Guideline sources The following summarized guidelines for the evaluation and management of vitamin D deficiency are prepared by our editorial team based on guidelines from the British Association of Dermatologists (BAD 2022), the U.S. Preventive Services Task Force (USPSTF 2021; 2018), the American Society of Anesthesiologists (ASA/ACE/OS/AACE/ASMBS/OMA 2020), the European Society of Endocrinology (ESE/ES 2017), the Canadian Task Force on Hyperparathyroidism (CTFH 2017), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2017), the American Association of Endocrine Surgeons (AAES 2016), the Obesity Society (OS/AACE 2013), the American Society for Parenteral and Enteral Nutrition (ASPEN 2013), the American College of Endocrinology (ACE/OS/AACE 2013), the Australian and New Zealand Bone and Mineral Society (ANZBMS/OA/ESA 2012), the Endocrine Society (ES 2011), the American College of Obstetricians and Gynecologists (ACOG 2011), and the Osteoporosis Canada Foundation (OC 2010). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Guidelines 1. Screening and diagnosis https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 1/8 6/29/23, 3:43 AM Vitamin D deficiency Pathway Definitions: Define vitamin D deficiency and insufficiency according to the level of serum 25- hydroxyvitamin D as follows: deficiency: < 20 ng/mL (50 nmol/L) insufficiency: 21-29 ng/mL (525-725 nmol/L). A Indications for screening: As per BAD 2022 guidelines, consider obtaining screening for vitamin D deficiency in patients with vitiligo avoiding all sun exposure. E As per USPSTF 2021 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic, community-dwelling, nonpregnant adults. I As per ESE 2017 guidelines, consider obtaining screening for vitamin D deficiency with a serum 25-hydroxyvitamin D measurement in patients with Turner syndrome at the age of 9 and 11 years and every 2-3 years thereafter throughout the lifespan. Treat with inactive vitamin D (ergocalciferol) as necessary. C As per AACE 2013 guidelines, obtain screening for vitamin D deficiency with a serum 25- hydroxyvitamin D measurement in individuals at risk for vitamin D deficiency, such as: elderly A individuals with hyperpigmented skin B institutionalized patients A malnourished patients A patients with known osteopenia or osteoporosis A patients with obesity. B As per ES 2011 guidelines: Obtain screening for vitamin D deficiency in individuals at risk for vitamin D deficiency. A Do not obtain screening for vitamin D deficiency in individuals not at risk for vitamin D deficiency. D As per OC 2010 guidelines: Obtain screening for vitamin D deficiency with a serum 25-hydroxyvitamin D measurement in patients with osteoporosis in any of the following conditions: prescribed to receive pharmacotherapy for osteoporosis sustained recurrent fractures having bone loss despite osteoporosis treatment having comorbid conditions affecting absorption or action of vitamin D. B Do not screen for vitamin D deficiency in healthy adults at low risk of vitamin D deficiency (without osteoporosis or conditions affecting the absorption or action of vitamin D). D 2. Diagnostic investigations Vitamin D measurement: obtain serum circulating 25-hydroxyvitamin D level, measured by a reliable assay, to evaluate vitamin D status in patients at risk for vitamin D deficiency. A Show 2 more https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 2/8 6/29/23, 3:43 AM Vitamin D deficiency Pathway 3. Medical management Vitamin D supplementation: As per ANZBMS 2012 guidelines: Initiate 3,000-5,000 IU of vitamin D3 (3-5 1,000 IU vitamin D3 capsules or 0.6-1 mL of 5,000 IU/mL liquid vitamin D3) for at least 6-12 weeks, with a check on 25-hydroxyvitamin D concentrations in most patients after 3 months, followed by ongoing treatment with a lower dose of around 1,000-2,000 IU/day (1 capsule of 1,000 IU or 0.2 mL of 5,000 IU/mL liquid daily) and adequate calcium intake in adult patients with vitamin D deficiency. E