Vitamins

  • Diagnosis
  • Screening
  • Monitoring
  • Background
  • Lab Tests
  • References
  • Related Content

Indications for Testing

  • Vitamin B12 – at-risk populations
    • Malabsorption, use of H2 receptor antagonists, proton-pump inhibitors, vegetarian diet, aged adults
  • Vitamin D – at-risk populations
    • Poor nutritional intake, limited sun exposure, malabsorption, liver failure, or renal insufficiency
    • Aged adults
    • Certain medications (eg, antiseizure and AIDS medications, glucocorticoids)
  • Vitamin K – patient with elevated INR and unresponsive to vitamin K supplementation (Choosing Wisely: 5 Things Physicians and Patients Should Question; American Society of Clinical Pathology, 2015)
  • Other vitamins – symptoms consistent with deficiency PLUS risk factor for deficiency

Laboratory Testing

  • Order specific testing based on symptoms and risk assessment
  • For B12 deficiency – consider concurrent testing for folate level; refer to the following for more information
  • For vitamin D deficiency
    • Testing not recommended while patient is ill – levels decrease with inflammation and acute illness but not true deficiency
    • Order test for 25-hydroxy vitamin D by chemiluminescence if available
      • 25-hydroxy vitamin D is the major and most stable circulating form of vitamin D
    • Recommended values – no consensus on optimal concentrations (Institute of Medicine, 2011)
      • 20-30 ng/mL – defined as insufficiency
      • <20 ng/mL – defined as deficiency
    • Do not order 1,25-dihydroxy test unless patient has hypercalcemia or decreased renal function (ASCP's Pathology-Related Choosing Wisely Recommendations, 2015 [Endocrine Society and American Association of Clinical Endocrinologists])
    • Fractionation testing for D2 and D3 not necessary for initial evaluation of vitamin D deficiency
      • Method used should ideally measure D2 and D3 metabolites equally
  • Universal screening
    • Insufficient evidence to assess harms or benefits of universal screening for vitamin D deficiency (USPSTF, 2015)
    • Do not perform as population-based screening (Choosing Wisely: 5 Things Physicians and Patients Should Question, 2015)
    • Other societies recommend against universal screening
      • ACOG (2011)
      • Endocrine Society (2011)
      • American Academy of Pediatrics (2014)
      • American Geriatrics Society (2014)
  • At risk population screening
    • Consider vitamin D deficiency screening for patients at risk
      • Institutionalized refugees
      • Celiac disease
      • Patients with osteoporosis
      • Patients from areas with high vitamin D deficiency
      • Older adults (age is a risk factor)
  • Vitamin D
    • Monitor therapy response – check 25-hydroxy vitamin D 10-12 weeks after initiating therapy
    • Patients who do not appear to be responding to therapy – vitamin D2 or D3 testing may be helpful

Vitamins are required in the diet because they are not adequately synthesized in the human body.

  • Only small amounts are necessary to catalyze essential biochemical reactions
  • Most deficiencies are rare in healthy persons in the U.S.
  • Disease states generally result from poor diet (eg, elderly, alcoholism)
  • Body stores vary by vitamin
    • Thiamine (B1) and folate stores are small and rapidly depleted
    • Cobalamin (B12) stores are large
  • Vitamins play several roles in disease processes
    • Diseases can cause vitamin deficiency
    • Vitamin deficiency or excess can cause disease
    • Therapeutic doses of certain vitamins can be used to manage some diseases

Indications for Laboratory Testing

Tests generally appear in the order most useful for common clinical situations.
Click on number for test-specific information in the ARUP Laboratory Test Directory

Vitamin B1 (Thiamine), Whole Blood 0080388
Method: Quantitative High Performance Liquid Chromatography

Vitamin B2 (Riboflavin) 0081123
Method: Quantitative High Performance Liquid Chromatography

Niacin (Vitamin B3) 0092168
Method: Quantitative High Performance Liquid Chromatography

