Variety of vitamin D loading dose recommendations in the UK - 2011

East & South East England Specialist Pharmacy Services (August 2011)
East of England, London, South Central & South East Coast

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Summary of variety in UK 2011: Adults

Different definitions

of Deficient

Less than	# groups
8 nanograms/ml	1
10 nanograms/ml	9
12 nanograms/ml	1
14 nanograms/ml	2
20 nanograms/ml	2

Vitamin D3 oral to restock deficiency

Frequency	Total dose	# 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

Vitamin D2 to restock

did not make a table

Different definitions of Insufficient

Less than	# groups
14 nanograms/ml	2
20 nanograms/ml	11
30 nanograms/ml	1
32 nanograms/ml	1

Notes:
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.

Missing: ability to give more vitamin D to groups who frequently need more

1) Have a condition which some of the vitamin D goes into fat, rather than into the blood

Obesity

2) Have a condition which Prevents Conversion to active vitamin D

Kidney vicious cycle
HIV both prevents conversion and consumes vitamin D

3) Have a condition which requires more vitamin D

    Pregnancy Not just bone. Need lots of vitamin D - Before , During, and After
    Dark Skinned and living far from equator or avoiding the hot sun
    Surgery and trauma many files

4) Have a condition which Prevents Adsorption in the gut (about half of the agencies did allow injection of Vitamin D2 in this case)

    Bariatric Surgery
    Colon Cancer
    IBD UC and CD at risk of being vitamin D deficient
    Extra Vitamin D needed for Crohn's
    Gluten Intolerance
    Celiac Disease
    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

Background

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.

Purpose of this document

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.

The update process for the document and your comments

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.

Please send any individual guidance from your organisation or any other comments to

Ben Rehman, Director, London Medicines Information Service at b.rehman@nhs.net; or
Varinder Rai, Principal Medicines Information Pharmacist at varinder.rai@nhs.net

References

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

PDF tables are entries for

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)

Details are in PDF available at the bottom of this page

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