Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

insufficiency

1st line – vitamin D

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ACUTE
|
insufficiency
1st line – 

vitamin D

A child or adult is considered vitamin D-insufficient if serum 25-hydroxyvitamin D level is between 21 and 29 nanograms/mL or if history suggests lack of adequate daily vitamin D (400 IU for children <1 year of age; 600 IU for children ≥1 year of age; and 1500-2000 IU for adults) from supplements, diet, and/or adequate sun exposure.

These patients should be treated with vitamin D replacement as for those with true deficiency. Vitamin D2 (ergocalciferol) and D3 (cholecalciferol) are equally effective in maintaining circulating concentrations of 25-hydroxyvitamin D.[77][98]​ Although ergocalciferol is the only official Food and Drug Administration-approved drug for treating vitamin D deficiency, cholecalciferol is readily available as an over-the-counter supplement and is widely used.

Data on the optimal dose for vitamin D insufficiency in pregnancy is lacking.[95]​ Seek specialist advice before starting treatment if a woman is pregnant.

Treatment course is 6 to 8 weeks, followed by a lower maintenance dose continued throughout childhood and adulthood.[2]

Primary options

ergocalciferol (vitamin D2): children: 2000 IU orally once daily or 50,000 IU orally once weekly for 6-8 weeks, followed by 400-1000 IU/day (children <1 year of age) or 600-1000 IU/day (children ≥1 year of age) as maintenance; nonpregnant adults: 6000 IU orally once daily or 50,000 IU orally once weekly for 8 weeks, followed by 1500-2000 IU/day as maintenance; pregnant adults: 1000-2000 IU orally once daily

OR

cholecalciferol (vitamin D3): children: 2000 IU orally once daily or 50,000 IU orally once weekly for 6-8 weeks, followed by 400-1000 IU/day (children <1 year of age) or 600-1000 IU/day (children ≥1 year of age) as maintenance; nonpregnant adults: 6000 IU orally once daily or 50,000 IU orally once weekly for 8 weeks, followed by 1500-2000 IU/day as maintenance; pregnant adults: 1000-2000 IU orally once daily

Plus – sensible sun or ultraviolet B (UV-B) radiation exposure

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ACUTE
|
insufficiency
Plus – 

sensible sun or ultraviolet B (UV-B) radiation exposure

Treatment recommended for ALL patients in selected patient group

Adequate sensible sun exposure is an excellent source of vitamin D. Usually, for a fair skinned individual in the summertime and a latitude of 42° North, exposure of the arms and legs (with sun protection on the face) for about 15-30 minutes (depends on degree of skin pigmentation, time of day, season, latitude, and age of patient) between 10 a.m. and 3 p.m. twice a week is effective in helping to maintain serum 25-hydroxyvitamin D concentration in the normal range. There are smartphone apps available that can provide advice about sensible sun exposure, give information about how much vitamin D is being made in the skin during current sun exposure, and alert the user when to stop the exposure to prevent sunburn.

If limited sunlight is available, UV-B radiation exposure using a tanning bed for 30% to 50% of the time recommended for tanning (sunscreen should be applied to the face) is an alternative. This can be effective for correcting vitamin D deficiency in patients with fat malabsorption syndromes.

Plus – calcium

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ACUTE
|
insufficiency
Plus – 

calcium

Treatment recommended for ALL patients in selected patient group

Because inadequate calcium intake may contribute to vitamin D deficiency or insufficiency and many patients do not meet daily calcium requirements from dietary sources alone, all patients at risk of calcium deficiency should be given calcium supplementation.[78]

Primary options

calcium carbonate: children: 45-65 mg/kg/day orally given in 4 divided doses; adolescents/adults: 1-2 g/day orally given in 3-4 divided doses

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deficiency

1st line – vitamin D

Back
ACUTE
|
deficiency
|
disorders of vitamin D intake or absorption
1st line – 

vitamin D

Treatment goal is to reach and maintain a serum 25-hydroxyvitamin D level in both children and adults of between 30 nanograms/mL and 100 nanograms/mL.[1][2]

Vitamin D2 (ergocalciferol) and D3 (cholecalciferol) are equally effective in maintaining circulating concentrations of 25-hydroxyvitamin D.​[77][98]​​​​​ Although ergocalciferol is the only official Food and Drug Administration-approved drug for treating vitamin D deficiency, cholecalciferol is readily available as an over-the-counter supplement and is widely used.

Patients with intestinal or fat malabsorption syndromes (including liver failure), or who have a history of gastric bypass surgery, usually require higher doses of vitamin D: 50,000 IU of vitamin D2 every day or every other day.[2]​ Similarly, obese patients or those taking antiepileptic medications, glucocorticoids, or other drugs that activate the steroid and xenobiotic receptors (e.g., highly active antiretroviral therapy, rifampin, or St John's wort) may require weekly doses of high-dose vitamin D for 8 to 10 weeks.