Vitamin B5 (Pantothenic Acid), Serum 2006982
Method: Quantitative Cell Based Assay

Vitamin B6 (Pyridoxal 5-Phosphate) 0080111
Method: Quantitative High Performance Liquid Chromatography

Vitamin B7 (Biotin)  2003184
Method: Bioassay

Vitamin B12 and Folate 0070160
Method: Quantitative Chemiluminescent Immunoassay

Vitamin B12 with Reflex to Methylmalonic Acid, Serum (Vitamin B12 Status) 0055662
Method: Quantitative Chemiluminescent Immunoassay/Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Folate, RBC 0070385
Method: Quantitative Chemiluminescent Immunoassay

Vitamin C (Ascorbic Acid), Plasma 0080380
Method: Quantitative High Performance Liquid Chromatography

Vitamin A (Retinol), Serum or Plasma 0080525
Method: Quantitative High Performance Liquid Chromatography

Limitations

This assay does not measure other vitamin A metabolites such as retinaldehyde or retinoic acid

Vitamin D, 25-Hydroxy 0080379
Method: Quantitative Chemiluminescent Immunoassay

Vitamin E, Serum or Plasma 0080521
Method: Quantitative High Performance Liquid Chromatography

Vitamin K1, Serum 0099225
Method: Quantitative High Performance Liquid Chromatography

Additional Tests Available

Vitamin B1 (Thiamine), Plasma 0080389
Method: Quantitative High Performance Liquid Chromatography

Comments

Assesses thiamine concentration in plasma to monitor vitamin B1 concentration in patients receiving supplementation

Do not use to determine thiamine deficiency

25-Hydroxyvitamin D2 and D3 by Tandem Mass Spectrometry, Serum 2002348
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Comments

Nonpreferred screening test for vitamin D deficiency

Alternative test for monitoring response in individuals who are not responding to supplementation

Vitamin B12  0070150
Method: Quantitative Chemiluminescent Immunoassay

Comments

Assesses vitamin B12 concentration in serum

Folate, Serum 0070070
Method: Quantitative Chemiluminescent Immunoassay

Comments

Assesses folate concentration in serum

Vitamin D, 1, 25-Dihydroxy 0080385
Method: Quantitative Chemiluminescent Immunoassay

Comments

Nonpreferred screening test for vitamin D deficiency

Preferred test for individuals with hypercalcemia or renal failure in addition to Vitamin D, 25-Hydroxy testing

Vitamin B12 Deficiency Panel 2012276
Method: Quantitative Gas Chromatography/Mass Spectrometry 

Comments

Not recommended for initial testing in suspected B12 deficiency; may be useful when B12 and MMA results alone are equivocal

Panel includes methylmalonic acid, 2-methylcitric acid, homocysteine, and cystathionine

Guidelines

American Society for Clinical Pathology. Choosing Wisely - Five Things Physicians and Patients Should Question. An initiative of the ABIM Foundation. [Last revision Feb 2015; Accessed: Jan 2016]

American Society for Clinical Pathology. Choosing Wisely - Pathology-Related Choosing Wisely Recommendations. An initiative of the ABIM Foundation. [Initial posting Feb 2015; Accessed: Nov 2015]

Carmel R. Biomarkers of cobalamin (vitamin B-12) status in the epidemiologic setting: a critical overview of context, applications, and performance characteristics of cobalamin, methylmalonic acid, and holotranscobalamin II. Am J Clin Nutr. 2011; 94(1): 348S-358S. PubMed

Holick M, Binkley N, Bischoff-Ferrari H, Gordon C, Hanley D, Heaney R, Murad H, Weaver C, Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96(7): 1911-30. PubMed

Institute of Medicine (US) Committee to Review Dietary Reference Intakes for Vitamin D and Calcium; Ross AC, Taylor CL, Yaktine AL, Del Valle HB Dietary Reference Intakes for Calcium and Vitamin D. Washington (DC): National Academies Press (US); 2011 :PubMed