Offer 50,000 IU of vitamin D3 once per month for 3-6 months as an alternative regimen in adult patients with vitamin D deficiency. E As per ES 2011 guidelines, consider using either vitamin D2 or vitamin D3 for the treatment and prevention of vitamin D deficiency. B Show 2 more 4. Specific circumstances Pediatric patients (daily requirements): ensure vitamin D intake of at least 400 IU/day in 0-1 year old infants and children, and at least 600 IU/day in 1 year old children, to maximize bone health. Insufficient evidence of whether 400 and 600 IU/day in 0-1 and 1-18 years old children, respectively, are enough to provide all the potential nonskeletal health benefits associated with vitamin D to maximize bone health and muscle function. Recognize that at least 1,000 IU/day of vitamin D may be required to raise the serum level of 25-hydroxyvitamin D consistently > 30 ng/mL. B Show 2 more Pediatric patients (treatment): Consider initiating 2,000 IU/day of vitamin D2 or vitamin D3, or 50,000 IU of vitamin D2 or vitamin D3 once weekly for 6 weeks, followed by maintenance therapy of 400-1,000 IU/day, in 0-1 year old infants and toddlers with vitamin D deficiency, to achieve a blood level of 25-hydroxyvitamin D > 30 ng/mL. y Consider initiating 2,000 IU/day of vitamin D2 or vitamin D3 for at least 6 weeks, or 50,000 IU of vitamin D2 once weekly for at least 6 weeks, followed by maintenance therapy of 600- 1,000 IU/d, in 1-18 years old pediatric patients with vitamin D deficiency, to achieve a blood level of 25-hydroxyvitamin D > 30 ng/mL. (2, high). B Pregnant patients: As per AACE 2020 guidelines, obtain screening for vitamin D deficiency every trimester as part of nutritional surveillance and laboratory screening for nutrient deficiencies in patients becoming pregnant after bariatric procedures. B As per ASPEN 2013 guidelines: Recognize that maternal vitamin D deficiency is a risk factor for neonatal vitamin D deficiency and abnormal bone health. B Consider screening pregnant women vitamin D deficiency and initiate supplementation if deficient. C As per ACOG 2011 guidelines, insufficient evidence to recommend screening all pregnant women for vitamin D deficiency. I https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 3/8 6/29/23, 3:43 AM Vitamin D deficiency Pathway Show 2 more As per ES 2011 guidelines, ensure intake of at least 600 IU/day of vitamin D during pregnancy recognizing that at least 1,500-2,000 IU/day of vitamin D may be needed to maintain a blood level of 25-hydroxyvitamin D > 30 ng/mL. B Patients with postmenopausal osteoporosis: measure baseline serum levels of 25- hydroxyvitamin D to confirm being within acceptable normal limits before initiating teriparatide. B Show 2 more Patients with chronic kidney disease: As per KDIGO 2017 guidelines, treat vitamin D deficiency/insufficiency in patients with CKD using treatment strategies recommended for the general population. B As per AACE 2013 guidelines, adjust calcitriol dosing to allow for adequate intestinal absorption of calcium in patients with advanced renal failure in whom renal activation of vitamin D is impaired. A Patients with primary hyperparathyroidism, preoperative: As per CTFH 2017 guidelines, correct vitamin D deficiency/insufficiency to lower serum PTH, without further elevating serum calcium, in patients with primary hyperparathyroidism. Correct serum 25-hydroxyvitamin D to > 50 nmol/L. E As per ES 2011 guidelines, consider initiating vitamin D as needed in patients with primary hyperparathyroidism and vitamin D deficiency. Monitor serum calcium levels. B Patients with primary hyperparathyroidism (postoperative): Consider administering short-term calcium and/or vitamin D supplementation for prophylaxis against hypocalcemia after parathyroidectomy. C Initiate vitamin D supplementation in patients with vitamin D deficiency after apparently successful parathyroidectomy. Advise following the recommended calcium intake by the IOM Dietary