(East Surrey CCG, Guildford & Waverley CCG, North West Surrey CCG, Surrey Downs CCG & ), 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