The National Osteoporosis Society has published a guideline in response to increased demand for vitamin D blood tests. Are these tests always necessary?
Although it is evident that vitamin D plays an important role in bone health, there is some confusion over the role of vitamin D blood tests. The National Osteoporosis Society has produced a guideline for health professionals to help clarify the type of blood test that should be carried out, who should be tested, how to interpret the results and how and when to use vitamin D supplements.
Citation: Leyland S (2014) Vitamin D and its role in maintaining bone health. Nursing Times; 110: online issue.
Author: Sarah Leyland is a senior nurse and helpline manager at the National Osteoporosis Society.
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Recently, there has been increasing interest in vitamin D and its potential for preventing a range of medical conditions. The role of vitamin D in the maintenance of bone health is well established (Box 1) but there is much debate within the scientific and medical community about the significance of low levels of vitamin D for bone health and how this should be managed in clinical practice.
Box 1. Role of vitamin D
Vitamin D is stored in fatty tissue and is converted in the liver into 25 hydroxyvitamin D (250HD), the main circulating form of vitamin D. Some is converted by the kidneys into an active form called 1, 25 dihyroxyvitamin D 1 25(OH)2D, which promotes calcium absorption from the intestine and the deposition of calcium into newly formed bone. It therefore helps to regulate calcium levels in the blood stream and maintain bone strength.
Media coverage of these issues has led to an increase in public demand for vitamin D blood tests, which has financial and resource implications for the health service. In addition, there has been confusion, even among health professionals, about the role of vitamin D blood tests -which type of blood test is most reliable, who should be tested, how to interpret the results and how to use vitamin D supplementation appropriately.
The National Osteoporosis Society has responded by producing a guideline, developed by clinicians and scientists with expertise in osteoporosis and vitamin D, to help health professionals manage their patients. It provides practical advice based on their own views, experience and on current evidence.
What test to use
The best way to measure vitamin D status is a blood test of serum 25 hydroxyvitamin D (250HD) (Prentice et al, 2008)
Who to test
Patients should only have a vitamin D blood test if the results are likely to affect clinical management, such as:
- Patients with bone diseases (such as osteoporosis or osteomalacia) that may improve with vitamin D treatment;
- Patients who are going to be prescribed specific osteoporosis drug treatments (denosumab and zoledronate) where vitamin D deficiency needs to be corrected to prevent patients from developing hypocalcaemia;
- Patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency. This would usually be generalised pain, which could be caused by osteomalacia (Atherton et al, 2009).
Who does not need a test
Routine vitamin D testing is usually unnecessary in patients with osteoporosis or fragility fractures who are being prescribed vitamin D supplements along with osteoporosis drug treatment.
Although people obtain small amounts of vitamin D from the diet, most vitamin D is produced by the body due to the action of sunlight on the skin.
Generally, if a patient cannot get enough calcium in their diet and is at risk of vitamin D deficiency, calcium and vitamin D tablets should be prescribed without the need for a blood test. Other patients at risk of vitamin D deficiency do not need a blood test before being prescribed vitamin D supplements (Box 2).
Box 2. Adults at risk of vitamin D deficiency
- All pregnant and breastfeeding women, especially teenagers and young women
- People aged 65 years and over
- People who have low or no exposure to the sun, such as those who cover their skin for cultural reasons, are housebound or are confined indoors for long periods
- People who have darker skin, such as those of African, African-Caribbean or South Asian origin, because their bodies are not able to make as much vitamin D
- All pregnant and breastfeeding women should take a daily supplement containing 10μg (400 IU) of vitamin D, to ensure the mother’s requirements for vitamin D are met and to build adequate foetal stores for early infancy
- People aged 65 years and over and people who are not exposed to much sun should also take a daily supplement containing 10μg (400 IU) of vitamin D
Department of Health (2012)
How to interpret vitamin D blood tests
Without evidence showing that there is a “sufficient” vitamin D level for everyone, the guideline reflects recommendations from the US (Holick et al, 2011; Institute of Medicine, 2011):
- Serum 25OHD <30nmol/L is “deficient”;
- Serum 25OHD of 30-50nmol/L “may be inadequate” in some people;
- Serum 25OHD >50 nmol/L is “sufficient” for almost the whole population.
