Vitamin D is an essential vitamin that helps regulate calcium and phosphorus in the body. It also plays a role in maintaining proper bone structure.
There are different forms of vitamin D, including ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). Vitamin D is found in fish, eggs, and fortified milk. It's also made in the skin when exposed to sunlight. During periods of sunlight, vitamin D is stored in fat and then released when sunlight is not available.
Vitamin D supplements are commonly used to treat and prevent vitamin D deficiency. People who don't get enough sun and people who are 65 years or older are at risk for deficiency. People also use vitamin D for weak and brittle bones, heart disease, asthma, hay fever, and many other conditions, but there's no good scientific evidence to support many of these uses. There is also no strong evidence to support using vitamin D supplements for COVID-19. But it is important to maintain healthy levels of vitamin D. This can be done by taking 400-1000 IU of vitamin D daily or spending 15-30 minutes in the sun each day.
Available on Wellkasa
- Familial hypophosphatemia.  Oral vitamin D in combination with phosphate is effective for bone disorders in patients with familial hypophosphatemia.
Login for details - Hypoparathyroidism.  Oral calcitriol increases serum calcium concentrations in people with hypoparathyroidism or pseudohypoparathyroidism.
Login for details - Osteomalacia.  Oral vitamin D is effective for osteomalacia.
Login for details - Renal osteodystrophy.  Oral calcitriol prevents renal osteodystrophy in patients with chronic renal failure.
Login for details - Rickets.  Oral vitamin D prevents and treats rickets.
Login for details - Vitamin D deficiency.  Oral vitamin D prevents and treats vitamin D deficiency.
Login for details
- Corticosteroid-induced osteoporosis.  Oral vitamin D prevents corticosteroid-induced osteopenia and osteoporosis.
Login for details - Osteoporosis.  Adequate intake of vitamin D in conjunction with adequate calcium intake helps to prevent the progression of osteoporosis. It might also reduce the risk of a first fracture in some patients. However, its place in the prevention of secondary facture is unclear.
Login for details - Psoriasis.  Topical vitamin D or vitamin D analogues improve symptoms of psoriasis. This benefit is not seen with oral vitamin D.
Login for details
- Allergic rhinitis (hay fever).  Some research suggests that oral vitamin D reduces symptoms of allergic rhinitis in children and adults. It is unclear if oral vitamin D during pregnancy is beneficial for the prevention of allergic rhinitis in the child.
Login for details - Dental caries.  Some research suggests that oral vitamin D reduces the risk of dental caries in children.
Login for details - Heart failure.  Limited research suggests that oral vitamin D reduces the risk of developing heart failure in some patients. However, vitamin D does not seem to improve outcomes in patients that have already developed heart failure.
Login for details - Hyperparathyroidism-related bone loss.  Limited evidence suggests that oral vitamin D is beneficial in patients with this condition.
Login for details - Respiratory tract infections.  Oral vitamin D supplementation reduces the risk for respiratory tract infections in children. However, this benefit is not seen with the use of prenatal vitamin D supplements, or in adults taking vitamin D. It is unclear if oral vitamin D is beneficial for the treatment of respiratory tract infections.
Login for details - Tooth retention.  Oral vitamin D with calcium seems to help with tooth retention in the elderly population.
Login for details
- Cardiovascular disease (CVD).  Most research shows that taking vitamin D with or without calcium does not reduce the risk of CVD or CVD complications. There is some speculation that there might be modest benefit in the elderly, but more research is needed to confirm.
Login for details - Critical illness (trauma).  Taking vitamin D 540,000 IU as a single oral dose does not reduce death or hospital stay in critically ill patients. However, limited research suggests that taking a smaller dose of vitamin D long-term might have a modest benefit.
Login for details - Fractures.  Most evidence shows that oral vitamin D alone does NOT prevent factures in people who do not have osteoporosis. Some research shows that taking vitamin D with calcium prevents fractures; however, more research is needed to determine who is most likely to benefit.
Login for details - Hypertension.  Overall, vitamin D does not seem to prevent or lower high blood pressure in most patients; however, it may lower blood pressure in hypertensive patients with vitamin D deficiency.
Login for details - Prostate cancer.  Oral vitamin D does not appear to affect prostate cancer progression or cancer-related mortality.
Login for details - Psychosis.  Oral vitamin D does not seem to improve symptoms in patients with a functional psychotic disorder.
Login for details - Tuberculosis.  Oral vitamin D seems to be ineffective for reducing the severity of tuberculosis or mortality from tuberculosis. Limited research suggests that vitamin D may have small benefits in newly diagnosed patients receiving tuberculosis treatment for the first time.
