Osteoporosis Treatment
New Medications and Current Guidelines
February 2013
Volume 4, Issue 1

Evaluation, Treatment, and Prevention of Vitamin D Deficiency: An Endocrine Society Clinical Practice Guideline

J Clin Endocrinol Metab. 2011;96(7):1911-30

The Endocrine Society published these guidelines on vitamin D deficiency in July 2011.  This summary of those guidelines will focus on the screening and treatment recommendations.

Screening for Vitamin D Deficiency
Population-wide screening for vitamin D deficiency is not warranted.  However, screening is warranted in individuals at risk for vitamin D deficiency.  This includes people with (list is not exhaustive):

  • rickets
  • osteoporosis
  • osteomalacia
  • chronic kidney disease
  • malabsorption syndromes (eg, cystic fibrosis)
  • hyperparathyroidism

The serum circulating 25-hydroxyvitamin D (25[OH]D)level, as measured by a reliable assay, is recommended to assess vitamin D status.  The guidelines recommend against serum 1,25(OH)2D assay.

The 25(OH)D level is the preferred screening level because it is the major circulating form of vitamin D; its half-life is 2 to 3 weeks.

In comparison, the circulating half-life of 1,25 (OH)2D is about 4 hours; serum 1,25(OH)2D also does not include vitamin D reserves.  For those 2 reasons, it is not a useful method for monitoring vitamin D status.

In using the 25(OH)D levels, the following definitions should be used:

  • Vitamin D deficiency:  25(OH)D below 20 ng/mL (50 nmol/liter)
  • Vitamin D insufficiency:  21-29 ng/mL (52.5-72.5 nmol/liter)
  • Vitamin D sufficiency:  30-100 ng/mL

Treatment of Vitamin D Deficiency
Either vitamin D2 or vitamin D3 should be used for treatment and prevention of vitamin D deficiency.  The following doses are recommended:

  • Infants and toddlers 0-1 year:  2,000 IU/day (vitamin D2 pr vitamin D3) or 50,000 IU once weekly (vitamin D2 or vitamin D3)for 6 weeks (followed by maintenance therapy of 400-1,000 IU/day after the serum 25(OH)D level is above 30 ng/mL)
  • Children 1-18 years:  2,000 IU/day (vitamin D2 or vitamin D3)for at least 6 weeks or 50,000 IU once weekly (vitamin D2) for at least 6 weeks (followed by maintenance therapy of 600-1,000 IU/d after the serum 25(OH)D level is above 30 ng/mL)
  • Adults:  50,000 IU once weekly (vitamin D2 or vitamin D3) for 8 weeks or 6,000 IU/day (vitamin D2 or vitamin D3) (followed by maintenance therapy of 1,500-2,000 IU/d after the serum 25(OH)D level is above 30 ng/mL)
  • Obese patients, patients with malabsorption syndromes, patients using medications that affect vitamin D metabolism:  at least 6,000-10,000 IU/day of vitamin D (followed by maintenance therapy of 3,000-6,000 IU/d after the serum 25(OH)D level is above 30 ng/mL)
  • Patients with extrarenal 1,25(OH)2D production:  Serial monitoring of 25(OH)D levels and serum calcium levels should be done in order to prevent hypercalcemia during vitamin D treatment.
  • Patients with primary hyperparathyroidism:  Treat as needed for vitamin D deficiency, but monitor serum calcium levels during vitamin D treatment.

Commentary

The threshold which defines vitamin D sufficiency continues to be a controversial topic. The Institute of Medicine recommended a level of 20 ng/ml.  This comprehensive guideline from the Endocrine Society recommends a 25(OH)D level of 30 ng/ml to definite sufficiency. Recommendations on screening and therapy for various clinical scenarios are clearly outlined in this clinical guideline.  You can access a full copy of the guidelines on the Endocrine Society website.

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