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Question answered:22/01/08 Warning! this question is over two years old.

We found few guidelines (and no British guidelines) on the management of vitamin D deficiency in both adults and children.

 

Treatment of adults

 

The Medical Journal of Australia issued a position statement on vitamin D and adult bone health in 2005. It states in relation to treating vitamin D deficiency:

 

“Dosages required to treat moderate to severe vitamin D deficiency
…While the daily requirement for vitamin D is 400–600 IU, a larger dose is needed to treat patients with deficiency. As vitamin D is distributed in the body fat compartment, which is larger than the plasma and extracellular fluid compartment, large doses are needed before changes in serum 25-OHD are seen. This may explain the lag time seen with vitamin D supplements before normalisation of serum 25-OHD levels. Vitamin D status should be assessed 3–4 months after commencing treatment. Recommendations for management of vitamin D deficiency states are summarised in Box 4.

 

In Box 4, the authors note:

 

“Vitamin D required to treat moderate to severe deficiency
? 3000–5000 IU (75–125 μg) per day for at least 6–12 weeks; this will usually return serum 25-hydroxyvitamin D levels to the reference range, and allow ongoing treatment with a lower dose (eg, 1000 IU per day).
? For example, Ostelin (1000 IU ergocalciferol; Boots), 3–5 capsules per day for 6–12 weeks, followed by 1 capsule per day.
? An alternative is Calciferol Strong (50 000 IU cholecalciferol; PSM Healthcare), 1 tablet once per month for 3–6 months (available in New Zealand only).
? Most patients will need ongoing treatment with a lower dose (eg, 1000 IU per day).”

 
It adds:

 

“High dosages of Ostelin (3000–5000 IU daily for 6–12 weeks) can be used to replete body stores. Indeed, oral doses of 10 000 IU per day have been given without adverse effects for at least 90 days in postmenopausal women.26 Oral dosing can be effective in individuals with malabsorption, unless it is very severe, but higher doses are required.

 

Higher single doses of 50 000–500 000 IU orally or 300 000–600 000 IU vitamin D3 intramuscularly can effectively treat vitamin D deficiency. One or two annual intramuscular doses of 300 000 IU of cholecalciferol have been shown to reverse vitamin D deficiency states. Intramuscular preparations are preferable for malabsorption. However, these formulations are not currently available in Australia, and there is concern about inducing hypercalcaemia or hypercalciuria if excessive doses are used. Vitamin D3 appears more effective than D2 in raising serum 25-OHD level.” [1]

 

GPNotebook has an entry on treatment of vitamin D deficiency in adults in which it states:

 

• “in adults with confirmed primary vitamin D deficiency 
o need a minimum daily dose of oral vitamin D of 20µg (800 IU)
? with this dose, it takes at least a year for bone to normalise
? in some cases higher doses of vitamin D, to a maximum of 55µg (2,200 IU) daily, may be needed to achieve adequate repletion with vitamin D, especially in older patients, and in 'at risk' ethnic minorities (e.g. south Asian, African Caribbean and Middle Eastern) and to achieve optimal health benefits for bone and soft tissue
? once vitamin D deficiency or insufficiency has been corrected, patients will generally need lifelong preventative vitamin D supplementation.”

 

In the ‘Notes’ section, it reads:

 

• “All patients receiving pharmacological doses of vitamin D should have the plasma-calcium concentration checked at intervals (initially weekly) and whenever nausea or vomiting are present
o serum calcium concentrations should be checked regularly for a few weeks after starting treatment for vitamin D deficiency; then vitamin D, parathyroid hormone (PTH) and calcium concentrations should be checked after 3-4 months of treatment to assess efficacy and adherence to therapy
? after this check at 3-4 months then vitamin D and calcium concentrations should be checked every 6-12 months. “ [2]

 

Treatment of children

 

A consensus statement published in the ‘Medical Journal of Australia’ on the prevention and treatment of infant and childhood vitamin D deficiency offers definitions of severity of vitamin D deficiency:

 

 

“Mild vitamin D deficiency: Serum 25-OHD concentration of 25–50 nmol/L. Serum levels over 50 nmol/L prevent secondary hyperparathyroidism14,20 and elevated alkaline phosphatase levels.

