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Vitamin D deficiency

Key sources
The following summarized guidelines for the evaluation and management of vitamin D deficiency are prepared by our editorial team based on guidelines from the British Association of Dermatologists (BAD 2022), the U.S. Preventive Services Task Force (USPSTF 2021; 2018), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the European Society of Endocrinology (ESE/ES 2017), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2017), the Canadian Task Force on Hyperparathyroidism (CTFH 2017), the American Association of Endocrine Surgeons (AAES 2016), the American College of Endocrinology (ACE/OS/AACE 2013), the American Society for Parenteral and Enteral Nutrition (ASPEN 2013), the Obesity Society (OS/AACE 2013), the Australian and New Zealand Bone and Mineral Society (ANZBMS/OA/ESA 2012), the Endocrine Society (ES 2011), the American College of Obstetricians and Gynecologists (ACOG 2011), and the Osteoporosis Canada (OC 2010).
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Guidelines

1.Screening and diagnosis

Definitions: define vitamin D deficiency and insufficiency according to the level of serum 25-hydroxyvitamin D as follows:
deficiency: < 20 ng/mL (50 nmol/L)
insufficiency: 21-29 ng/mL (525-725 nmol/L)
A
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  • Indications for screening

2.Diagnostic investigations

Vitamin D measurement: obtain serum circulating 25-hydroxyvitamin D level, measured by a reliable assay, to evaluate vitamin D status in patients at risk for vitamin D deficiency.
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3.Medical management

Vitamin D supplementation
As per ANZBMS 2012 guidelines:
Initiate 3,000-5,000 IU of vitamin D3 (3-5×1,000 IU vitamin D3 capsules or 0.6-1 mL of 5,000 IU/mL liquid vitamin D3) for at least 6-12 weeks, with a check on 25-hydroxyvitamin D concentrations in most patients after 3 months, followed by ongoing treatment with a lower dose of around 1,000-2,000 IU/day (1 capsule of 1,000 IU or 0.2 mL of 5,000 IU/mL liquid daily) and adequate calcium intake in adult patients with vitamin D deficiency.
E
Offer 50,000 IU of vitamin D3 once per month for 3-6 months as an alternative regimen in adult patients with vitamin D deficiency.
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4.Specific circumstances

Pediatric patients, daily requirements: ensure vitamin D intake of at least 400 IU/day in 0-1 year old infants and children, and at least 600 IU/day in ≥ 1 year old children, to maximize bone health. Insufficient evidence of whether 400 and 600 IU/day in 0-1 and 1-18 years old children, respectively, are enough to provide all the potential nonskeletal health benefits associated with vitamin D to maximize bone health and muscle function. Recognize that at least 1,000 IU/day of vitamin D may be required to raise the serum level of 25-hydroxyvitamin D consistently > 30 ng/mL.
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  • Pediatric patients (treatment)

  • Pregnant patients

  • Patients with postmenopausal osteoporosis

  • Patients with CKD

  • Patients with primary hyperparathyroidism (preoperative)

  • Patients with primary hyperparathyroidism (postoperative)

  • Patients undergone bariatric surgery

5.Preventative measures

Vitamin D requirements
As per AACE 2013 guidelines:
Prescribe vitamin D supplementation of at least 1,000-2,000 IU of vitamin D2 or vitamin D3 daily in most patients, to keep the plasma 25-hydroxyvitamin D level > 30 ng/mL.
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Advise older adults, individuals with increased skin pigmentation, or those exposed to insufficient sunlight to increase their vitamin D intake from vitamin D-fortified foods and/or supplements to at least 800-1,000 IU/day.
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  • Prevention of fractures

  • Prevention of falls

  • Prevention of CVD

6.Follow-up and surveillance

Serial vitamin D measurement: as per ANZBMS 2012 guidelines, measure serum 25-hydroxyvitamin D concentrations in most patients after 3 months of treatment initiation.
E