Vit-D deficiency (Adults)

Review of Vitamin D deficiency in adults. This chart on A4Medicine covers the background causes and management of this common nutritional deficiency. Aspects as what is adequate sun exposure, complications, risk factors and management based on the level are shown in an easy to use visual. Referral criteria are shown clearly and the GP may wish to refer direct the patients to a useful information leaflet from Public Health England. Also useful info from NHS Choices available on

Vitamin D ( fat soluble sterols ) is a nutrient but can also be synthesized in the
 human skin by sunlight exposure. Main function is regulation of calcium and 
phosphate metabolism ( ie essential for bone health )

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

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

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