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Vit-D deficiency (Adults)

Vitamin D is a fat soluble vitamin used by body for normal bone development and maintenance by increasing the absorption of Calcium , Magnesium and Phsophate
 ( Omeed Sizar , Swapnil Khare , Amy Gilver 2019 )

A UK survey ( BMJ 2010 ) showed that more than 50% of the adult population have 
insufficient levels of Vit D and that 16 % have severe deficiency during winter and spring

It is the most common nutritional deficiency in the world

Causes- Insufficient 
exposure to
 sunlight Inadequate 
dietary and supplemental
 vit D Impaired absorption eg
Malabsorption , obesity ,
 severe liver failure Impaired activation 
of Vit D eg
CKD , Liver disease , inherited enzyme disorders Nephrotic syndrome Drugs eg

Orlistat
Anticonvulsants – carbamazepine , phenobarbital , phenytoin
colestyramine , corticosteroids , 
HAART ( antiretroviral therapy )
rifampicin

Recommended test is
 to check circulating 25-hydroxyvitamin D – 
{25 (OH )D level }

Risk factors –Pigmented skin Limited sun exposure or atmospheric pollution
○ More than 90 % of Vit D is derived from UV B light
○ Winter months ( oct- april ) in most of Western world UV B is inadequate for Vit D synthesis
○ cultural reasons- covering skin
○ strict sunscreen use Dietary eg
○ strict vegans – who do not eat fish Pregnant or breast feeding○ Exclusive breast fed babies Multiple short interval pregnancies Ageing ( reduced ability of skin to produce vit D ) Obese – BMI > 30 ( inverse association of seum 25(OH)D and BMI
or had gastric bypass surgery Institutionalized or housebound Family h/o vit D deficiency

No evidence 
demonstrating benefits
 of screening for 
Vit D deficiency at a 
population level

Suspected Rickets-Deficient mineralisation at growth plate of long bones – particularly at sites of rapid bone growth Progressive bowing of legs
bowing of legs can also be a normal finding in toddlers Progressive knock knees Wrist swelling Rachitic rosary – swelling of the costochondral junctions Craniotabes- skull softening with frontal bossing and delayed fontanelle closure Delayed tooth eruption and enamel hypoplasia

Who to test

Long standing ( > 3 mts ) unexplained bone pain Proximal muscular weakness and pain Tetany due to low calcium Seizures due to low calcium
( usually in infancy ) Infantile cardiomayopathy Bone disease as osteomalacia , osteoporosis or Paget’s disease

Low Calcium or Phosphate High AlkPo4 -
more than 80 % adults with osteomalacia have ↑↑ AlkPo4 Radiographs showing osteopenia , rickets or pathological fractures Chronic renal disease Chronic liver disease Malabsorption syndromes
○ coeliac
○ Crohn’s
○ cystic fibrosis

Investigations- Bone profile Renal liver and thyroid function PTH FBC including Ferritin Malabsorption screen Rheumatoid and other autoimmune screening Inflammatory markers – ESR/ CRP

Treatment- Invita D3 oral solution ( plastic ampoules )
two oral ampoules ( 25000 Units each ) every week for 6 weeks Plenachol or Aviticol 20,000 Units , 3 caps weekly for 5 weeks Fultium -D3 3200 unit capsules – once / day for 12 weeks Hux D3 – 3 capsules once a week for 5 weeks supplements should be taken with food to aid absorption Ergocalciferol IM inj – 7.5 mg ( 300 , 000 IU ) in 1 , 2 ml ampoules Maintenance regimens may be considered 1 month after loading dose- given daily or intermittently. Maintenance – consider 1 month after loading dose and doses 800- 2000 units daily

Eg Fultium D-3 20 mcg
 ( 800 IU capsules )

Follow up-Calcium and renal profile – 1 month Check Vit D level atleast 3 months after initiating therapy Consider more regular calcium level checking in people receiving Ca supplements in addition to high dose vitamin

Lifestyle advice-Consider 400 IU of Vit D through the year- for all adults in UK including those at higher risk Fair skinned people 20-30 minutes of sunlight exposure on the face and forearms at midday can generate upto 2000 IU of Vit D two to three such exposure a week can be enough Sunbeds –> not effective emit high levels of UVA which do not contribute to Vit D synthesis Most important dietary source
○ oily fish- as salmon , mackerel , sardines
○ cod liver oil
○ Egg yolk , meat , offal , milk , mushrooms and fortified foods Also important to maintain dietary intake of calcium

