A Pragmatic Framework for Risk-Based Vitamin D Supplementation in Epilepsy Care in Sub-Saharan Africa

Epilepsy remains a major public health challenge in sub-Saharan Africa, where treatment options are often limited to older, low-cost enzyme-inducing antiseizure medications such as phenobarbital, carbamazepine, and phenytoin. Although these medications are essential for seizure control in resource-constrained settings, prolonged use may accelerate vitamin D metabolism and contribute to hypovitaminosis D, impaired bone mineralization, reduced bone mineral density, osteomalacia, and increased fracture risk. Despite these potential complications, vitamin D assessment is rarely integrated into epilepsy care in the region, and evidence regarding the burden of deficiency among people with epilepsy remains limited. This paper proposes a pragmatic framework for risk-based vitamin D supplementation in epilepsy care adapted to sub-Saharan African contexts. Given the limited availability and affordability of serum 25-hydroxyvitamin D testing, routine laboratory-guided screening is often not feasible. We therefore advocate for a clinically oriented risk-stratification approach prioritizing preventive supplementation among patients at highest risk of deficiency and skeletal complications. High-risk groups may include individuals receiving long-term enzyme-inducing antiseizure medications, children and adolescents, older adults, pregnant women, and patients with malnutrition, reduced sunlight exposure, or physical disability. The framework emphasizes integration of low-cost empirical vitamin D supplementation into routine epilepsy services, particularly at the primary-care level. It also highlights the need for context-adapted clinical algorithms, healthcare provider awareness, patient education, and implementation research to evaluate feasibility, safety, and cost-effectiveness in African settings. Integrating bone health into epilepsy management may represent a feasible and scalable strategy to reduce preventable morbidity and improve long-term outcomes among people living with epilepsy in sub-Saharan Africa.