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  • Vitamin D deficiency

Vitamin D deficiency

Table of Contents
  • Overview
  • Triage
  • Risk factors
  • Clinical features
  • Investigations
  • Management
  • References

Overview #

Serum 25-OH D3 levels (1):

Severity (1)Nanomol/L
MILD30-49
MODERATE12.5-29
SEVERE< 12.5
  • Indications for testing:
    • (see section on risk factors)
    • MBS criteria for billing https://www.nps.org.au/radar/articles/mbs-item-number-changes-for-vitamin-b12-folate-and-vitamin-d-tests
  • No indication to check vitamin D levels in low risk, healthy individuals (1) 
  • Note that the Vitamin D biochemistry request assesses for the pre-cursor form of vitamin D (25-OH cholecalciferol, see diagram in physiology), hence would not reflect activity if the patient is receiving calcitriol therapy.
  • More relevant for subacute settings (geriatrics/ rehab/ GP) vs acute inpatient
  • Important to treat if:
    • Moderate/ severe deficiency (see Ix section)
    • Symptomatic
    • Before starting osteoporosis treatment e.g. Denosumab injections (have to be calcium + vitamin D replete)

Triage #

Non-urgent – attend by end of your shift and/or clarify during morning ward round

Risk factors #

Intrinsic factors (1) 

  • Elderly – malnutrition
  • Impaired absorption or conversion of vitamin D precursors – liver, renal, GIT, hypoparathyroidism 
  • People with a dark skin tone 

Extrinsic factors (1) 

  • Reduced sunlight exposure e.g. housebound, reduced mobility

Clinical features #

  • Most often asymptomatic
  • Otherwise mild bone pain, muscle weakness, progressing to osteomalacia/ osteoporosis if severe 
  • Osteoporosis can present as minimal trauma fracture e.g. post-fall from standing height

Investigations #

Serum 25-OH D3 interpretation (1):

Severity (1)Nanomol/L
MILD30-49
MODERATE12.5-29
SEVERE< 12.5
  • 25-OH levels (instead of activated vitamin D) are associated with fracture risk, and reflect total body stores (3) 
  • Note that the precursor form of vitamin D (25-OH) is irrelevant in patients with chronic renal impairment, and the activated form would have to be requested specifically 

Other Ix: 

  • Calcium
    • Hypocalcaemia has to be corrected before starting denosumab therapy (4)
    • Ca/Mg/PO4 as part of nutrition screen, refeeding protocol 
  • PTH
    • If Ca2+ levels are abnormal, to identify hyper/hypoparathyroidism 

Management #

1st lineIf mild:
Consider lifestyle modification e.g. sunlight exposure If from nursing home or housebound, or osteoporosis/ high falls risk:
Colecalciferol 25-50 microg PO daily while inpatient, then 25 microg PO daily on discharge 25 microg = 1000 international unitsContraindications: hypercalcaemia, caution if hyperphosphataemia, if on calcitriol/ other over-the-counter vitamin D products (5) 
If moderate – severe:Colecalciferol 50 microg PO BD daily while inpatient, then 50 microg PO daily on discharge 
To consider higher doses of cholecalciferol if (1):High BMI Drugs affecting liver metabolism e.g. RifampicinFat malabsorption e.g. cystic fibrosis, IBD 
If factors below apply, then 2nd line Mx, to consult endocrine team (6):mod- severe renal impairment e.g. requiring dialysis hypocalcaemia in hypoparathyroidismhypophosphataemic rickets
2nd lineCalcitriol 0.25 microg PO daily, then increase by 0.25 microg every 2-4 weeks, aiming for 0.5-1 microg PO daily (6)Monitor serum Ca2+ at baseline, then twice during first week, then 2-4 weeks, then every 2-3 months

Follow-up

  • GP to recheck Vitamin D levels in 4-6 weeks post d/c, if levels are replete
    • But not if patient is on calcitriol (would need Ix with activated vitamin D)
    • Aim to reduce to 25microg daily/ 1000 international units

Monitor for complications e.g. hyper Ca2+ – nausea, vomiting, constipation, muscle weakness (5), and withhold/cease if necessary

References #

  1. eTG Complete [Internet]. Melbourne (Vic): Therapeutic Guidelines Ltd; 2021. Vitamin D deficiency [updated 2019 Jun; cited 2021 Aug 20]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?topicfile=vitamin-d-deficiency&guidelineName=Bone%20and%20Metabolism&topicNavigation=navigateTopic#toc_d1e209
  1. Costanzo L. Physiology. 4th ed. Philadelphia: Saunders, Inc; 2010.
  2. Glendenning P. Measuring Vitamin D [Internet]. NPS Medicinewise. 2021 [cited 16 September 2021]. Available from: https://www.nps.org.au/australian-prescriber/articles/measuring-vitamin-d
  3. Australian medicines handbook online [Internet]. Adelaide (S.Australia): Australian Medicines Handbook Pty Ltd; 2000. Denosumab; [updated 2021 Jul; cited 2021 Sept 16]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/chapters/endocrine-drugs/drugs-affecting-bone/other-drugs-affecting-bone/denosumab?menu=vertical 
  4. Australian medicines handbook online [Internet]. Adelaide (S.Australia): Australian Medicines Handbook Pty Ltd; 2000. Vitamin D; [updated 2021 Jul; cited 2021 Aug 20]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/chapters/endocrine-drugs/drugs-affecting-bone/vitamin-d?menu=vertical 
  5. Australian medicines handbook online [Internet]. Adelaide (S.Australia): Australian Medicines Handbook Pty Ltd; 2000. Calcitriol; [updated 2021 Jul; cited 2021 Aug 20]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/chapters/endocrine-drugs/drugs-affecting-bone/vitamin-d/calcitriol?menu=vertical
  • Contributors

  • Reviewing Consultant/Senior Registrar

Dr Dolly Png

Dr Rahul Barmanray

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Updated on April 12, 2023
Table of Contents
  • Overview
  • Triage
  • Risk factors
  • Clinical features
  • Investigations
  • Management
  • References

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