 

Moderate vitamin D deficiency: Serum 25-OHD concentration of 12.5–25 nmol/L. The incidence of hypocalcaemia and rickets increases with moderate deficiency.

 

Severe vitamin D deficiency: Serum 25-OHD concentration less than 12.5 nmol/L. Vitamin D concentrations less than 12.5 nmol/L are seen in over 70% of children with rickets and over 90% of children with hypocalcaemia.”

 

Its recommendations for treating moderate to severe vitamin D deficiency are:

 

“Both ergocalciferol (25-OHD2) and cholecalciferol (25-OHD3) are effective therapy for vitamin D deficiency, with ergocalciferol being the most widely available preparation (Box 3). Replenishment of vitamin D stores requires a total vitamin D dose of 100 000–500 000 IU, depending on age (Box 3). Treatment with calcitriol (1,25-[OH]2D) is only indicated for hypocalcaemia (see below). Calcium supplementation is recommended if dietary intake is poor (Box 4)…”

 

Please refer to the guideline for acute and maintenance doses by age.

 

“Stoss therapy
High-dose vitamin D therapy (stoss therapy) is an effective method for treating established or recalcitrant vitamin D deficiency.31,35 It involves oral or intramuscular administration of the total treatment dose of vitamin D (cholecalciferol or ergocalciferol), 300 000 IU (7500 μg) to 500 000 IU (12 500 μg), as a single dose, or two to four divided doses.The interval between doses can vary from days to several weeks depending on the protocol followed. There are many stoss therapy regimens, and further study is required to finalise the most effective regimen and ensure safety. After stoss therapy, the biochemical follow-up recommended is similar to that for daily dosing...” [3]

 

An e-Medicine article on rickets offers the following information on treatment:

 

• “Treatment for rickets may be administered gradually over several months or in a single day's dose with 15,000 mcg (600,000 U) of vitamin D. If the gradual method is chosen, 125-250 mcg (5000-10,000 U) is given daily for 2-3 months until healing is well established and the alkaline phosphatase concentration is approaching the reference range. Because this method requires daily treatment, success depends on compliance.

• An alternative and recommended therapy is to administer the vitamin D in a single day, usually divided into 4 or 6 oral doses. An intramuscular injection also is available. Vitamin D is well stored in the body and released gradually over many weeks. Neither calcitriol nor calcidiol with their short half-lives are suitable. The single-day therapy avoids problems with compliance and, on occasion, is helpful in differentiating nutritional rickets from FHR [familial hypophosphatemia rickets].

• In nutritional rickets, the phosphate level rises in 96 hours and radiographic healing is visible in 6-7 days. Neither happens with FHR.

• One must be careful in the single-day regimen not to use a preparation of vitamin D suspended in propylene glycol. At this dosage, the vehicle is toxic. One may use 50,000-U capsules of ergosterol that are softened in water and fed with a blended food, such as applesauce.” [4]

References
1. eMJA. Vitamin D and adult bone health in Australia and New Zealand: a position statement. 2005.
http://www.mja.com.au/public/issues/182_06_210305/dia10848_fm.html
2. GPNotebook. Treatment of vitamin D deficiency. (http://www.gpnotebook.co.uk/simplepage.cfm?ID=1872363567&linkID=35618&cook=yes)
3. eMJA. Prevention and treatment of infant and childhood vitamin D deficiency in Australia and New Zealand: a consensus statement. 2006. (http://www.mja.com.au/public/issues/185_05_040906/mun10153_fm.html#0_CHDJACBE)
4. Finberg L. Rickets. April 2006. (http://www.emedicine.com/ped/topic2014.htm#section~treatment)

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