East & South East England Specialist Pharmacy Services (August 2011)
East of England, London, South Central & South East Coast
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Insufficient levels outside of UK range from 20 to 50 nanograms/ml
# = number of agencies specifying this level or amount
Missing: co-factors such as Calcium, Magnesium, Vitamin K2, Strontium, Vitamin A, Boron, Zinc,
The body can become seriously unbalanced by adding lots of vitamin D without adding some of the co-factors
Note: one agency did recommend adding Calcium (Calcichew) - but it has the worst kind of Calcium and too much as well
Calcium carbonate 1250 mg (equivalent to 500 mg of elemental calcium)
Missing: testing for allergic reactions to vitamin D
Approximately 0.3% of the population have a bad reaction to vitamin D
Reaction may be due to lack of co-factors, as mentioned above. Need to start vitamin D slowly to check to this reaction.
4) Have a condition which Prevents Adsorption in the gut (about half of the agencies did allow injection of Vitamin D2 in this case)
IBD UC and CD at risk of being vitamin D deficient
Extra Vitamin D needed for Crohn's
Fat malabsorption syndromes
(Supplement options if have gut problem: Opt1 - Opt2)
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Vitamin D deficiency and insufficiency in adults and paediatrics: a guideline collation document for London and East & South-East England
Awareness of Vitamin D deficiency in the UK population has increased substantially in recent years and there have been numerous articles published on the subject. Developing guidance in this area has, however, been hampered for a number of reasons:
- Opinions on the ideal level of vitamin D and optimal serum concentrations vary (although there is suggestion that normal vitamin D status is represented by 25-hydroxyvitamin D (25-OHD) of 75nmol/L or more, insufficiency by 25-OHD of 25-50nmol/L, and deficiency by 25-OHD levels <25nmol/L1).
- The evidence-base is not completely defined in relation to best management of different vitamin D deficiency states and the monitoring required following treatment.
- The availability of licensed vitamin D products is limited and unlicensed products have variable (and often substantial) costs.
This document outlines prescribing guidance in use in London and East and South-East England for the management of vitamin D deficiency in adults and children. The document outlines commonalities and differences in guidance both for the treatment of deficiency, and for maintenance following insufficiency. The document covers only those prescribing guidelines of which the London Medicines Information where aware of as at March 2011 following contact with hospital pharmacy departments and PCTs.
The document does not offer a consensus view on the use of vitamin D products, nor does it make regional recommendations. It is provided merely as an aid to enable comparison between work already undertaken and to assist local and sector based guideline development.
The document is presented as two tables: the first comparing adult guidelines, the second paediatric.
Each table summarises pharmacological recommendations (i.e. not those related to diet and sunshine) from the various guidelines.
The following should be noted:
- Vitamin D preparations are specified as colecalciferol or ergocalciferol, or where guidance did not specify the form “vitamin D” is stated. Many of the guidelines reviewed indicated that colecalciferol is preferred despite the BNF stating that the forms should be considered bioequivalent and interchangeable (with 10 micrograms of ergocalciferol or colecalciferol giving 400 IU of vitamin D2).
- Where the route of administration is not stated in the tables the oral route should be assumed.
- The doses and main monitoring recommendations in each guideline for the various deficiency states have been re-reproduced; other detail has not.
- The guidelines reviewed do not generally cover vitamin D use in more complex patients such as those with secondary deficiency due to renal disease, primary hyperthyroidism, hypercalcaemia, or hypocalcaemia.
This document does not provide any element of cost comparision.
The document Using appropriate available products on NeLM should be referred to for information on currently available vitamin D preparations and to aid recommendations and prescribing.
This document was produced with information available on prescribing guidance in use across London as at March 2011.
A process of review with primary care QIPP and other colleagues precluded publication until August 2011.
The document will be updated every 6 months initially and then annually thereafter. We welcome comment both on its specific content and overall usefulness.
We would also welcome receipt of any local guidance in place that we will add to the document at each review.
- Ben Rehman, Director, London Medicines Information Service at b.rehman at nhs.net; or
- Varinder Rai, Principal Medicines Information Pharmacist at varinder.rai at nhs.net
1. Pearce S, Cheetham D. Diagnosis and management of vitamin D deficiency. BMJ 2010; 340: b5664
2. British National Formulary 61st Edition. London: BMJ Group and Pharmaceutical Press, 2011
NHS Barking and Dagenham (published February 2011/review February 2012)
Barking, Havering and Redbridge University Hospitals NHS Trust
Barnet and Chase Farm Hospital NHS Trust (published November 2010/ review November 2012)
Barts and The London Clinical Effectiveness Group (published January 2011)
NHS Ealing (published December 2010 / review December 2012)
Guys and St Thomas NHS Foundation Trust / King’s College Hospital NHS Foundation Trust (review March 2012)
Harrow NHS PCT (published January 2010)
Hounslow NHS Trust (published September 2010)
Imperial College Healthcare NHS Trust
Kensington and Chelsea NHS Trust
Kingston Hospital NHS Trust (published December 2010)
Lewisham Healthcare NHS Trust (review January 2013)
NHS North Central London (published May 2011 / review May 2013)
North Middlesex University Hospital NHS Trust (published February 2011 / review February 2013)
Oxfordshire (published 25th July 2009 / review January 2010)
St George’s Healthcare NHS Trust / NHS Wandsworth (published August 2010)
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- Vitamin D Recommendations
- Recommendations from around the world and during the past 50 years have varied a lot.
- All Megadose vitamin D items
- Can You Overdose on Vitamin D - It's Harder Than You Think
- Overview How Much vitamin D
- 300,000 IU vitamin D helped seniors in many ways – May 2011
- Vitamin D3 loading dose of 500,000 IU for elderly – Aug 2009
- Vitamin D loading dose guidelines - April 2010
- IU LOADING dose to achieve 30ng (in ng and pounds) = 35 x (30-serum 25-OHD(3)) x body weight
- Many reasons why vitamin D deficiency has become epidemic
- Vitamin D also TREATS
- Must balance co-factors when increasing vitamin D
- France attempts to restock vitamin D levels with 7000 or 14000 IU daily – Nov 2011
- Huge gap between vitamin D advice and actual prescriptions – April 2012
Only four (1.4%) of those with < 10 nanograms were prescribed a loading dose