Vitamin D

25-hydroxyvitamin D may be requested as part of the investigation of abnormal bone metabolism (reflected by abnormal calcium, phosphate or PTH blood test results). Guidelines from the National Osteoporosis Society (2018) recommend that 25-hydroxy vitamin D should also be measured in: 

• Patients with bone diseases (e.g; osteoporosis or osteomalacia) that may be improved by giving vitamin D supplementation. 
• Patients with bone diseases that may need supplementation of vitamin D prior to starting a specific form of treatment to avoid development of low blood calcium levels (e.g; Potent anti-osteoporotic medications such as Zoledronate, Denosumab or treating Paget’s disease with bisphosphonates). 
• Patients with musculoskeletal symptoms that may be due to vitamin D deficiency (e.g. long term wide spread pain). 
• Asymptomatic individuals at higher risk of vitamin D deficiency: 
  • Those aged 65 years and over. 
  • Those with low or no sun exposure. 
  • Those with darker skin. 

Routine monitoring of vitamin D is usually unnecessary, but may be required for patients that continue to have symptoms of vitamin D deficiency despite supplementation or poor compliance with medication is suspected. Since vitamin D is a fat-soluble vitamin and is absorbed from the intestine like a fat, it may also need to be monitored in individuals with diseases that interfere with fat absorption, such as cystic fibrosis and Crohn’s disease. It is also used to monitor people who have had gastric bypass surgery and may not be able to absorb enough vitamin D. 

Screening for vitamin D deficiency is not recommended in asymptomatic individuals. 

Routine vitamin D testing is unnecessary in patients with osteoporosis or fragility fracture, who may be co-prescribed vitamin D supplementation with an osteoporosis treatment.

25-hydroxyvitamin D may be requested: 

• If there is evidence of a defect in bone metabolism reflected by an abnormal calcium, phosphate or PTH concentration in the blood. 
• If a patient has symptoms of vitamin D deficiency, such as bone malformation in children (rickets) and bone weakness, softness, or fracture in adults (osteomalacia).
• If a patient may need supplementation of vitamin D prior to starting a specific form of treatment for bone disease. 
• If a patient suffers from malabsorption. Malabsorption, causing vitamin D deficiency may occur in individuals following a gastric bypass or in patients with fat malabsorption such as in cystic fibrosis or Crohn’s disease. 
• If a patient that is supplemented with vitamin D continues to experience symptoms of vitamin D deficiency. 
• In those receiving supplementation to avoid toxicity. 
• In those considered to be at a higher risk of vitamin D deficiency. 

1,25 dihydroxyvitamin D may be requested if the calcium concentration is high or the patient has a disease that might produce excess amounts of 1,25 dihydroxyvitamin D, such as sarcoidosis or some forms of lymphoma.

The National Osteoporosis society (NOS) guidelines (UK, 2013) and the Institute of Medicine (US) classify vitamin D results as follows: 

• 25-hydroxyvitamin D of less than 25 nmol/​L is deficient 
• 25-hydroxyvitamin D of 25–50 nmol/​L may be inadequate in some people 
• 25-hydroxyvitamin D of greater than 50 nmol/​L is sufficient for almost the whole population. 

Low blood levels of 25-hydroxyvitamin D may mean that you are not getting enough exposure to sunlight or enough vitamin D in your food to meet your body’s demand or that there is a problem with its absorption from the intestines. Occasionally, drugs used to treat seizures, particularly phenytoin (epanutin), can interfere with the liver’s production of 25-hydroxyvitamin D. 

High levels of 25- hydroxyvitamin D usually reflect excess supplementation from vitamin pills or other nutritional supplements. 

Low levels of 1,25-dihydroxyvitamin D can be seen in patients with kidney disease. 

High levels of 1,25-dihydroxyvitamin D can be seen in patients with sarcoidosis or some lymphomas, as a result of 1,25 dihydroxyvitamin D being made outside of the kidneys. 

