Specific treatment[5]

Children:
o Oral calciferol in the form of either ergocalciferol or colecalciferol is the
treatment of choice for children with rickets.
o Children aged less than 6 months should be treated with 3,000 IU of
calciferol daily, increasing to 6,000 IU daily after 6 months of age. The
daily dose for those aged 12-18 years should be 10,000 IU.[2]
o Calcium supplementation is advisable during the first weeks of therapy for
a growing child.[2]
o A maintenance dose of 400 IU calciferol daily is appropriate for a child of
any age.
o A relatively rapid biochemical response is typically seen in children, with
normalisation of alkaline phosphatase levels within three months.
o It is likely that the mother, siblings, and other family members of a child
with rickets are also vitamin D-deficient. A maintenance dose of calciferol
is recommended for other family members (who should be investigated for
vitamin D deficiency and may require therapeutic doses).
Adults:
o Calciferol treatment, in a daily dose of 10,000 IU or a weekly dose of
60,000 IU, will lead to restoration of body stores of vitamin D over 8 to 12
weeks. A maintenance dose of 1,000-2,000 IU calciferol daily or 10,000
IU weekly is adequate. Combined calcium and vitamin D preparations
should be avoided in the long term, as the calcium component is usually
unnecessary.
o Short-acting, potent vitamin D analogues such as 1-alpha calcidol or
calcitriol are ineffective in correcting vitamin D deficiency and may lead
to hypercalcaemia.
o In adults with severe malabsorption, or those in whom concordance with
oral therapy is suspect, an intramuscular dose of 300,000 IU calciferol
monthly for three months followed by the same dose once or twice a year
may be considered.
o Pathological lesions in the bone are characterised by inadequate
mineralisation and may take many months to heal. Levels of serum
alkaline phosphatase and PTH will start to decline during the first three
months of treatment in adults, but may take a year to fall into the reference
range.
o Few adults have truly reversible risk factors for vitamin D deficiency and
so lifelong supplementation will be required.
o Vitamin D is contra-indicated in patients with hypercalcaemia or
metastatic calcification. Relative contra-indications include primary
hyperparathyroidism, renal stones, and severe hypercalciuria.[8]
o Caution is required when prescribing vitamin D for patients also taking
certain drugs, including thiazide diuretics (which impair calcium
excretion) and digoxin (enhance the effect of digoxin).

Monitoring

Serum calcium concentrations should be checked regularly for a few weeks after
starting treatment for vitamin D deficiency and then vitamin D, PTH and calcium
concentrations should be checked after 3-4 months of treatment to assess efficacy
and adherence to therapy. Vitamin D and calcium concentrations should be
checked every 6-12 months.[8]
Renal disease: 1,25-dihydroxycholecalciferol with response monitored until
alkaline phosphatase level returns to normal, when therapy should be reduced to
maintenance. Alfacalcidol (1-hydroxy derivative of calciferol) can be used in
vitamin D deficiency due to renal disease.
Renal tubular disorders and hypophosphataemia: the acidosis needs to be
corrected by giving bicarbonate and an adequate phosphate intake of 3-5 g/day.
Small doses of 1,25-dihydroxycholecalciferol may also be required.
Hypocalcaemic tetany requires urgent treatment with intravenous calcium
gluconate (10 mmol of a 10% solution initially).

Once vitamin D deficiency has been treated, prevention is required to prevent recurrence.
This includes correction of any underlying cause, lifestyle advice (diet, sunshine) and
often long-term vitamin D supplements:

Babies aged under 1 year: 200 units (5 micrograms) daily.

Children aged over 1 year: 280-400 units (7-10 micrograms) daily.
Adults: 400 units (10 micrograms) daily (more for certain groups, eg those who
get no sunshine, elderly, taking anticonvulsant medications, liver or kidney
disease).

Prognosis

This depends on the underlying cause but the outcome of treatment of vitamin D
deficiency is generally very good.
Treatment of simple deficiency with vitamin D replacement and/or sunlight and
correction of predisposing factors should lead to dramatic improvements.
Rickets and osteomalacia should respond rapidly to vitamin D. Increased mobility
with increase in muscle strength may be the first clinical response but there may
be a temporary increase in bone pain.
Some groups (eg those in long-term institutional care) may require long-term
maintenance therapy.
As long as there is no specific resistance to treatment then bone healing often
begins within a few weeks of starting treatment and complete healing within six
months.