Data on the optimal dose for vitamin D deficiency in pregnancy is lacking.[95]​ Seek specialist advice before starting treatment if a woman is pregnant.

Dosing regimens have been recommended.[1][2] Treatment course is 6 to 8 weeks, followed by a lower maintenance dose continued throughout childhood and adulthood.[2]

Primary options

ergocalciferol (vitamin D2): children: 2000 IU orally once daily or 50,000 IU orally once weekly for 6-8 weeks, followed by 400-1000 IU/day (children <1 year of age) or 600-1000 IU/day (children ≥1 year of age) as maintenance; nonpregnant adults: 6000 IU orally once daily or 50,000 IU orally once weekly for 8 weeks, followed by 1500-2000 IU/day as maintenance; pregnant adults: 1000-2000 IU orally once daily

OR

cholecalciferol (vitamin D3): children: 2000 IU orally once daily or 50,000 IU orally once weekly for 6-8 weeks, followed by 400-1000 IU/day (children <1 year of age) or 600-1000 IU/day (children ≥1 year of age) as maintenance; nonpregnant adults: 6000 IU orally once daily or 50,000 IU orally once weekly for 8 weeks, followed by 1500-2000 IU/day as maintenance; pregnant adults: 1000-2000 IU orally once daily

Plus – sensible sun or UV-B radiation exposure

Back
ACUTE
|
deficiency
|
disorders of vitamin D intake or absorption
Plus – 

sensible sun or UV-B radiation exposure

Treatment recommended for ALL patients in selected patient group

Adequate sensible sun exposure is an excellent source of vitamin D. Usually, for a fair skinned adult living at 42° North latitude, exposure of the arms and legs (with sun protection on the face) for about 15-30 minutes (depends on degree of skin pigmentation, time of day, season, latitude, and age of patient) between 10 a.m. and 3 p.m. twice a week is helpful in maintaining serum 25-hydroxyvitamin D concentration in the normal range. There are smartphone apps available that can provide advice about sensible sun exposure, give information about how much vitamin D is being made in the skin during current sun exposure, and alert the user when to stop the exposure to prevent sunburn.

Patients with fat malabsorption who are unable to absorb vitamin D when taken orally can benefit from exposure to UV-B radiation.[1] This is usually achieved by using a tanning bed for 30% to 50% of the time recommended for tanning (sunscreen should be applied to the face).[1] Tanning beds may also be considered in climates with limited sunlight. This can be effective for correcting vitamin D deficiency in patients with fat malabsorption syndromes.

Plus – calcium

Back
ACUTE
|
deficiency
|
disorders of vitamin D intake or absorption
Plus – 

calcium

Treatment recommended for ALL patients in selected patient group

Because inadequate calcium intake may contribute to vitamin D deficiency and many patients do not meet daily calcium requirements from dietary sources alone, all patients at risk of calcium deficiency should be given calcium supplementation.[78]

Primary options

calcium carbonate: children: 45-65 mg/kg/day orally given in 4 divided doses; adolescents/adults: 1-2 g/day orally given in 3-4 divided doses

More

1st line – vitamin D

Back
ACUTE
|
deficiency
|
disorders of vitamin D metabolism
1st line – 

vitamin D

Treatment goal is to reach and maintain a serum 25-hydroxyvitamin D level in both children and adults of between 30 nanograms/mL and 100 nanograms/mL.[1]

Vitamin D2 (ergocalciferol) and D3 (cholecalciferol) are equally effective in maintaining circulating concentrations of 25-hydroxyvitamin D.[77] Although ergocalciferol is the only official Food and Drug Administration-approved drug for treating vitamin D deficiency, cholecalciferol is readily available as an over-the-counter supplement and is widely used.

Data on the optimal dose for vitamin D deficiency in pregnancy is lacking.[95]​ Seek specialist advice before starting treatment if a woman is pregnant.