Reference Intakes. B Patients undergone bariatric surgery: initiate at least 2,000-3,000 IU/day of vitamin D, titrated to therapeutic 25-hydroxyvitamin D levels > 30 ng/mL, in patients undergone biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, sleeve gastrectomy A , and laparoscopic adjustable gastric banding. B Show 3 more 5. Preventative measures Vitamin D requirements: As per AACE 2013 guidelines: Prescribe vitamin D supplementation of at least 1,000-2,000 IU of vitamin D2 or vitamin D3 daily in most patients, to keep the plasma 25-hydroxyvitamin D level > 30 ng/mL. A Advise older adults, individuals with increased skin pigmentation, or those exposed to insufficient sunlight to increase their vitamin D intake from vitamin D-fortified foods and/or supplements to at least 800-1,000 IU/day. A https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 4/8 6/29/23, 3:43 AM Vitamin D deficiency Pathway As per ANZBMS 2012 guidelines, advise maintaining vitamin D intake (from dietary sources and supplementation) of at least 600 IU/day in 70 years old adults and 800 IU/day in > 70 years old adults. Consider advising higher doses in individuals at high risk or with substantial sun avoidance. E As per ES 2011 guidelines, consider advising intake of at least 600 IU/day of vitamin D in 19- 50 years old adults, to maximize bone health and muscle function. Insufficient evidence whether 600 IU/day is enough to provide all the potential nonskeletal health benefits associated with vitamin D. Recognize that at least 1,500-2,000 IU/day of vitamin D may be required to raise the blood level of 25-hydroxyvitamin D consistently > 30 ng/mL. B Show 3 more As per OC 2010 guidelines: Advise routine daily supplementation of 400-1,000 IU (10-25 g) of vitamin D3 in healthy adults at low risk of vitamin D deficiency. B Advise daily supplementation of 800-1,000 IU (20-25 g) of vitamin D3 daily in > 50 years old adults at moderate risk of vitamin D deficiency. Recognize that > 1,000 IU (25 g) daily supplementation may be required to achieve optimal vitamin D status. Recognize that daily doses of up to 2,000 IU (50 g) are safe and do not necessitate monitoring. B Prevention of fractures: As per USPSTF 2018 guidelines, insufficient evidence to assess the balance of benefits and harms of vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in males and premenopausal females. I Show 3 more As per ANZBMS 2012 guidelines, advise vitamin D supplementation of 1,000 IU (25 g) daily, combined with adequate calcium intake, to reduce fracture risk in older adults. E Prevention of falls: prescribe vitamin D supplementation for fall prevention. B Prevention of cardiovascular diseases: do not prescribe vitamin D supplementation beyond recommended daily needs for the purpose of preventing CVD or death or improving quality of life. D 6. Follow-up and surveillance Serial vitamin D measurement: As per ANZBMS 2012 guidelines, measure serum 25-hydroxyvitamin D concentrations in most patients after 3 months of treatment initiation. E As per ES 2011 guidelines, consider obtaining serial monitoring of serum 25-hydroxyvitamin D and calcium levels during treatment with vitamin D to prevent hypercalcemia in patients with extrarenal production of 1, 25-dihydroxyvitamin D. B As per OC 2010 guidelines, measure serum 25-hydroxyvitamin D after 3-4 months of adequate supplementation and do not repeat if an optimal level ( 75 nmol/L) is achieved. B Clinical findings https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 5/8 6/29/23, 3:43 AM Vitamin D deficiency Pathway Patient demographics Symptoms Dark skin color Bone pain Hip pain Past medical history Malabsorption Muscle pains CKD Muscle weakness Corticosteroid use History of fracture Medication history IBD Osteoporosis Anticonvulsants Rickets Social history Past surgical history Limited sun exposure Bariatric surgery Lab findings Musculoskeletal exam serum PTH Bowed legs serum 25-hydroxyvitamin D Kyphosis serum calcium Pectus carinatum Imaging findings Osteopenia Studies 2019 VIOLET (vitamin D) In critically ill, vitamin D-deficient patients who were at high risk for death, vitamin D was not superior to placebo with respect to a all-cause mortality at 90 days. National Heart et al. N Engl J Med. 2019 Dec 26. References 1. V Eleftheriadou, R Atkar, J Batchelor et al. British Association of Dermatologists guidelines for the management of people with vitiligo 2021. Br J Dermatol. 