Vitamin D Supplementation for Patients on Corticosteroids
All patients receiving corticosteroids at doses ≥2.5 mg/day prednisone equivalent for more than 3 months should receive 800 IU of vitamin D daily along with 800-1000 mg of calcium daily. 1
Standard Dosing Regimen
Maintenance Supplementation
- 800 IU vitamin D daily is the evidence-based dose for all patients on corticosteroids, regardless of baseline vitamin D status 1
- 800-1000 mg elemental calcium daily should be co-administered, either through diet or supplementation 1
- This regimen should be initiated at the onset of corticosteroid therapy and continued throughout the entire treatment course 1
If Vitamin D Deficiency is Present
- For patients with documented vitamin D deficiency (<20 ng/mL), treat with 50,000 IU weekly for 6 weeks initially, then transition to the standard 800 IU daily maintenance dose 1
- The loading dose corrects the deficiency rapidly, while the 800 IU daily dose prevents recurrence during ongoing steroid therapy 1
Mechanism and Evidence Base
Why This Specific Dose Works
- Corticosteroids reduce calcium absorption from the gut and increase urinary calcium losses, leading to secondary hyperparathyroidism and bone resorption 1
- A Cochrane review of five trials confirmed that calcium and vitamin D supplementation prevents bone loss from the lumbar spine and forearm in all patients treated with steroids 1
- In patients with Crohn's disease, supplementing with 800 IU vitamin D and 500-1000 mg calcium daily resulted in a small but significant increase in bone density over 4 years 1
Guideline Consensus
- The British Society of Gastroenterology provides a strong recommendation (GRADE: strong recommendation, very low-quality evidence) for this specific regimen of 800-1000 mg/day calcium and 800 IU/day vitamin D 1
- The American College of Rheumatology (2023) conditionally recommends optimizing age-appropriate dietary and supplemental calcium and vitamin D for all adults and children beginning chronic glucocorticoids ≥2.5 mg/day for >3 months 1
- The American College of Rheumatology recommends supplementing vitamin D to maintain serum 25(OH)D levels ≥30-50 ng/mL, typically requiring 600-800 IU daily or more 1
Practical Implementation
Calcium Delivery Options
- "Calcium and ergocalciferol" tablets: Two tablets daily provide 800 IU vitamin D and 200 mg calcium (requires additional dietary calcium to reach 800-1000 mg total) 1
- Calcichew D3 Forte: Two tablets daily provide 800 IU vitamin D (cholecalciferol) and 1000 mg calcium (no additional calcium needed) 1
- If dietary calcium intake is already adequate (≥800-1000 mg/day), vitamin D supplementation alone is sufficient 1
Monitoring Requirements
- Serum vitamin D levels (25(OH)D) should be monitored to ensure levels are maintained ≥30-50 ng/mL 1
- For patients on prolonged corticosteroids (>3 months) or repeated courses, bone mineral density should be assessed by DEXA scan 1
- Patients with high FRAX scores (≥20% major fracture risk or ≥3% hip fracture risk) require more aggressive osteoporosis management beyond calcium and vitamin D alone 1
Risk Stratification and Additional Interventions
When Bisphosphonates Are Required
- Patients at high risk for osteoporosis should be started on bisphosphonate therapy at the onset of corticosteroid therapy (GRADE: strong recommendation, high-quality evidence), after ensuring adequate calcium intake and vitamin D supplementation 1
- High-risk criteria include: previous fragility fracture, prolonged steroid use (>3 months), age ≥40 years with FRAX score indicating high risk, or T-score ≤-1.5 on DEXA 1
FRAX Score Adjustments for Steroid Dose
- FRAX assumes an average prednisolone dose of 2.5-7.5 mg/day, so adjustments are needed for higher or lower doses 1
- For high-dose steroids (>7.5 mg/day): multiply hip fracture risk by 1.2 and major osteoporotic fracture risk by 1.15 1
- For low-dose steroids (<2.5 mg/day): multiply hip fracture risk by 0.65 and major osteoporotic fracture risk by 0.8 1
Essential Lifestyle Modifications
Non-Pharmacologic Interventions
- Stop smoking and reduce excess alcohol intake (≤2 servings daily) 1
- Regular weight-bearing exercise such as weight training or running 1
- Maintain weight in the recommended range and eat a balanced diet 1
- These modifications should be provided to all patients starting corticosteroids 1
Critical Safety Considerations
Cardiovascular Risk
- Calcium supplementation may increase cardiovascular risk, particularly if not accompanied by vitamin D supplementation 1
- This risk is mitigated by co-administering vitamin D with calcium, as recommended in all guidelines 1
Hypercalcemia Risk
- The 800 IU daily dose is safe without routine monitoring of serum calcium 1
- Higher doses of vitamin D (such as calcitriol) carry significant risk of hypercalcemia and should not be used for routine supplementation 1
- Daily doses up to 4,000 IU are generally considered safe for adults 1, 2
Common Pitfalls to Avoid
Inadequate Dosing
- The recommended daily allowance (RDA) for vitamin D in the general population (600-800 IU) is the minimum for patients on steroids, not a target to exceed 1
- Many patients require monitoring to ensure 25(OH)D levels remain ≥30 ng/mL, as individual responses vary 1
Delayed Initiation
- Fracture risk increases within 3 months of starting corticosteroids, so supplementation must begin immediately at the onset of steroid therapy 1
- Waiting to assess bone density before starting calcium and vitamin D is inappropriate; these should be started prophylactically 1
Forgetting to Assess Baseline Vitamin D Status
- Approximately 50% of patients with inflammatory bowel disease have vitamin D deficiency at baseline 1
- If deficiency is present, the loading dose (50,000 IU weekly for 6 weeks) should be given before transitioning to maintenance 1