Vitamin D: Treatment of Vitamin D Deficiency in Adults Part 4

[BruceZ]

Performing a search of the National Guidelines Clearinghouse (www.guideline.gov), “Recommendations for the diagnosis and management of vitamin D deficiency in adults” (1) was obtained as the only guideline found for the adult population.

Treatment of Vitamin D Deficiency in Adults

Diagnosis Screening (USPSTF grading and ratings)

Individuals who have a history of the following should be evaluated for vitamin D deficiency.

• Chronic musculoskeletal pain including fibromyalgia (Grade A, Evidence Good)
• Osteoporosis (Grade A, Evidence Good)
• Rheumatoid arthritis (Grade A, Evidence Good)
• Malabsorption syndromes (Grade A, Evidence Good)
• Obesity, metabolic syndromes, type II diabetes (Grade A, Evidence Good)
• Cardiovascular disease (Grade A, Evidence Good)
• Chronic kidney disease & hyperparathyroidism (Grade B, Evidence Fair)
• Depression (Grade B, Evidence Fair)
• High risk population such as elderly (over 71 years of age) & dark skinned individuals (Grade A, Evidence Good)
• Chronic use of corticosteroids (Grade A, Evidence Good)
• Personal/social history of inadequate sun exposure & insufficient dietary intake of vitamin D fortified foods (Grade A, Evidence Good)

Pharmacologic Therapy

Vitamin D deficiency

• “Nutritional deficiency [25(OH)D < 20 ng/ml] requires initial treatment with 50,000 IU of vitamin D2 or D3 orally once per week for six to eight weeks (may take longer depending on starting 25(OH)D level), and then 800 to 1000 IU of vitamin D3 daily thereafter. Intramuscular cholecalciferol (300,000 U) in one or two doses per year is also an option for increasing serum 25(OH)D levels. (Grade A, Evidence Good).” (1)

Vitamin D insufficiency

• “Nutritional insufficiency [25(OH)D 20 to 30 ng/ml] requires treatment with 800 to 1000 IU of vitamin D3 daily. This intake will bring the average adult to 30 ng/ml over a three month period, but many individuals will need higher doses. (Grade B, Evidence Fair).” (1)

NOTE: Patients with malabsorption syndrome, kidney and hepatic disease, and obesity may require different treatment. (1)

Laboratory evaluation of treatment for vitamin D deficiency or insufficiency
Serum 25(OH)D levels should be examined approximately 6-8 weeks after initiating therapy. Adjustments may be needed depending on the results of the laboratory tests. (Grade B, Evidence Fair). (1)


Maintenance Therapy

• Daily oral recommended vitamin D requirements for adults 18-50: 200 IU; and for adults 51-70: 400 IU with adequate sun exposure. (Grade C, Evidence Poor). (1)
• Without adequate sun exposure and for high risk population such as elderly (over 65 years of age) and dark-skinned individuals the recommendation is 800 to 1000 IU per day. (Grade A, Evidence Good). (1)1
• Adequate sun exposure is defined as sun exposure to arm and legs 5 to 30 minutes depending on time of day, season, latitude, and skin pigmentation between 10a and 3p; twice weekly is often adequate. (Grade C, Evidence Fair). (1)

Current Research

As noted in the discussion found in part 3 (July 28, 2010) of this series, research on vitamin D (VITAL study) will test 20,000 men and women who will be taking 2000 IU of vitamin D per day for 5 years. This is an interventional trial being conducted by JoAnn E. Manson, MD, DrPH as its principal investigator. (2) We will have to wait until the results of the research is provided for more evidence-based research data.

?? Reader Question ??

• Are you concerned about treating vitamin D deficiency or insufficiency with sun exposure as prescribed above and concerns individuals as well as providers have about skin cancer?

Bruce S. Zitkus, EdD, ARNP, ANP-BC, FNP-BC, CDE

References
1. National Guideline Clearinghouse (2009). Recommendations for the diagnosis and management of vitamin D deficiency in adults. University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Austin (TX): University of Texas at Austin, School of Nursing; 2009 May. 16 p. [40 references]. Retrieved from http://www.guideline.gov/content.asp...n+d+deficiency.

2. Milone A. (2010, July). Surge of information on benefits of vitamin D, but no interventional trial of data exist yet to ensure safety. Endocrine Today, 8(7):1 and 10-12.