2022 Jan;186 1 18 29. Open 2. Mechanick JI, Youdim A, Jones DB et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient 2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Endocr Pract. 2013 Mar-Apr;19 2 337 72. Open 3. Michael F Holick, Neil C Binkley, Heike A Bischoff-Ferrari et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96 7 1911 30. Open 4. Papaioannou A, Morin S, Cheung AM et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. 2010 Nov 23;182 17 1864 73. Open https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 6/8 6/29/23, 3:43 AM Vitamin D deficiency Pathway 5. Scott M Wilhelm, Tracy S Wang, Daniel T Ruan et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg. 2016 Oct 1;151 10 959 968. Open 6. Nehra D, Carlson SJ, Fallon EM et al. A.S.P.E.N. clinical guidelines: nutrition support of neonatal patients at risk for metabolic bone disease. JPEN J Parenter Enteral Nutr. 2013 Sep;37 5 570 98. Open 7. Caryl A Nowson, John J McGrath, Peter R Ebeling et al. Vitamin D and health in adults in Australia and New Zealand: a position statement. Med J Aust. 2012 Jun 18;196 11 686 7. Open 8. Gravholt CH, Andersen NH, Conway GS et al. Clinical practice guidelines for the care of girls and women with Turner syndrome: proceedings from the 2016 Cincinnati International Turner Syndrome Meeting. Eur J Endocrinol. 2017 Sep;177 3 G1 G70. Open 9. Khan AA, Hanley DA, Rizzoli R et al. Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus. Osteoporos Int. 2017 Jan;28 1 1 19. Open 10. Kidney Disease: Improving Global Outcomes KDIGO CKD MBD Update Work Group. KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease Mineral and Bone Disorder CKD MBD . Kidney Int Suppl. 2017 Jul;7 1 1 59. Open 11. Gonzalez-Campoy JM, St Jeor ST, Castorino K et al. Clinical practice guidelines for healthy eating for the prevention and treatment of metabolic and endocrine diseases in adults: cosponsored by the American Association of Clinical Endocrinologists/the American College of Endocrinology and the Obesity Society. Endocr Pract. 2013 Sep-Oct;19 Suppl 3 1 82. Open 12. Jeffrey I Mechanick, Caroline Apovian, Stacy Brethauer et al. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity Silver Spring). 2020 Apr;28 4 O1 O58. Open 13. US Preventive Services Task Force, David C Grossman, Susan J Curry et al. Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Apr 17;319 15 1592 1599. Open 14. US Preventive Services Task Force, Alex H Krist, Karina W Davidson et al. Screening for Vitamin D Deficiency in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021 Apr 13;325 14 1436 1442. Open 15. No authors listed. ACOG Committee Opinion No. 495 Vitamin D Screening and supplementation during pregnancy. Obstet Gynecol. 2011 Jul;118 1 197 198. Open 16. National Heart, Lung, and Blood Institute PETAL Clinical Trials Network et al. Early High-Dose Vitamin D 3 for Critically Ill, Vitamin D Deficient Patients. N Engl J Med. 2019 Dec 26;381 26 2529 2540. Open 17. Karin Amrein, Christian Schnedl, Alexander Holl et al. Effect of high-dose vitamin D3 on hospital length of stay in critically ill patients with vitamin D deficiency: the VITdAL ICU randomized clinical trial. JAMA. 2014 Oct 15;312 15 1520 30. Open 18. Julie Parrott, Laura Frank, Rebecca Rabena et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 7/8 6/29/23, 3:43 AM Vitamin D deficiency Pathway Micronutrients. Surg Obes Relat Dis. 2017 May;13 5 727 741. Open https://web.pathway.md/diseases/recYhVy1LYAhfEAVS 8/8