Download Vitamin D Deficiency in patients with eGFR >30ml/min

In partnership with The Ipswich Hospital NHS Trust
Primary Care Pathway for Adult (>18 years) Vitamin D
Deficiency in patients with eGFR >30ml/min
Serum 25-OHD concentration
Vitamin D status
Manifestation
Management
Deficient
Rickets, Osteomalacia
Treat with high dose colecalciferol
30-50nmol/L
Adequate in some
Associated with disease risk
Vitamin D supplementation
50 nmol/L
Sufficient for almost
whole population
Healthy
Lifestyle advice
<30nmol/L
Does patient have symptom(s)
of vitamin D deficiency?
e.g. Gradual onset and persistent
musculoskeletal pain (often in back
or lower limbs); proximal muscle
weakness; waddling gait.
Or
Is the patient in one of the
following high risk groups?
e.g. Osteoporosis patients who will
or are being prescribed potent
antiresorptive agents (zoledronate
or denosumab), high fracture risk,
osteomalacia; on certain
medication (rifampicin,
antiretrovirals (HAART),
antiepileptics, cholestyramine,
Yes
glucocorticoids,
antifungals.)
Refer to secondary care (this list is not exhaustive):
Vit D <30 nmol/L
Deficiency
Malabsorption syndromes, short bowel or cholestatic liver disease
o Adjusted doses may be required

Primary Hyperparathyroidism
o Vitamin D replacement: Initiate in secondary care due to risk of
worsening hypercalcaemia. Treatment can be continued in primary care.
o Vitamin D maintenance: Use preparations that contain vitamin D only.
No




Yes
Investigations
2+
Serum 25-OHD; bone profile (Ca ,
PO4); U&Es; LFTs, PTH


Chronic Kidney Disease (CKD) (eGFR<30ml/min)
Does patient fall into another risk
category?
≥65 years
Pregnancy + breastfeeding
Low or no exposure to the sun (e.g.
those who cover their skin for cultural
reasons; housebound patients; care
home residents.)
Pigmented skin
Vit D 30–50 nmol/L
Adequate
Vit D >50 nmol/L
Sufficient
No
 Vitamin D 50,000 units once weekly
for 6 weeks
 Prescribed as:
InVita D3 50,000 units oral
solution (colecalciferol) ONE
ampoule weekly for 6 weeks.
InVita D3 is a licensed medicine in
the UK. It is suitable for vegetarians,
price of 6 week course £12.50
In patients with corrected calcium
levels >2.50mmol/L vitamin D
replacement should only be initiated
with advice from secondary care.
2+
Check Ca after 4 weeks in these
patients.
Retesting is not routinely required
but may be useful if patient remains
symptomatic or for patients with poor
compliance.
Recommend patient purchases
vitamin D 1000 units daily after
treatment course, see overleaf for
options.
No
Yes
Do not routinely check vitamin D
levels if asymptomatic
Provide lifestyle advice (see overleaf
for additional information)
Treat Deficiency

Do NOT check vitamin D levels –
consider alternative diagnosis
Does the patient have the
following?
Yes







Fragility fracture, osteoporosis
or high fracture risk
Treatment with antiresorptive
medication
Symptoms 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 parathyroid hormone
(PTH).
Medication with antiepileptic
drugs or oral glucocorticoids.
Conditions associated with
malabsorption.
 Regular, safe, sun exposure
 Dietary sources of vitamin D
 Consider recommending over the
counter vitamin D supplements where
appropriate (see overleaf for suitable
products)
 Vitamin D plus calcium
supplementation may be indicated in
those with or at risk of osteoporosis
(e.g. postmenopausal women), vegans,
and those on bisphosphonate therapy.
The Department of Health recommends
vitamin D supplements for the following
groups:
 People aged 65 years and over and
people who are not exposed to sun
should take a daily supplement
containing 400 units (10 mcg) of
vitamin D.
 All pregnant and breastfeeding
women should take a daily
supplement containing 400 units (10
mcg) of vitamin D.
MHRA recommends that vitamin D
supplementation is considered for at risk
patients who receive treatment with
primidone, phenytoin, carbamazepine,
phenobarbital, or sodium valproate.
In partnership with The Ipswich Hospital NHS Trust
Adult Vitamin D Deficiency Pathway Continued
Sun Exposure