Treatment course is 6 to 8 weeks, followed by a lower maintenance dose continued throughout childhood and adulthood.[2]

Primary options

ergocalciferol (vitamin D2): children: 2000 IU orally once daily or 50,000 IU orally once weekly for 6-8 weeks, followed by 400-1000 IU/day (children <1 year of age) or 600-1000 IU/day (children ≥1 year of age) as maintenance; nonpregnant adults: 6000 IU orally once daily or 50,000 IU orally once weekly for 8 weeks, followed by 1500-2000 IU/day as maintenance; pregnant adults: 1000-2000 IU orally once daily

OR

cholecalciferol (vitamin D3): children: 2000 IU orally once daily or 50,000 IU orally once weekly for 6-8 weeks, followed by 400-1000 IU/day (children <1 year of age) or 600-1000 IU/day (children ≥1 year of age) as maintenance; nonpregnant adults: 6000 IU orally once daily or 50,000 IU orally once weekly for 8 weeks, followed by 1500-2000 IU/day as maintenance; pregnant adults: 1000-2000 IU orally once daily

Plus – sensible sun or UV-B radiation exposure

Back
ACUTE
|
deficiency
|
disorders of vitamin D metabolism
Plus – 

sensible sun or UV-B radiation exposure

Treatment recommended for ALL patients in selected patient group

Adequate sensible sun exposure is an excellent source of vitamin D. Usually, for a fair skinned adult living at 42° North latitude, exposure of the arms and legs (with sun protection on the face) for about 15-30 minutes (depends on degree of skin pigmentation, time of day, season, latitude, and age of patient) between 10 a.m. and 3 p.m. twice a week can help maintain serum 25-hydroxyvitamin D concentrations in the normal range. There are smartphone apps available that can provide advice about sensible sun exposure, give information about how much vitamin D is being made in the skin during current sun exposure, and alert the user when to stop the exposure to prevent sunburn.

If limited sunlight is available, UV-B radiation exposure using a tanning bed for 30% to 50% of the time recommended for tanning (sunscreen should be applied to the face) is an alternative. This can be effective for correcting vitamin D deficiency in patients with fat malabsorption syndromes.

Plus – 1,25-dihydroxyvitamin D3 or active analog

Back
ACUTE
|
deficiency
|
disorders of vitamin D metabolism
Plus – 

1,25-dihydroxyvitamin D3 or active analog

Treatment recommended for ALL patients in selected patient group

Given that acquired or inherited conditions of vitamin D metabolism adversely affect the metabolism of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, or the recognition of 1,25-dihydroxyvitamin D, vitamin D replacement alone is not usually sufficient but should be given together with 1,25-dihydroxyvitamin D3 (calcitriol) or one of its active analogs (e.g., paricalcitol or doxercalciferol).

Patients with chronic kidney disease who have a GFR of <50% of normal usually require 1,25-dihydroxyvitamin D3 or one of its active analogs in conjunction with vitamin D to treat and prevent secondary hyperparathyroidism. This is due to a decreased capacity to produce 1,25-dihydroxyvitamin D, which causes secondary hyperparathyroidism.

Primary options

calcitriol: children and adults: consult specialist for guidance on dose

OR

paricalcitol: children and adults: consult specialist for guidance on dose

OR

doxercalciferol: children and adults: consult specialist for guidance on dose

Plus – calcium

Back
ACUTE
|
deficiency
|
disorders of vitamin D metabolism
Plus – 

calcium

Treatment recommended for ALL patients in selected patient group

Because inadequate calcium intake may contribute to vitamin D deficiency and many patients do not meet daily calcium requirements from dietary sources alone, all patients at risk of calcium deficiency should be given calcium supplementation.[78]

Furthermore, patients with chronic kidney disease have high-normal or elevated serum phosphate levels and a decreased capacity to produce 1,25-dihydroxyvitamin D, which causes secondary hyperparathyroidism. Therefore, they need to maintain a serum 25-hydroxyvitamin D of between 30 nanograms/mL and 100 nanograms/mL, which can independently reduce parathyroid hormone levels, and control their serum phosphorus level by using a phosphate binder such as calcium carbonate.[10][99]

Primary options

calcium carbonate: children: 45-65 mg/kg/day orally given in 4 divided doses; adolescents/adults: 1-2 g/day orally given in 3-4 divided doses

More

Consider – phosphate

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ACUTE
|
deficiency
|
disorders of vitamin D metabolism
Consider – 

phosphate

Treatment recommended for SOME patients in selected patient group

Phosphate supplementation is not usually necessary unless there is an acquired or inherited disorder causing phosphate wasting in the kidneys, such as hypophosphatemic rickets or oncogenic osteomalacia.[4][5]​​​ These patients require phosphate supplementation in addition to vitamin D replacement and 1,25-dihydroxyvitamin D3 or one of its active analogs.

Caution should be exercised when giving phosphate supplements because high-dose phosphate multiple times a day causes a reduction in ionized calcium, resulting in an increase in parathyroid hormone production and tertiary hyperparathyroidism. Therefore, smaller doses of phosphate should be taken more frequently throughout the day to maintain a normal serum phosphate level without causing significant hyperparathyroidism.

Phosphate supplementation should be avoided in patients with chronic kidney disease, due to their already high-normal or elevated serum phosphate levels.

Primary options

sodium phosphate/potassium phosphate: children and adults: consult specialist for guidance on dose

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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