Prevention

Information about appropriate sunlight exposure, the use of vitamin D supplements, and
eating oily fish should be made available to the whole population.[5]

Education: dietary advice, advice about the importance of sun exposure.

Either colecalciferol or ergocalciferol can be used to prevent primary vitamin D
deficiency. A daily dose of 400 IU (10 micrograms) prevents simple vitamin D
deficiency in otherwise healthy adults at risk of deficiency (those adults at high
risk of vitamin D deficiency may require higher doses, eg 800 IU daily).[8]
Early diagnosis and treatment of potential causes such as intestinal malabsorption
or renal failure.

In February 2012 the Chief Medical Officers for the United Kingdom issued the
following recommendations:[15]

All pregnant and breast-feeding women should take a daily supplement containing
10 micrograms of vitamin D, to ensure the mothers requirements for vitamin D
are met and to build adequate fetal stores for early infancy.
All infants and young children aged 6 months to 5 years should take a daily
supplement containing vitamin D in the form of vitamin drops, to help them meet
the requirement set for this age group of 7-8.5 micrograms of vitamin D per day.
However, those infants who are fed infant formula will not need vitamin drops
until they are receiving less than 500ml of infant formula a day, as these products
are fortified with vitamin D. Breast-fed infants may need to receive drops
containing vitamin D from one month of age if their mother has not taken vitamin
D supplements throughout pregnancy.
People aged 65 years and over and people who are not exposed to much sun
should also take a daily supplement containing 10 micrograms of vitamin D.

Provide Feedback

Usual Adult Dose for Hypocalcemia

50,000 to 200,000 units orally or IM once a day.

Usual Adult Dose for Hypoparathyroidism

25,000 to 200,000 units orally or IM once a day. Should be given with calcium
supplementation.

Usual Adult Dose for Familial Hypophosphatemia

Oral or IM:
250 to 1500 mcg/day (10,000 to 60,000 international units) with phosphate supplements

Usual Adult Dose for Osteomalacia

2000 to 5000 units orally once a day. In patients with malabsorption of vitamin D, the
dose is 10,000 units IM once a day or 10,000 to 300,000 units orally once a day.

Usual Adult Dose for Renal Osteodystrophy

20,000 units orally or IM once a day.

Usual Adult Dose for Vitamin D Deficiency

1000 units orally once a day. In patients with malabsorption of vitamin D, the dose is
10,000 units IM once a day or 10,000 to 100,000 units orally once a day.

Usual Adult Dose for Rickets

Oral or IM
Vitamin D-dependent rickets (in addition to calcium supplementation): 250 mcg to 1.5
mg/day (10,000 to 60,000 international units); doses as high as 12.5 mg/day may be
necessary
Nutritional rickets:
Adults with Normal Absorption: 25 to 125 mg/day (1,000 to 5,000 international units) for
6 to 12 weeks
Adults with Malabsorption: 250 to 7500 mcg/day (10,000 to 300,000 international units)

Usual Adult Dose for Vitamin/Mineral Supplementation

400 units orally once a day.

Usual Pediatric Dose for Vitamin/Mineral

Supplementation
Oral:
Dietary Supplementation for Prevention of Vitamin D Deficiency:
Dietary Intake Reference (DIR) (1997 National Academy of Science Recommendations):
Neonates, and Children: 200 international units/day.
(Note: DIR is under review as of March 2009)

