The mainstay of therapy for vitamin D deficiency is vitamin D, either vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol). Vitamin D supplements could be used as a daily loading regimen followed by the maintenance. The alternative regimen is high weekly dose (stoss therapy) and maintenance therapy.

There are two major forms of vitamin D; ergocalciferol (vitamin D2), cholecalciferol (vitamin D3). Both of them are commonly used. However, a systematic review and meta-analysis of Tripkovic L et al. in 2011, indicated that vitamin D3 compared to vitamin D2 is more effective to raise the serum level of 25OHD and is preferred for treatment and prevention of vitamin D deficiency.^[1]

• Endocrine Society published a clinical practice guideline for the treatment of vitamin D deficiency to reach and sustain a serum 25(OH)D level of 30 ng/ml.^[2]

• High risk patients include African American, obese, patients with malabsorption syndromes and who are on anticonvulsants.

• The American Academy of Pediatrics (AAP) recommends an initial phase of treatment with high dose of vitamin D for 2-3 months to treat vitamin D deficiency rickets. The recommended dose is 1000 IU/d in neonates, 1000-5000 IU/d in infants, and 5000 IU/d for children over 1-year-old. After raising the serum 25 OHD levels to 30 ng/ml, a maintenance dose of 400 IU/d is required for all age groups. Higher maintenance dose (800 IU/d) might be needed in at risk groups.^[3][4]

• An alternative strategy for treatment, also known as stoss therapy, is a single dose therapy in patients over 1 month old. 100,000 – 600,000 IU of ergocalciferol orally single dose followed by maintenance therapy is recommended, especially in noncompliant patients.^[5]

A more recent randomized controlled trial showed that, among white women with vitamin D insufficiency and deficiency (levels 13 to 50 nmol/L;5 to 20 ng/mL ), a dose of 600 to 800 IU per day of vitamin D3 will raise the level above Institute of Medicine recommendations (20 ng/mL or 50 nmol/L) in 97% of women.^[6]

Regarding choice of preparation, D3 (cholecalciferol) may be more effective than D2 (ergocalciferol).^[7]

Obese patients need more vitamin D to raise their level.^[8]

Does higher than at least 800 IU daily may be best for the prevention of fractures.^[9]

One option is a combination pill. Either the size below once per day, or a half size twice per day.

• Elemental calcium 1200 mg, daily
• Vitamin D3 800 international units (20 micrograms), daily

• Patients on anticonvulsant drugs are at risk of vitamin D deficiency. If osteopenia occurs, treatment with 2000-4000 IU/d must be started. In case of osteomalacia, a larger dose of vitamin D, 5000-15000 IU/d is required.^[10]

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