Treatment of vitamin D deficiency: divergence between clinical practice and expert advice

Postgrad Med J 2012;88:255-260 doi:10.1136/postgradmedj-2011-130243
Mark Findlay 1, Julia Anderson 2, Susan Roberts 3, Alison Almond 4, Chris Isles 1 chris.isles at nhs.net
1 Department of Medicine, Dumfries and Galloway Royal Infirmary, Dumfriesshire, UK
2 Department of Biochemistry, Dumfries and Galloway Royal Infirmary, Dumfriesshire, UK
3 Pharmacy Department, Dumfries and Galloway Royal Infirmary, Dumfriesshire, UK
4 Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfriesshire, UK
Contributors CI and MF had the idea and wrote the first draft. JA extracted the results from the biochemistry lab browser. SR is the guarantor of the pharmacy data. JA, SR and AA provided comments on the first draft and all five authors contributed to the final draft.
Received 8 August 2011; Accepted 16 January 2012; Published Online First 23 February 2012

Background Current recommendations for the treatment of vitamin D deficiency vary from calciferol 800 IU per day to loading doses of vitamin D followed by maintenance therapy of up to 2000 IU per day.

Objective To assess the preparations and doses of vitamin D used to load and maintain patients with serum 25-hydroxyvitamin D (25OHD) <25 nmol/l.

Methods We examined all requests for serum 25OHD over a 12-month period, from September 2009 to 2010 in southwest Scotland. We wrote to all 33 general practices asking whether they usually started replacement therapy with a loading dose and/or recommended over-the-counter maintenance preparations. We accessed the Emergency Care Summary for all patients with serum 25OHD <25 nmol/l to determine whether they had been prescribed maintenance therapy.

Results Serum 25OHD was requested in 1162 patients.
Levels were <25 nmol/l in 282 (24%) patients, only 173 (61%) of whom were receiving vitamin D replacement therapy 3–15 months after diagnosis.

• Only four (1.4%) were prescribed a loading dose
• One hundred and fifty-three (54%) were treated with cholecalciferol or ergocalciferol and
• 19 (7%) with alfacalcidol or calcitriol.

The median dose of chole/ergocalciferol was 800 IU per day, usually in combination with 1200 mg calcium per day.

Conclusions We have shown a divergence between clinical practice and even the most conservative expert advice for vitamin D replacement.

Possible explanations are

• conflicting advice on treatment and
• difficulty obtaining suitable vitamin D preparations, particularly high dose vitamin D and vitamin D without calcium, in the UK.

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See also VitaminDWiki

(Even the most conservative group would have loading dose of 140,000 IU for person with <10 nanograms)

• Variety of vitamin D loading dose recommendations in the UK which has the following

Vitamin D3 oral to restock deficiency, by different groups in the UK

Frequency	Total dose	# of groups
Daily	200,000 IU	1
Daily	280,000 IU	3
Daily	300,000 IU	1
Monthly	240,000 IU	1
Monthly	600,000 IU
Monthly	720,000 IU	2
Once	300,000 IU	1

• All Megadose vitamin D items 26 items as of Feb 2012
• Vitamin D3 loading dose of 500,000 IU for elderly – Aug 2009
• Loading dose of 500,000 IU for elderly - Whiting 2010 PDF file of the entire study
• 300,000 IU injection of vitamin D – Mar 2010
• 300,000 IU vitamin D helped seniors in many ways – May 2011
• Overview How Much vitamin D
• Doctors now able to prescribe vitamin D3 as of March 2012
• Vitamin D Replentishment – Feb 2012 Plotnikoff
• Must balance co-factors when increasing vitamin D
• France attempts to restock vitamin D levels with 7,000 or 14,000 IU daily – Nov 2011
• Overview Loading of vitamin D which contains the following March 2012
  IU LOADING dose to achieve 30ng (in ng and pounds) = 35 x (30-serum 25-OHD(3)) x body weight.
  which is 140,000 IU for 10 ng, 200 lb person
  This research generally spread the loading dose over a 2 month time period
  A very commonly prescribed loading dose in the US is 50,000 IU per week for 2 months, for a total of 400,000 IU