Referral to secondary care- Malabsorption disorders – need higher doses Fragility fracture , documented osteoporosis or high risk fracture or is being treated with an antiresorptive drug Severe kidney disease People with conditions with ↑↑ sensitivity to Vit D –> higher risk of toxicity ( need lower doses ) Repeated low calcium with or without symptoms Children with suspected rickets Poor response to treatment ie
25(OH) D level < 50 8-12 weeks after treatment Persistent low serum phosphate or low/high alkaline phosphatase On anti-eplileptic medication or an oral corticosteroid or taking any other medication which can cause deficiency Unexplained deficiency

Pregnant and
 breastfeeding women 
should take 400 IU 
( 10 mcg ) of Vit D daily to prevent deficiency

LINKS AND RESOURCES

INFORMATION FOR PATIENTS

The patient can register and request Vit D Supply Health Start Vitamin Vouchers https://www.healthystart.nhs.uk/

How much calcium and Vitamin D- does a patient need ? Information from National Osteoporosis Foundation https://www.nof.org/patients/treatment/calciumvitamin-d/

A 2 page plain  pdf summary factsheet for patients from The Association of UK Dietitians on Vitamin D https://www.bda.uk.com/foodfacts/VitaminD.pdf

A very useful 3 page pdf  summary from National Institutes of Healthhttps://ods.od.nih.gov/pdf/factsheets/VitaminD-Consumer.pdf

A page on Vitamin D from the British Association of Dermatologists http://www.bad.org.uk/skin-cancer/vitamin-d

An authoritative information resource for patients from the National Osteoporosis Society https://theros.org.uk/media/98141/vitamin-d-supplements-and-tests.pdf

A paper on Vitamin D –  particularly written for patients from The Journal of Clinical Endocrinology and Metabolism https://academic.oup.com/jcem/article/96/7/1/2833362

Medline Plus information for patients- a comprehensive patient resource https://medlineplus.gov/vitamind.html

Rickets information for parents from The Royal Free London https://www.rcpch.ac.uk/sites/default/files/BPSU_Rickets_Public_information_leaflet_v6-02082016.pdf

Rickets information from Rare Diseases Database https://rarediseases.org/rare-diseases/rickets-vitamin-d-deficiency/

INFORMATION FOR CLINICIANS

NICE Vitamin D supplement use in specific population groups https://www.nice.org.uk/guidance/ph56

Scientific Advisory Committee on Nutrition – Vitamin D and health 2016 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/537616/SACN_Vitamin_D_and_Health_report.pdf 

National Institute of Health – Information for clinicians https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

National Osteoporosis Society – Vitamin D and Bone Health https://theros.org.uk/media/100233/nos_vitamin_d_and_bone_health_in_children_web.pdf

Royal Osteoporosis Society– a quick treatment summary for GPs https://theros.org.uk/healthcare-professionals/courses-and-cpd/osteoporosis-resources-for-primary-care/investigation/how-should-gps-assess-vitamin-d-deficiency/

European Society of Endocrinology – Vitamin D testing and treatment: a narrative review of current evidence in Endocrine Connections – Open access an excellent comprehensive review https://ec.bioscientifica.com/view/journals/ec/8/2/EC-18-0432.xml

 

References NOGG 2017 Clinical guideline for the prevention and treatment of osteoporosis Vitamin D and Bone Health : A Practical Clinical guideline for Patient Management National Osteoporosis Society 2013 Vitamin D and bone health : a practical clinical guideline for management in children and young people Diagnosis and management of vitamin D deficiency BMJ 2010 ;340: b5664 What dose of vitamin D should be prescribed for the treatment of vitamin D deficiency UKMi April 2015 Coventry & Warwickshire Area Prescribing Committee Clinical guideline – CG019 Vitamin D Prescribing Guidelines- Adults June 2017 Evaluation , Treatment and Prevention of Vitamin D Deficiency ; an Endocrine Society Clinical Practice Guideline The Journal of Clinical Endocrinology & Metabolism , Volume 96 , Issue 7 , July 2011 , Pages 1911-1930 CKS NICE Vitamin D deficiency in adults- treatment and prevention November 2016 Vitamin D Deficiency BMJ Best practice Vitamin D in the healthy European Population European Society for Paediatric Hepatology and Nutrition NHS Wales ( 2014) Diagnosis and management of vitamin D deficiency in adults PHE guidance on Vit D accessed via https://www.gov.uk/government/news/phe-publishes-new-advice-on-vitamin-d Vitamin D Deficiency Omeed Sizar , Swapnil Khare , Amy Givler StatPearls December 2019

 

 

 

 

 

 

 

 

 

 

 

 

 

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