab or teriparatide), the recommended treatment regimen is based on fixed loading doses followed by regular maintenance therapy.

Example regimens

Loading

Loading regimens for the treatment of deficiency up to a total of approximately 300,000 IU given either as weekly or daily split doses. The exact regimen will depend on the local availability of vitamin D preparations but will include:¹

50,000 iu (tablets, capsules or liquid) once weekly for six weeks (300,000 iu).
40,000 iu given weekly for seven weeks (280,000 iu).
1,000 iu tablets, four a day for 10 weeks (280,000 iu).
800 iu capsules, five a day given for 10 weeks (280,000 iu).

This list is not exhaustive. the following should be borne in mind:

Advise that calcium/vitamin d combinations not be used as sources of vitamin d for the above regimens, given the resulting high dosing of calcium. however, some calcium supplementation may be required, especially where a patient’s dietary calcium intake is low or osteomalacia is suspected. however, giving calcium may increase the risk of hypercalcaemia in rare cases where primary hyperparathyroidism is unmasked.

Maintenance

Maintenance regimens should generally be started one month after loading with doses equivalent to 800 to 2,000 iu daily (occasionally up to 4,000 iu daily), given either daily or intermittently at a higher equivalent dose.

The strategies below have been demonstrated not to work or to have a high risk of being ineffective or causing toxicity, and are therefore not to be recommended:¹

Annual depot vitamin d therapy either by intramuscular injection or orally.

Use of activated vitamin d preparations (calcitriol and alfacalcidol).

Monitoring

Assess plasma calcium levels one month after administration of the last loading dose.
Routine monitoring of plasma 25(oh)d is generally unnecessary but may be appropriate in patients with symptomatic vitamin d deficiency or malabsorption and where poor compliance with medication is suspected.

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References

1. Royal Osteoporosis Society: Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management. Available at: https://strwebprdmedia.blob.core.windows.net/media/ef2ideu2/ros-vitamin-d-and-bone-health-in-adults-february-2020.pdf Last accessed: November 2023.

KKI/UK/STX/0024 November 2023