Surrey (East Surrey CCG, Guildford & Waverley CCG, North West Surrey CCG, Surrey Downs CCG & Surrey Heath), Crawley CCG and Horsham & Mid-Sussex CCG
Pathway 1-Vitamin D Pathway for Adults (>18 years) in Primary Care-adapted from CKS FOR PATIENTS WITHOUT BONE DISEASE EXCLUSIONS : patients with chronic kidney disease (eGFR <30mmol/L), h/o renal stones, hypercalcaemia, sarcoidosis, liver disease, TB, lymphoma, metastatic cancer, parathyroid disorders, atypical biochemistry (persistent hypophosphatemia, elevated creatinine) , pregnancy – seek specialist advice FOR ALL PATIENTS – see prevention advice below and offer lifestyle advice including British Dietetic Association leaflet Food Fact Sheet on vitamin D
ROUTINE TESTING for at risk groups should NOT be undertaken (NICE PH56) Does the patient have at least one PERSISTENT SYMPTOM suggesting vitamin D deficiency?
Symptoms of osteomalacia, such as bone discomfort or pain (often throbbing) in lower back, pelvis, and lower extremities; impaired physical function; muscle aches and weakness (may be marked, usually most noticeable in the quadriceps and glutei, and can result in difficulty in rising from a seating position, or a waddling gait); symmetric lower back pain;
chronic widespread pain. For patients with fragility fracture, osteoporosis, high risk of fracture or prior to initiating anti-resorptive drugs follow Pathway 2-for patients with bone disease YES NO It is appropriate to request a TEST for vitamin D deficiency and bone profile. It is NOT Vitamin D will naturally be lower October-March due to seasonal variation appropriate to Please note that labs may report levels and offer advice in different ways request a test for vitamin D Vitamin D levels deficiency
0-30nmol/L (deficiency) 30-50nmol/L (maybe insufficient) >50nmol/L Only prescribe if symptoms suggestive Prescribe on Acute Consider other of vitamin D deficiency; or taking an possible causes a weekly regimen of either antiepileptic drug/oral corticosteroid / Colecalciferol 50,000iu/ml oral of symptoms solution unit dose ampoules sugar on long-term treatment with other free ONE weekly for 6 weeks OR drugs known to cause vitamin D PREVENT deficiency by giving
Colecalciferol 20,000iu capsules TWO deficiency e.g. colestyramine; or have lifestyle advice and recommend a malabsorption disorder over the counter supplement weekly or 40,000iu capsules ONE weekly for 7 weeks Prescribe on Acute containing at least 400iu (10mcg) OR a daily regime n of a daily regimen for up to 12 weeks vitamin D daily especially during Colecalciferol 3,200iu capsules OR Colecalciferol 800iu capsules/tablets autumn and winter for all adults. At colecalciferol 4,000iu tablets ONE daily risk groups - people over 65, or ONE daily for 12 weeks pigmented skin or little/no sun Colecalciferol 1,000iu capsules/tablets ONE daily exposure should consider taking a supplement all year round. Calculate dietary calcium intake. Offer dietary advice (BDA Factsheet) to obtain Recommend a daily supplement to optimum calcium intake and ONLY consider a calcium supplement if adequate all pregnant and breast feeding dietary intake cannot be achieved (combined products are unsuitable for women (PHE Guidance) - some may treatment of deficiency). qualify for Healthy Start Vitamins.
At 4 weeks check for hypercalcaemia due to unmasked primary hyperparathyroidism
Still symptomatic at 12 weeks?
NO YES After treatment course for deficiency or insufficiency give lifestyle advice Discuss concordance and recommend over the counter supplement as above. However, Repeat vitamin D level-wait for minimum of 3 prescribers may use discretion around continuing to prescribe a months from starting treatment maintenance dose of colecalciferol 800 -1000iu daily for institutionalized Refer non-responsive patients to 2ary care or housebound patients with ongoing risk of deficiency after treatment. Produced: January 2017 Agreed at PCN on: 1ST February 2017 For Review: January 2020