Over 90% of the body’s vitamin D is produced from the action of sunlight on the skin. Sun exposure between 10am to 3pm from
April to October for 5-15mins should be sufficient to improve vitamin D status.
In a fair skinned person, 20-30minutes of sunlight exposure to the face and forearms at midday generates about 2000 units
(50mcg) of vitamin D.
Two or three sunlight exposures per week can achieve adequate vitamin D levels in the summer so long as the individuals have
sufficient levels to begin with.
Dietary Sources

Excellent food sources (greater than 200 units (5mcg) per portion) of vitamin D include 2 teaspoons cod liver oil, 70g sardines,
100g tinned salmon, pilchards or tuna, 110g of cooked mackerel or herring and 130g cooked kipper. Other sources are egg
yolks, mushrooms, fortified breakfast cereals, milk and margarine.
Examples of vitamin D products available for adults
Product
Supermarket own brand Vitamin D3
1000 units (25mcg) tablets
Approximate price
90 tablets from £2
Source
Suitability
Major supermarket chains in
store and online
Check product packaging
Boots Pharmaceuticals Vitamin D3
1000 units (25mcg) tablets
90 tablets £5.10
Available for purchase only from
Boots www.boots.com
Suitable for vegetarians but
not vegans
Deva Vegan Vitamin D
Vitamin D2 800 units (20mcg) tablets
Holland and Barrett Better You Dlux
Spray Fast Acting Liquid Vitamin D3
1000 units (25mcg)/1 spray
90 tablets £6.95
Available for purchase online
Suitable for vegetarians
and vegans
15mls £7.29
Available for purchase only from
Holland and Barrett
www.hollandandbarrett.com
Suitable for vegetarians but
not vegans
56 tablets free of
charge where eligible
Available from midwives, health
visitors and childrens centres
and also some pharmacies. For
more info visit
www.healthystart.nhs.uk
Suitable for vegetarians but
not vegans
30 tablets
Price vary from £4.00
Various supermarkets, chemists
and online
Suitable for vegetarians but
not vegans
Examples of vitamin D products for pregnant women
Healthy Start Vitamins for Pregnant
women
Vitamin D3 400 units (10mcg)
(Also contains vitamin C and folic acid)
Pregnacare multivitamins and minerals
Vitamin D3 400 units (10mcg)
(Also contains multiple other
constituents)
Sanatogen Mum to Be Multivitamins
and minerals
Vitamin D3 400 units (10mcg)
(Also contains multiple other
constituents)
30 tablets
Prices vary from £5
Various supermarkets, chemists
and online
Suitable for vegetarians but
not vegans
References
Pearce S and Cheetham T. Diagnosis and management of vitamin D deficiency. BMJ. Volume 340. January 2010
PresQIPP. Vitamin D: Deficiency & insufficiency practical information for GPs. July 2012
Vitamin D deficiency & insufficiency in adults and paediatrics: a guideline collation document for London and East and South East England. March
2011
Summary of Product Characteristics. InVita D3 50,000 IU oral solution. Last Updated 3-Feb-2016. Accessed via www.medicines.org.uk on
08/06/16
National Osteoporosis Society, Vitamin D and Bone Health; A practical clinical guideline for patient management, April 2013, accessed 29/3/16
North of England Commissioning Support Unit, Guidance for Treatment of Vitamin D Insufficiency and Deficiency, June 2015
Developed by Medicines Management, Ipswich and East Suffolk CCG in collaboration with Ipswich Hospital NHS Trust.
Version 3.0 updated June 2016. Next review June 2018.