VITAMIN D DEFICIENCY
By Dr Rukhsana Hussain
GP ST3
22nd January 2013
CONTENT
 Background
 Prevention
of Vitamin D Deficiency
 Local Adult pathway for Vitamin Deficiency in
Primary Care
 Some issues with Adcal D3 for maintenance
therapy
 Some recommendations
 Take home messages...
 References
VITAMIN D
 Important
to maintain calcium and phosphate
homeostasis and bone and muscle integrity

http://www.youtube.com/watch?v=DrBIDdgFTRc
VITAMIN D
2
sources
- 90% synthesised in skin via UVB light exposure
-Cholecalciferol (vitD3 = inactive)
- 10% from food – Ergocalciferol (vit D2=
inactive)
 Activation
 Calcitriol
in liver and kidneys to CALCITRIOL
acts on intranuclear receptors present
on most body cells
VITAMIN D
 Calcitriol
stimulates absorption of calcium from
GI tract and reduces loss of calcium in urine
 Calcitriol
 PTH
directly stimulates bone remodelling
activates enzyme which converts inactive
vitamin D to the active form – and so can be
raised in vitamin D deficiency.
WHY DO PEOPLE BECOME VITAMIN D
DEFICIENT?
 Lack
of UVB sunlight exposure (90% UK too far
north to have adequate levels for 6 months of
the year!)
 Small
quantities in food
 Sunscreen
synthesis
with SPF 15+ blocks 99% vitamin D
WHY IS IT IMPORTANT?
 Vitamin
D insufficiency and deficiency common
 Implications for bone and muscle health
 Public health issue and raised awareness
 More requests for testing and cost implications
in testing and prescribing
 Possibility
of many other health problems
associated with Vitamin D deficiency inc
cardiovascular disease, infections, autoimmune
diseases and cancers...
ALTHOUGH ....

A consensus statement representing the unified views of
a number of organisations (the British Association of
Dermatologists, Cancer Research UK, Diabetes UK, the
Multiple Sclerosis Society, the National Heart Forum, the
National Osteoporosis Society and the Primary Care
Dermatology Society), states that the evidence
suggesting that vitamin D might protect against cancer,
heart disease, diabetes, multiple sclerosis and other
chronic diseases is still inconclusive.
(GP notebook - 2010)
PREVENTING VITAMIN D DEFICIENCY
IN CHILDREN
DOH recommendations:
 All
infants and children under 5 years should
take supplements – at least 280 IU daily
 All pregnant women should take 400IU vitamin
D supplements daily
 All breastfeeding should take 400 IU vitamin D
supplements daily
PREVENTING VITAMIN D DEFICIENCY
IN ADULTS
 Fair
skinned young person – needs 20-30min
UVB exposure at midday to face and forearms
3 x /wk for healthy vitamin D levels (each
exposure = 2000IU)
 Elderly
and those with pigmented skin need
more frequent and longer sun exposure to
achieve same levels (2 to 10 fold!)
 Healthy
adults at risk of deficiency – 400IU
vitamin D supplement daily
 Adults
at high risk of deficiency e.g. South
Asians, aged over 65 years, extensive covering
take 800IU vitamin D supplement daily
COMPLIANCE ISSUES
“Clinicians should avoid giving combined
calcium and vitamin D preparations in the long
term because the calcium component is usually
unnecessary, makes for unpalatability, and
reduces concordance.”
(BMJ 2010; 340:B5664 (Clinical Review))
PATIENT SAFETY/RISKS
1)
Risk of hypercalcaemia
“Adcal D3 can be prescribed on FP10 but
contains calcium carbonate and may require
monitoring”
The local guidelines say this!
Are we doing this? Probably not!
In contrast , vitamin D-only preparations for
maintenance therapy require no monitoring
and there is a very low risk of toxicity.
PATIENT SAFETY/RISKS
2) Double standards!
Question – Why are we ok to advise patients to
buy vitamin D-only preparations OTC for
maintenance therapy BUT insist on prescribing
calcium with vitamin D?
Which is better? If calcium with vitamin D is
better then we should recommend that to all!
PATIENT SAFETY/RISKS
3) Possible long term implications of
calcium supplementation
FRONT PAGE NEWS!
COST
COST ISSUES
 Patients
not complying with maintenance
therapy will mean they will likely become
symptomatic again incurring more costs inc:



