Alfacalcidol and calcitriol are forms of activated vitamin D which should only be prescribed under the advice of a specialist.

Patients receiving alfacalcidol and calcitriol should have their plasma calcium and phosphate levels checked regularly at intervals recommended by specialists and whenever nausea and vomiting occur. SPS suggests monitoring should be carried out by blood tests taken once or twice a week after starting, then every 2 weeks to 3 months depending on the CKD stage. Monitoring is usually completed by specialist services.

Good prescribing principles for alfacalcidol and calcitriol:

• Micrograms and nanograms should not be abbreviated
• Avoid the use of decimals by using alternative units of measure (e.g. use 250 nanograms instead of 0.25 micrograms).
• Take additional care with alfacalcidol oral drops, 2 micrograms/mL; one drop contains approximately 100 nanograms.

Specific information regarding COVID-19 and vitamin D supplementation can be found here

Information contained in the page includes:

• The NICE COVID-19 rapid guideline (NG187): Vitamin D, issued in collaboration with PHE and the Scientific Advisory Committee on Nutrition (SACN), which states do not offer a vitamin D supplement solely to prevent or treat COVID-19, except as part of a clinical trial. For more information, see the guideline here.
• The NICE guideline highlights that it is more important than usual to take vitamin D supplements to prevent deficiency this winter (10 micrograms (400 IU) per day).
• Patients can purchase suitable vitamin D supplements from supermarkets, pharmacies and other retailers
• Adults in England who are at high risk (clinically extremely vulnerable) from coronavirus (COVID-19) are eligible to receive free vitamin D supplements this winter
  • Eligible patients will receive a letter from the NHS or DHSC inviting them to apply for four months' supply of vitamin D.
• Women and children who qualify for the Healthy Start scheme can get free supplements containing the recommended amounts of vitamin D.
• Vitamin D should not be routinely prescribed in primary care unless there is a medically diagnosed deficiency

Alfacalcidol

• Capsules 250nanograms, 500nanograms, 1micrograms (click here for preferred brand)
• Oral drops 2micrograms in 1ml (£21.30 = 10ml)
• Injection 2micrograms in 1ml

Indications

• Vitamin D supplementation in severe renal impairment

Dose

• As recommended by specialist

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Calcitriol

• Capsules 250nanograms, 500nanograms (£9.03 = 500nanograms daily)

Indications

• Vitamin D supplementation in severe renal impairment

Dose

• As recommended by specialist

Colecalciferol (vitamin D3)

NHS England (NHSE) has published new prescribing guidance for items of limited clinical effectiveness that should not be routinely prescribed in primary care (quick reference guide). This included vitamins and minerals, unless there is a medically diagnosed deficiency, or when using calcium and vitamin D for osteoporosis, or for treating malnutrition including alcoholism. The guidance also excludes patients suitable to receive Healthy Start vitamins.

Many vitamin products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

For guidance on the management of vitamin D deficiency, please refer to Management of Vitamin D deficiency.

Clinicians should use the cheapest preparation available after consideration of clinical indications and potential risks.

Vitamin D is a fat soluble vitamin. Supplements containing vitamin D should therefore be taken with food to aid absorption.

Colecalciferol

• Tablets 1,000units (25micrograms), 25,000units (625micrograms) (click here for preferred brands)
• Oral solution 25,000units (625micrograms)/ml, 50,000units (1.25mg)/ml (click here for preferred brands)

Indications and corresponding dose

• Tablets:
  • Treatment of vitamin D deficiency in adults: 50,000units/week for 6 weeks
  • Maintenance therapy following treatment of deficiency in adults / Prevention of deficiency in adults / Adjunct to specific therapy for osteoporosis in adults: 25,000units/month or 1,000units/day. In certain situations higher doses may be required.
• Oral solution:
  • Vitamin D deficiency in adults: 50,000units per week for 6-8 weeks
  • Prevention of adult vitamin D deficiency: 25,000units per month, higher doses may be required in certain situations
  • Adjunct to specific therapy for osteoporosis: 25,000units per month

Notes

1. When using the oral solution, the 50,000units / ml, 1ml ampoule, should be used for the treatment of vitamin D deficiency.
2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)

Fultium-D3

(Colecalciferol)

• Capsules 3,200units (80micrograms) (£12.43 = one daily)

Notes

1. To be used only in patients with hyperparathyroidism in the perioperative period.
2. For specialist initiation only.

Ergocalciferol

• Injection 300,000units in 1ml

Colecalciferol (vitamin D3) plus calcium

For specific advice on the use of calcium with or without Vitamin D in osteoporosis see section 6.6.2 Bisphosphonates and other drugs affecting bone metabolism

It is accepted that patients post bariatric surgery may require non-formulary products and/or off-label doses. Specialists should be consulted for further advice.

Colecalciferol with calcium carbonate

• Tablets 400units (10micrograms) + 1.5g (click here for preferred brands)
• Chewable tablets 880units (22micrograms) + 2.5g (click here for preferred brands)
• Chewable tablets 400units (10micrograms) + 1.5g (click here for preferred brands)
• Effervescent tablets 400units (10micrograms) + 1.5g (click here for preferred brands)
• Caplets 200units (5micrograms) + 750mg (click here for preferred brands)

Notes

1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)