High levels of vitamin D and calcium can lead to the calcification and damage to organs particularly the kidneys and blood vessels. 

If magnesium levels are low, they can cause a low calcium level that is resistant to vitamin D and parathyroid hormone regulation. It may be necessary to supplement both magnesium and calcium to regain normal function.

According to the 25-hydroxyvitamin D result following is the treatment recommendation 

• 25-hydroxyvitamin D< 25 nmol/​L: treatment recommended. 
• 25-hydroxyvitamin D 25–50 nmol/​L: treatment is advised in patients with the following: 
  • fragility fracture
  • documented osteoporosis or high fracture risk treatment with antiresorptive medication for bone disease 
  • symptoms suggestive of vitamin D deficiency 
  • increased risk of developing vitamin D deficiency in the future because of reduced exposure to sunlight (e.g; religious/​cultural dress code, dark skin, etc.) 
  • Raised PTH
  • medication with antiepileptic drugs or oral glucocorticoids conditions associated with malabsorption. 
• 25-hydroxyvitamin D> 50 nmol/​L: provide reassurance and give advice on maintaining adequate vitamin D levels through safe sunlight exposure and diet 

The European Union has set a Recommended Daily Allowance (RDA) of 5 micrograms for food labelling purposes. The UK Department of Health, Public Health England incorporating Scientific Advisory Committee on Nutrition now recommends vitamin D supplementation to prevent vitamin D deficiency in all children, young people and adult living in the UK including those at increased risk of vitamin D deficiency. The recommendation is to take a daily vitamin D supplement throughout the year including winter months. The following are specific recommendations from the European food safety authority: 

• For infants aged 7–11 months, the European food safety authority sets an adequate intake for vitamin D at 10 μg/​day (400 IU). 
• For children aged 1–17 years, the European food safety authority sets an adequate intake for vitamin D for all children at 15 μg/​day (600 international units [IU]). 
• For adults, the European food safety authority sets an adequate intake for vitamin D at 15 μg/​day (600 IU). 
• For pregnant and lactating women, the European food safety authority considers that the adequate intake is the same as for non-pregnant non-lactating women, i.e. 15 μg/​day. 

Yes. The amount of vitamin D produced by the body may be insufficient, especially when there is limited exposure to sunlight. Since dietary vitamin D is found naturally only in a few foods, such as cod liver oil, oily fish (salmon, mackerel, sardines) red meat, liver and egg yolk; dietary intake may not be sufficient for most people. In the UK vitamin D is added to many fortified cereals and infant preparations and, by law, to margarine (fat spreads). Vitamin D was originally added to margarine to reduce rickets and osteomalacia in some parts of the UK (as butter is a source of these nutrients and margarine is often used instead of butter). Most vitamin D (up to 90%) is obtained from the action of sunlight on the skin, but some groups of people have less exposure to sunlight, e.g. some children and older people, particularly if they live in the northern part of the UK, or amongst people who habitually cover most of their skin surfaces for cultural or religious reasons. 

Unlike some countries, milk is not routinely fortified with vitamin D in the UK but in general, dairy products do contain some vitamin D.

Yes, there is a topical form of vitamin D cream that is used to treat psoriasis.

Since absorption of calcium is dependent on vitamin D, many manufacturers of calcium supplements add vitamin D to assure optimal calcium uptake. If you have adequate amounts of vitamin D from other sources the additional vitamin D is not necessary. The amount of vitamin D in these tablets is not likely to lead to excess vitamin D or be harmful either.

• All pregnant and breastfeeding women, especially teenagers and young women 
• Older people, aged 65 years and over 
• People who have darker skin, for example people of African, African-Caribbean or South Asian origin, because their bodies are not able to make as much vitamin D. 
• People who have low or no exposure to the sun, for example those who cover their skin for cultural reasons, who are housebound or who are confined indoors for long periods 

Vitamin D3 is recommended as the vitamin D preparation of choice. Route of administration is oral.