Recommendations for the diagnosis and management of vitamin D deficiency in adults.

http://www.guideline.gov/summary/summary.aspx?doc_id=14868&nbr=007366&string=%22vitamin+d%22

* University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations for the diagnosis and management of vitamin D deficiency in adults. Austin (TX): University of Texas at Austin, School of Nursing; 2009 May. 16 p. 40 references

Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of the "Major Recommendations" field.

Diagnosis

1. Consider screening patients who report a current or past medical history of the following:

• Chronic musculoskeletal pain including fibromyalgia

(Cannell & Hollis, 2008; Holick, 2007; Lyman, 2005; Leventis & Patel, 2008; Bischoff-Ferrari, Orav, & Dawson-Hughes, 2006) (Grade A, Evidence Good).

• Osteoporosis

(Holick, 2007; Lyman, 2005; Leventis & Patel, 2008; Cannell & Hollis, 2008; Bischoff-Ferrari et al., 2009; Bischoff-Ferrari, Orav, & Dawson-Hughes, 2006; Autier and Gandini, 2007) (Grade A, Evidence Good).

• Rheumatoid arthritis

(Leventis & Patel, 2008; Holick, 2007; Cannell & Hollis, 2008; Mouyis et al., 2008; Plotnikoff & Quigley, 2003) (Grade A, Evidence Good).

• Malabsorption syndromes

(Holick, 2007; Agus & Drezner, 2008; Johnson et al., 2006) (Grade A, Evidence Good).

• Obesity, metabolic syndromes, and type II diabetes

(Holick, 2007; Giovannucci et al., 2008; Cannell & Hollis, 2008; Konradsen et al., 2008; Rodriguez-Rodriguez et al., 2009; Pittas et al., 2007; Mattila et al., 2007; Melamed et al., 2008) (Grade B, Evidence Fair).

• Cardiovascular disease

(Martins et al., 2007; Autier & Gandini, 2007; Lee et al., 2008) (Grade A, Evidence Good).

• Chronic kidney disease and hyperparathyroidism

(Holick, 2007; Agus & Drezner, 2008; Cuppari & Garcia-Lopez, 2009; Dusso, Brown, & Slatopolsky, 2005) (Grade B, Evidence Fair).

• Depression

(Berk et al., 2007; Wilkins et al., 2006; Murphy & Wagner, 2008; Holick, 2007) (Grade B, Evidence Fair).

• High risk population such as elderly (over 71 years of age) and dark-skinned individuals

(Bischoff-Ferrari et al., 2004; Agus & Drezner, 2008; Cannell & Hollis, 2008; Holick, 2007; Lyman, 2005; National Institutes of Health, 2008) (Grade A, Evidence Good).

• Chronic use of corticosteroids

(Holick, 2007; Lyman, 2005; Leventis & Patel, 2008; Cannell & Hollis, 2008) (Grade A, Evidence Good).

• Personal/social history of inadequate sun exposure

(e.g., working indoors, homebound, living in higher latitude, wearing excessive clothing, dark skinned and use of sun block)

• and insufficient dietary intake of vitamin D fortified foods

(Holick, 2007; Lyman, 2005; Leventis & Patel, 2008; Cannell & Hollis, 2008; Cranney et al., 2007) (Grade A, Evidence Good).

2. Physical exam including general appearance, vital signs, height and weight, general skin assessment, skin color, and assessment for bone pain

• may provide the examiner with clues to possible vitamin D deficiency

(Cannell & Hollis, 2008; Holick, 2007) (Grade B, Evidence Fair).

3. Diagnostic tests as indicated: serum 25-hydroxyvitamin D (25OHD) concentrations

(Holick, 2007; Heaney, 2008; Lyman, 2005; Leventis & Patel, 2008; Cannell & Hollis, 2008; Cranney et al., 2007; Cashman et al., 2008) (Grade A, Evidence Good).
Bone pain due to vitamin D deficiency is best assessed by using moderate force to press the thumb on the sternum or anterior tibia, which can elicit bone pain (in some cases can be a sign of osteomalacia) (Cannell & Hollis, 2008).

Maintenance

* Daily oral recommended vitamin D requirements. Adequate intake: adults 18 to 50 – 200 international units (IU); 51 to 70 – 400 IU with adequate sun exposure (Institute of Medicine, 1999; Cannell & Hollis, 2008; Bischoff-Ferrari et al., 2004; Lyman, 2005) (Grade C, Evidence Poor).
* 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 (Bischoff-Ferrari et al., 2009; Holick, 2007; Cranney et al., 2007; U.S. Department of Health and Human Services, 2005) Grade A, Evidence Good).
* 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 (Holick, 2007) (Grade C, Evidence Fair)

Pharmacological Therapy to Treat Vitamin D Deficiency

* Nutritional deficiency (25OHD <20 ng/ml 50 nmol/L) 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 25OHD level), and then 800 to 1000 IU of vitamin D3 daily thereafter (Dawson-Hughes, 2008; Lyman, 2005; Holick, 2007). Intramuscular cholecalciferol (300,000 U) in one or two doses per year is also an option for increasing serum 25OHD levels (de Torrente de la Jara, Pecoud, & Favrat, 2006) (Grade A, Evidence Good).
* Nutritional insufficiency (25OHD 20 to 30 ng/ml 50 to 75 nmol/L) requires treatment with 800 to 1000 IU of vitamin D3 daily. This intake will bring the average adult to 30 ng/ml (75 nmol/L) over a three month period, but many individuals will need higher doses (Lyman, 2005; Holick, 2007) (Grade B, Evidence Fair).
* 25OHD concentrations should be measured approximately eight to twelve weeks after initiating therapy. The dose of vitamin D may require adjustment depending upon individual absorption (Dawson-Hughes, 2008; Holick, 2007) (Grade B, Evidence Fair).

Definitions: Quality of Evidence (Based on U.S. Preventive Services Task Force USPSTF Ratings)

Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence of health outcomes.

Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their designs or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Grading of Recommendations (Based on U.S. Preventive Services Task Force USPSTF Ratings)

A. The USPSTF strongly recommends that clinicians provide the service to eligible patients. The USPSTF found good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.
B. The USPSTF recommends that clinicians provide this service to eligible patients. The USPSTF found at least fair evidence that the service improves important health outcomes and concludes that benefits outweigh harms.
C. The USPSTF makes no recommendation for or against routine provision of the service. The USPSTF found at least fair evidence that the service can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D. The USPSTF recommends against routinely providing the service to asymptomatic patients. The USPSTF found at least fair evidence that the service is ineffective or that harms outweigh benefits.

I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. Evidence that the service is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
CLINICAL ALGORITHM(S)

A clinical algorithm is provided in the original guideline document for Diagnosis and Management of Vitamin D Deficiency.
* University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Recommendations for the diagnosis and management of vitamin D deficiency in adults. Austin (TX): University of Texas at Austin, School of Nursing; 2009 May. 16 p. 40 references

DATE RELEASED 2009 May

Print copies: Available from the University of Texas at Austin, School of Nursing. 1700 Red River, Austin, Texas, 78701-1499

This NGC summary was completed by ECRI Institute on February 5, 2010. The information was verified by the guideline developer on April 26, 2010.

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