Interpretation of total 25-OH Vitamin D (please note new NICE guidelines on treatment from 22/06/21):
<25 nmol/L: NICE guidelines recommend treat for vitamin D deficiency.
25 – 50 nmol/L: NICE guidelines recommend advice on measures to prevent vitamin D deficiency.
NICE guidelines recommend treating for vitamin D insufficiency if vitamin D levels are in the range of 25–50 nmol/L and the patient :
>50 nmol/L: Vitamin D replete. If the patient has musculoskeletal symptoms (such as muscle pain or weakness) despite adequate Vitamin D levels, consider an alternative diagnosis.
Vitamin D is the hormone that enhances intestinal absorption of calcium and insures healthy bone formation. The best way to obtain vitamin D is through direct exposure of the skin to sunlight, because ultraviolet B rays stimulate the skin to synthesize vitamin D3. Some people do not have adequate exposure to sunlight and are at higher risk of developing vitamin D deficiency. Examples include individuals who:
Individuals living under these conditions can only receive adequate vitamin D by ingesting vitamin D rich foods or supplements. The current recommended daily intake is 200 IU for children and adults up to age 50 years, 400 IU for adults aged 50 to 71 years, and 600 IU for those aged 71 years or older. Some experts now believe that adults should take 800 to 1000 IU daily.
Vitamin D is inert and must be converted to its active form. The liver metabolises vitamin D to 25-hydroxyvitamin D (25-OHD), which is the major storage and circulating form of the hormone. The kidney converts 25-OHD to 1,25-dihydroxyvitamin D (1,25-OHD) under the regulation of parathyroid hormone. Therefore, normal vitamin D metabolism is dependent on sunlight exposure, intestinal absorption, and liver and kidney function. Vitamin D malabsorption may be associated with several GI disorders including Crohn’s disease, coeliac disease, and pancreatic insufficiency.
As vitamin D levels fall, the initial compensatory mechanism is increased PTH secretion, which stimulates the kidneys to increase phosphate excretion and decrease the calcium excretion. Blood calcium levels remain normal until the very late stages of vitamin D deficiency. Alkaline phosphatase (ALP) is usually elevated in response to the effect of PTH on calcium absorption from bone. The combination of a normal serum calcium, low phosphate, and elevated alkaline phosphatase is suggestive of disturbed vitamin D metabolism. If creatinine and urea are also increased, the problem probably lies with the renal production of 1,25-OHD. If liver function tests are abnormal or serum albumin is low, the problem may be a low 25-OHD level due to liver disease or malnutrition.
When 1,25-OHD levels are low, either due to deficient vitamin D stores or renal disease, the parathyroid glands release more PTH to try to synthesize more 1,25-OHD. Since this cannot happen, increased PTH promotes calcium absorption from skeletal bone, which may result in severe bone disease. Children develop rickets, while adults develop osteomalacia. Osteomalacia may present as a diffuse, dull, aching pain affecting many areas of the body including ribs and sternum. Vitamin D deficiency is a major risk factor for bone loss, weakness and fracture in the elderly.
Some patients taking long-term antiepileptic drug therapy develop a syndrome of low plasma 25-OHD, intestinal malabsorption of calcium, slight decrease in plasma calcium, secondary hyperparathyroidism and cortical osteopenia. In one study of inpatients on a medical ward, the most common disorders associated with vitamin D deficiency were anticonvulsant therapy, renal dialysis, nephrotic syndrome, and winter season. Cirrhosis, malabsorption and glucocorticoid therapy were also contributory factors (NEJM 1998; 338:777).
Both 25-OHD and 1,25-OHD can be measured to assess vitamin D status. 25-OHD is the preferred test for patients with normal renal function. 1,25-OHD should be measured in patients with renal disease.
Ergocalciferol (D2) can be measured
Colecalciferol (D3) can be measured
Calcitriol (1, 25 dihydroxy vitamin D) CANNOT be measured
Alfacalcidol (1 alpha hydroxycholecalciferol) CANNOT be measured
Can be added on to an existing request up to 4 days following sample receipt
3 monthsSpecimen Labelling Procedure