LeFevre M, U.S. Preventive Services Task Force. Screening for vitamin D deficiency in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015; 162(2): 133-40. PubMed

Yetley E, Coates P, Johnson C. Overview of a roundtable on NHANES monitoring of biomarkers of folate and vitamin B-12 status: measurement procedure issues. Am J Clin Nutr. 2011; 94(1): 297S-302S. PubMed

Yetley E, Pfeiffer C, Phinney K, Bailey R, Blackmore S, Bock J, Brody L, Carmel R, Curtin R, Durazo-Arvizu R, Eckfeldt J, Green R, Gregory J, Hoofnagle A, Jacobsen D, Jacques P, Lacher D, Molloy A, Massaro J, Mills J, Nexo E, Rader J, Selhub J, Sempos C, Shane B, Stabler S, Stover P, Tamura T, Tedstone A, Thorpe S, Coates P, Johnson C, Picciano M. Biomarkers of vitamin B-12 status in NHANES: a roundtable summary. Am J Clin Nutr. 2011; 94(1): 313S-321S. PubMed

Yetley E, Pfeiffer C, Phinney K, Fazili Z, Lacher D, Bailey R, Blackmore S, Bock J, Brody L, Carmel R, Curtin R, Durazo-Arvizu R, Eckfeldt J, Green R, Gregory J, Hoofnagle A, Jacobsen D, Jacques P, Molloy A, Massaro J, Mills J, Nexo E, Rader J, Selhub J, Sempos C, Shane B, Stabler S, Stover P, Tamura T, Tedstone A, Thorpe S, Coates P, Johnson C, Picciano M. Biomarkers of folate status in NHANES: a roundtable summary. Am J Clin Nutr. 2011; 94(1): 303S-312S. PubMed

General References

Chawla J, Kvarnberg D. Hydrosoluble vitamins. Handb Clin Neurol. 2014; 120: 891-914. PubMed

Davies D, Baxter J, Baxter J. Nutritional deficiencies after bariatric surgery. Obes Surg. 2007; 17(9): 1150-8. PubMed

Hunt A, Harrington D, Robinson S. Vitamin B12 deficiency. BMJ. 2014; 349: g5226. PubMed

LeBlanc E, Zakher B, Daeges M, Pappas M, Chou R. Screening for vitamin D deficiency: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015; 162(2): 109-22. PubMed

Marian M, Sacks G. Micronutrients and older adults Nutr Clin Pract. 2009; 24(2): 179-95. PubMed

Mooney S, Leuendorf J, Hendrickson C, Hellmann H. Vitamin B6: a long known compound of surprising complexity. Molecules. 2009; 14(1): 329-51. PubMed

Oberley M, Yang D. Laboratory testing for cobalamin deficiency in megaloblastic anemia. Am J Hematol. 2013; 88(6): 522-6. PubMed

Orr K, Hume A. An evidence-based update on vitamins. Med Health R I. 2010; 93(4): 122-4. PubMed

Rosen C. Clinical practice. Vitamin D insufficiency. N Engl J Med. 2011; 364(3): 248-54. PubMed

Taylor C, Thomas P, Aloia J, Millard P, Rosen C. Questions About Vitamin D for Primary Care Practice: Input From an NIH Conference. Am J Med. 2015; 128(11): 1167-70. PubMed

Thacher T, Clarke B. Vitamin D insufficiency. Mayo Clin Proc. 2011; 86(1): 50-60. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Barker T, Henriksen V, Martins T, Hill H, Kjeldsberg C, Schneider E, Dixon B, Weaver L. Higher serum 25-hydroxyvitamin D concentrations associate with a faster recovery of skeletal muscle strength after muscular injury. Nutrients. 2013; 5(4): 1253-75. PubMed

Barker T, Leonard S, Trawick R, Martins T, Kjeldsberg C, Hill H, Traber M. Modulation of inflammation by vitamin E and C supplementation prior to anterior cruciate ligament surgery. Free Radic Biol Med. 2009; 46(5): 599-606. PubMed

