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Vitamin D and bone health: a practical clinical guideline for patient management


  • Measurement of serum 25-hydroxy vitamin D (25OHD) is the best way of estimating vitamin D status
  • Serum 25OHD measurement is recommended for patients with:
    • bone diseases that may be improved with vitamin D treatment
    • bone diseases, prior to specific treatment where correcting vitamin D deficiency is appropriate
    • musculoskeletal symptoms that could be attributed to vitamin D deficiency
  • Routine vitamin D testing may be unnecessary in patients with osteoporosis or fragility fracture, who may be co-prescribed vitamin D supplementation with an oral antiresorptive treatment

Who to treat

  • In those patients where 25OHD is tested, the results should be acted upon as follows:
  • serum 25OHD <30 nmol>
  • serum 25OHD 30–50 nmol/l (may be inadequate in some people) treatment is advised in patients with the following:
    • 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 reduced exposure to sunlight, religious/cultural dress code, dark skin, etc
    • raised parathyroid hormone
    • medication with antiepileptic drugs or oral glucocorticoids
    • conditions associated with malabsorption
  • serum 25OHD >50 nmol/l (is sufficient for almost the whole population) provide reassurance and give advice on maintaining adequate vitamin D, levels through safe sunlight exposure and diet


  • Oral vitamin D3 is the treatment of choice in vitamin D deficiency
  • Where rapid correction of vitamin D deficiency is required, such as in patients with symptomatic disease or about to start treatment with a potent antiresorptive agent (zoledronate or denosumab), the recommended treatment regimen is based on fixed loading doses followed by regular maintenance therapy
  • Loading regimens for treatment of deficiency up to a total of approximately 300,000 international units (IU) given either as weekly or daily split doses. The exact regimen will depend on the local availability of vitamin D preparations but will include:
    • 50,000 IU capsules, one given weekly for 6 weeks (300,000 IU)
    • 20,000 IU capsules, two given weekly for 7 weeks (280,000 IU)
    • 800 IU capsules, five a day given for 10 weeks (280,000 IU)
  • The following should be borne in mind:
    • supplements should be taken with food to aid absorption
    • calcium/vitamin D combinations should not be used as sources of vitamin D for the above regimens, given the resulting high dosing of calcium
  • Maintenance regimens may be considered 1 month after loading with doses equivalent to 800–2000 IU daily (occasionally up to 4000 IU daily), given either daily or intermittently at a higher equivalent dose
  • The strategies below have been demonstrated not to work or to have a high risk of being ineffective or causing toxicity, and are, therefore, not to be recommended:
    • annual depot vitamin D therapy either by intramuscular injection or orally
    • use of activated vitamin D preparations (calcitriol and alfacalcidol)
  • Where correction of vitamin D deficiency is less urgent and when co-prescribing vitamin D supplements with an oral antiresorptive agent, maintenance therapy may be started without the use of loading doses

Calcium supplementation

  • Considering optimisation of bone health and the public health agenda, it is important to promote the relevance of adequate dietary calcium intake and consider use of ‘calcium calculators’ to help patients and primary-care clinicians (e.g. www.rheum.med.ed.ac.uk/calcium-calculator.php)
  • If patients with osteoporosis are found to not be reliably or regularly consuming at least 700 mg calcium per day, titrated supplementation with either calcium-only supplements or calcium and vitamin D combined supplements is recommended


  • Adjusted serum calcium should be checked 1 month after completing the loading regimen or after starting vitamin D supplementation in case primary hyperparathyroidism has been unmasked
  • Routine monitoring of serum 25OHD is generally unnecessary but may be appropriate in patients with symptomatic vitamin D deficiency or malabsorption and where poor compliance with medication is suspected

full guidelines available from…

National Osteoporosis Society. Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management. April 2013
First included: June 2013.