Alternative dosing:
1 Month to 12 years (Wagner, 2008): 10 mcg/day (400 international units/day)
Less than 38 weeks gestational age: 10 to 20 mcg/day (400 to 800 international units), up
to 750 mcg/day (30,000 international units)
1 Month to 1 Year Fully or Partially Breastfed: 10 mcg/day (400 international units/day)
beginning in the first few days of life. Continue supplementation until infant is weaned to
greater than or equal to 1,000 mL/day or 1 qt/day of vitamin D-fortified formula or whole
milk (after 12 months of age)
Nonbreast-fed infants, older children ingesting less than 1,000 mL of vitamin D-fortified
formula or milk: 10 mcg/day (400 international units/day)
Children with increased risk of vitamin D deficiency (chronic fat malabsorption,
maintained on chronic antiseizure medications): Higher doses may be required.
Laboratory testing (25(OH)D, PTH, bone mineral status) should be used to evaluate.
Adolescents without adequate intake: 10 mcg/day (400 international units/day)

Usual Pediatric Dose for Hypoparathyroidism

50,000 to 200,000 units orally or IM once a day. Should be given with calcium
supplementation.

Usual Pediatric Dose for Osteomalacia

1000 to 5000 units orally once a day. In patients with malabsorption of vitamin D, the
dose is 10,000 units IM once a day or 10,000 to 25,000 units orally once a day.

Usual Pediatric Dose for Renal Osteodystrophy

4000 to 40,000 units orally or IM once a day.

Usual Pediatric Dose for Rickets

Oral or IM:
Vitamin D-dependent rickets (in addition to calcium supplementation):
Less than 1 month: 25 mcg/day (1,000 international units) for 2 to 3 months; once
radiologic evidence of healing is observed, dose should be decreased to 10 mcg/day (400
international units/day).
1 to 12 months: 25 to 125 mcg/day (1,000 to 5,000 international units) for 2 to 3 months;

once radiologic evidence of healing is observed, dose should be decreased to 10 mcg/day

(400 international units/day).
Greater than 12 months: 125 to 250 mcg/day (5,000 to 10,000 international units) for 2 to
3 months; once radiologic evidence of healing is observed, dose should be decreased to
10 mcg/day (400 international units/day).
Nutritional rickets:
Children (with normal absorption): 25 to 125 mcg/day (1,000 to 5,000 international units)
for 6 to 12 weeks.
Children with malabsorption: 250 to 625 mcg/day (10,000 to 25,000 international units).

Usual Pediatric Dose for Familial Hypophosphatemia

Oral or IM:
Initial: 1000 to 2000 mcg/day (40,000 to 80,000 international units) with phosphate
supplements. Daily dosage is increased at 3 to 4 month intervals in 250 to 500 mcg
(10,000 to 20,000 international units) increments.

Usual Pediatric Dose for Vitamin D Deficiency

Vitamin D insufficiency or deficiency associated with CKD (stages 2-5, 5D): serum 25
hydroxyvitamin D (25[OH]D) level less than 30 ng/mL:
Serum 25(OH)D level 16 to 30 ng/mL: Children: 2000 international units/day for 3
months or 50,000 international units every month for 3 months.
Serum 25(OH)D level 5 to 15 ng/mL: Children: 4000 international units/day for 12
weeks or 50,000 international units every other week for 12 weeks.
Serum 25(OH)D level less than 5 ng/mL: Children: 8000 international units/day for 4
weeks then 4000 international units/day for 2 months for total therapy of 3 months or
50,000 international units/week for 4 weeks followed by 50,000 international units 2
times/month for a total therapy of 3 months.
Maintenance dose [once repletion accomplished; serum 25(OH)D level greater than 30
ng/mL]: 200 to 1000 international units/day.
Dosage adjustment: Monitor 25(OH)D, corrected total calcium and phosphorus levels 1
month following initiation of therapy, every 3 months during therapy and with any
Vitamin D dose change.
Prevention and treatment of vitamin D Deficiency in cystic fibrosis:
Infants less than 1 year: 400 international units/day.

Children greater than 1 year: 400 to 800 international units/day.

Renal Dose Adjustments

Data not available

Liver Dose Adjustments

Data not available

Dialysis
Vitamin D and its metabolites are not dialyzable.

Other Comments
Patients should receive adequate calcium during ergocalciferol therapy. Serum calcium
should be monitored 1 to 2 times a week during dosage titration, and approximately once
a month after stabilization of dosage. Ergocalciferol should be withheld if hypercalcemia
develops.
1 mcg = 40 USP international units