Cost of attendances to surgery
Cost of blood tests
Cost of high dose therapy compared with
maintenance therapy
October 2012 Drug Tariff prices - monthly cost
Brand
Price (£)
Quantity
Adcal D3
(400IU/750mg Ca)
3.65
56
Adcal D3
(200IU/750mg Ca)
3.65
112
Calcichew D3
(200IU)
7.68
100
Calcichew D3 forte
(400IU)
4.24
60
Calcichew D3 caplets
(200IU)
7.43
100
Cacit D3 granules
4.06
30
Calfovit D3 sachets
(800IU/ca phosphate)
4.32
30
Fultium D3
(800IU - cholecalciferol only)
3.60
30
High dose Vitamin D - PRESCRIBE BY BRAND
Brand
Price (£)
Quantity
Dekristol 20, 000IU caps
4.14
8
Pro D3 20, 000IU caps
5.33
8
Bio-vitamin D3 20,000IU caps
3.72
8
Hux D3 20,000IU caps
1.40
8
NOTES 1. Dekristol - unlicensed - fee per prescription is £20 approx
2. Others are commercially available and so no licence fee!
3. ProD3 suitable for vegetarians, halal, gelatin-free
4. Hux D3 - The product is available long term and is the product of
choice for North London and Manchester CCGs.
OTC vitamin D supplements prices Oct 2012 (internet-based)
Brand
Source
Price (£)
Quantity
Sunvite D3
10mcg (400IU)
Sunvite D3
25mcg
(1000IU)
VitD3 1000IU
Vit D3 500IU
Vit D3 1000IU
capsule
Vit D3 1000IU
capsule
Vit D3 tablets
Holland and
Barrett
Holland and
Barrett
3.55
100
Cost per
month (£)
2.13
8.05
100
2.41
Boots
Boots
Nature's
remedy
Nature's
remedy
Nature's
remedy
Nature's
remedy
Lifestyle
natural health
Solgar
5.10
1.99
6.99
90
90
100
1.70
1.33
2.10
14.99
250
1.80
6.99
100
2.10
11.99
200
1.80
31.93
360
2.66
11.00
180
1.83
Solgar
7.25
100
2.18
Vit D3 tablets
Biolife vit D3
1000IU
Vitamin D3
tabs
1000IU
Vitamin D3
softgels
1000IU
ALTERNATIVES
REASONABLE ALTERNATIVES
•
It is obvious that we have reasonable
alternatives to Adcal D3 that:
Don’t unnecessarily contain calcium and so reduce
any risk of potential harm
– patients would be willing to take because they are
more palatable
– will improve compliance due to less frequent dosing
and palatability
– will reduce costs of multiple blood tests and
attendances to the surgery
– Are cost-effective!!!
–
RECOMMENDATIONS
1. To treat vitamin D deficiency with 60,000IU
per week for 12 weeks
2. To encourage patients to buy OTC
supplements and share the approximate costs
with them as they may perceive the cost to be
much higher.
3. To prescribe Hux D3/Biovit D3 instead of
Dekristol (cheaper as not unlicensed)
RECOMMENDATIONS
4. To prescribe vitamin D supplement by brand
5. To prescribe Fultium D3 as maintenance
therapy instead of AdcalD3 in vitamin D
deficiency
TAKE HOME MESSAGES
 Think
about vitamin D deficiency.. It is very
common!
 Consider including vitamin D in TATT screen in at
risk groups
 Often people need higher doses than
recommended to feel symptomatic benefit ...
....Use your judgement
 OTC supplements are cheap! SELL them to
patients and avoid prescribing if possible : )
REFERENCES
1. Pearce SHS, Cheetham TD. Clinical Review :Diagnosis
and management of vitamin D. BMJ 2010; 340: 142-147
(B5664)
2. Drug Tariff October 2012
3. Adult pathway for Vitamin D deficiency in Primary care ,
Calderdale and Huddersfield NHS Trust Dec 2011
4. Bolland MJ et al. Effect of calcium supplements on risk of
myocardial infarction and cardiovascular events: metaanalysis. BMJ2010;341:c3691
REFERENCES
5. Li K et al. Associations of dietary calcium intake and
calcium supplementation with myocardial infarction and
stroke risk and overall cardiovascular mortality in the
Heidelberg cohort of the European Prospective
Investigation into Cancer and Nutrition study (EPICHeidelberg) Heart 2012;98:920-925
6. Calcium supplements with or without vitamin D and risk
of cardiovascular events: reanalysis of the Women’s
Health Initiative limited access dataset and metaanalysis BMJ2011;342:d2040
7. www.gpnotebook.co.uk