Who to treat with vitamin supplements after the blood test
This recommendation covers three groups:
- Those with very low levels (serum 25OHD <30nmol/L) need vitamin D supplements;
- Those in the middle range (serum 25OHD 30-50nmol/L) need a supplement if they fall into one of the following groups:
- Fragility fracture, documented osteoporosis or high fracture risk;
- Treatment with antiresorptive medication for bone disease;
- Symptoms suggestive of vitamin D deficiency;
- Increased risk of developing vitamin D deficiency in the future because of exposure to sunlight, religious dress, dark skin;
- Raised parathyroid hormone levels;
- Medication with antiepileptic drugs or oral glucocorticoids;
- Conditions associated with malabsorption.
For anyone else in this range, there is insufficient evidence of any benefit from taking vitamin D supplements and patients should be given lifestyle advice on maintaining adequate vitamin D levels through safe sunlight exposure and diet.
Those with adequate levels (serum 25OHD >50 nmol/L) can be reassured and given lifestyle advice as above.
Vitamin D3 is thought to be more effective than vitamin D2 (Tripkovic et al, 2012) but D2 may be the only acceptable form for vegans. Tablets or capsules are preferable to injections as there is some evidence they are better absorbed (Nugent et al, 2009).
What doses of vitamin D supplement are appropriate?
If patients need vitamin D levels to be corrected quickly, a “fixed loading” dose can be given once, followed by “maintenance” therapy.
The following doses are recommended:
- A loading regimen to provide a total of approximately 300,000 IU vitamin D, given either as separate weekly or daily doses over six to 10 weeks;
- Maintenance therapy comprising vitamin D in doses equivalent to 800-2000 IU daily (occasionally up to 4,000 IU daily), given either daily or intermittently at higher doses.
There is no recommendation to use higher doses where there is no urgency.
Follow up blood tests
A month after a loading dose of vitamin D has been given, a calcium blood test is recommended to make sure the patient does not have primary hyperparathyroidism (Hannan et al, 2004).
Routine follow-up vitamin D blood tests are generally unnecessary unless vitamin D deficiency symptoms continue, a patient has malabsorption problems or if it is likely they have not been taking the prescribed supplements.
If a patient is likely to be deficient in vitamin D, taking supplements is a sensible preventive measure and they do not necessarily need a blood test. However, in specific situations, testing will be useful to plan treatment.
- Many patients are requesting vitamin D blood tests, which may not always be necessary
- Vitamin D blood tests should only be given if the results are likely to affect clinical management
- If supplements are prescribed, tablets or capsules are thought to be better absorbed than injections
- There is a lack of evidence on what a “sufficient” level of vitamin D is for everyone
- If a patient is thought to have low levels of vitamin D, supplements can be given without a blood test being carried out
Atherton K et al (2009) Vitamin D and chronic widespread pain in a white middle-aged British population: evidence from a cross-sectional population survey. Annals of the Rheumatic Diseases; 68: 6, 817-822.
Department of Health (2012) Vitamin D – advice on supplements for at risk groups. Letter from the Chief Medical Officers for the United Kingdom.
Hannan FM et al (2004) Vitamin D deficiency masking primary hyperparathyroidism. Annals of Clinical Biochemistry; 41, Pt 5, 405-407.
Holick MF et al (2011) Evaluation, treatment and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism; 96: 7.
Institute of Medicine (2011) Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: IOM.
Nugent C et al (2009) The effect of intramuscular vitamin D (cholecalciferol) on serum 25OH vitamin D levels in older female acute hospital admissions. Irish Journal of Medical Science; 179: 1, 57-61.
Prentice A et al (2008) Vitamin D across the lifecycle: physiology and biomarkers. The American Journal of Clinical Nutrition; 88: 2, 500S-506S.
Tripkovic L et al (2012) Comparison of vitamin D2 and vitamin D3 supplementation in raising serum 25-hydroxyvitamin D status: a systematic review and meta-analysis. The American Journal of Clinical Nutrition; 95: 6, 1357-1364