Barker T, Martins T, Hill H, Kjeldsberg C, Dixon B, Schneider E, Henriksen V, Weaver L. Circulating pro-inflammatory cytokines are elevated and peak power output correlates with 25-hydroxyvitamin D in vitamin D insufficient adults. Eur J Appl Physiol. 2013; 113(6): 1523-34. PubMed

Barker T, Martins T, Hill H, Kjeldsberg C, Dixon B, Schneider E, Henriksen V, Weaver L. Vitamin D sufficiency associates with an increase in anti-inflammatory cytokines after intense exercise in humans. Cytokine. 2014; 65(2): 134-7. PubMed

Barker T, Martins T, Hill H, Kjeldsberg C, Henriksen V, Dixon B, Schneider E, Dern A, Weaver L. Different doses of supplemental vitamin D maintain interleukin-5 without altering skeletal muscle strength: a randomized, double-blind, placebo-controlled study in vitamin D sufficient adults. Nutr Metab (Lond). 2012; 9(1): 16. PubMed

Barker T, Martins T, Kjeldsberg C, Trawick R, Hill H. Circulating interferon-γ correlates with 1,25(OH)D and the 1,25(OH)D-to-25(OH)D ratio. Cytokine. 2012; 60(1): 23-6. PubMed

Coelho D, Kim J, Miousse I, Fung S, Moulin M, Buers I, Suormala T, Burda P, Frapolli M, Stucki M, Nürnberg P, Thiele H, Robenek H, Höhne W, Longo N, Pasquali M, Mengel E, Watkins D, Shoubridge E, Majewski J, Rosenblatt D, Fowler B, Rutsch F, Baumgartner M. Mutations in ABCD4 cause a new inborn error of vitamin B12 metabolism. Nat Genet. 2012; 44(10): 1152-5. PubMed

Genzen J, Gosselin J, Wilson T, Racila E, Krasowski M. Analysis of vitamin D status at two academic medical centers and a national reference laboratory: result patterns vary by age, gender, season, and patient location. BMC Endocr Disord. 2013; 13: 52. PubMed

Illson M, Dempsey-Nunez L, Kent J, Huang Q, Brebner A, Raff M, Watkins D, Gilfix B, Wittwer C, Rosenblatt D. High resolution melting analysis of the MMAB gene in cblB patients and in those with undiagnosed methylmalonic aciduria. Mol Genet Metab. 2013; 110(1-2): 86-9. PubMed

Johnson-Davis K, Moore S, Owen W, Cutler J, Frank E. A rapid HPLC method used to establish pediatric reference intervals for vitamins A and E. Clin Chim Acta. 2009; 405(1-2): 35-8. PubMed

Jovanovich A, Chonchol M, Cheung A, Kaufman J, Greene T, Roberts W, Smits G, Kendrick J, HOST Investigators. Racial differences in markers of mineral metabolism in advanced chronic kidney disease. Clin J Am Soc Nephrol. 2012; 7(4): 640-7. PubMed

Kushnir M, Shushan B, Roberts W, Pasquali M. Serum acylcarnitines and vitamin B12 deficiency. Clin Chem. 2002; 48(7): 1126-8. PubMed

Laha T, Strathmann F, Wang Z, de Boer I, Thummel K, Hoofnagle A. Characterizing antibody cross-reactivity for immunoaffinity purification of analytes prior to multiplexed liquid chromatography-tandem mass spectrometry. Clin Chem. 2012; 58(12): 1711-6. PubMed

Lu J, Frank E. Rapid HPLC measurement of thiamine and its phosphate esters in whole blood. Clin Chem. 2008; 54(5): 901-6. PubMed

Strathmann F, Sadilkova K, Laha T, LeSourd S, Bornhorst J, Hoofnagle A, Jack R. 3-epi-25 hydroxyvitamin D concentrations are not correlated with age in a cohort of infants and adults. Clin Chim Acta. 2012; 413(1-2): 203-6. PubMed

Medical Reviewers

Last Update: February 2016