Login for details
- Acne.  It is unclear if oral vitamin D is beneficial for acne.
Login for details - Age-related cognitive decline.  It is unclear if oral cholecalciferol is beneficial for preventing age-related cognitive decline.
Login for details - Alzheimer disease.  It is unclear if oral vitamin D is beneficial for this condition.
Login for details - Asthma.  Oral vitamin D might reduce asthma exacerbations in adults and children with mild, but not severe or persistent, asthma. Prenatal vitamin D may prevent the development of asthma in the child at 3 years but not 6 years.
Login for details - Athletic performance.  It is unclear if oral vitamin D is beneficial for athletic performance.
Login for details - Atopic dermatitis (eczema).  Most research shows that oral vitamin D reduces eczema severity in children. However, most research shows that oral vitamin D, taken during pregnancy or infancy, does not prevent eczema in the child.
Login for details - Atrial fibrillation.  It is unclear if oral vitamin D is beneficial for preventing atrial fibrillation.
Login for details - Attention deficit-hyperactivity disorder (ADHD).  It is unclear if oral vitamin D is beneficial for ADHD.
Login for details - Autism spectrum disorder.  It is unclear if oral vitamin D is beneficial for autism spectrum disorder.
Login for details - Bacterial vaginosis.  It is unclear if oral vitamin D is beneficial for bacterial vaginosis.
Login for details - Breast cancer.  It is unclear if oral vitamin D is beneficial for the prevention of breast cancer.
Login for details - Bronchopulmonary dysplasia.  Limited research suggests that vitamin D deficiency is linked with bronchopulmonary dysplasia in the infant.
Login for details - Cancer.  Vitamin D does not seem to reduce overall cancer risk. However, some research shows that vitamin D might slightly reduce the risk of metastatic cancer and mortality.
Login for details - Child growth.  It is unclear if oral vitamin D is beneficial for improving infant growth or bone structure.
Login for details - Chronic kidney disease (CKD).  It is unclear if oral vitamin D is beneficial in patients with CKD. Most research suggests that it does not reduce the risk for adverse cardiovascular events.
Login for details - Chronic obstructive pulmonary disease (COPD).  It is unclear if oral vitamin D is beneficial for COPD; benefits may be limited to patients with vitamin D deficiency.
Login for details - Cognitive function.  It is unclear if oral vitamin D is beneficial for cognitive function.
Login for details - Colorectal cancer.  It is unclear if oral vitamin D is beneficial for the treatment or prevention of colorectal cancer.
Login for details - Coronavirus disease 2019 (COVID-19).  The evidence is mixed with respect to oral vitamin D supplementation for the prevention and treatment of COVID-19. Also, although some observational research has suggested a correlation between vitamin D status and risk for COVID-19, not all studies agree, and this association may be due to other confounders such as age and comorbidities.
Login for details - Crohn disease.  Limited evidence suggests that vitamin D reduces relapses in patients with Crohn disease.
Login for details - Dementia.  It is unclear if oral vitamin D is beneficial for dementia.
Login for details - Depression.  It is unclear if oral vitamin D is beneficial for treating depression. Vitamin D does not seem to prevent the development of depression.
Login for details - Diabetes.  Oral vitamin D might improve glycemic indices in some patients with type 2 diabetes and gestational diabetes. It is unclear if oral vitamin D is beneficial for the prevention of type 1 or gestational diabetes. It is also unclear if intramuscular vitamin D is beneficial for the treatment of gestational diabetes.
Login for details - Diabetic foot ulcers.  It is unclear if oral vitamin D is beneficial for diabetic foot ulcers.
Login for details - Diabetic nephropathy.  Limited evidence suggests that vitamin D improves some markers of kidney function in patients with diabetic nephropathy.
Login for details - Dysmenorrhea.  Limited evidence suggests that vitamin D reduces pain in adolescent females with dysmenorrhea.
Login for details - Exercise-induced muscle damage.  Small studies suggest that vitamin D does not improve exercise-induced muscle damage.
Login for details - Fall prevention.  The role of vitamin D in fall prevention is confusing and controversial. Oral vitamin D should be considered for those with vitamin D deficiency.
Login for details - Fetal and premature infant mortality.  Taking vitamin D during pregnancy might reduce the risk of fetal or early infant death.
Login for details - Fibromyalgia.  A small clinical study suggests that vitamin D might improve pain in patients with fibromyalgia.
Login for details - Food allergies.  It is unclear if prenatal or infant oral vitamin D supplementation reduces the risk of developing food allergies.
Login for details - Frailty.  It is unclear if oral vitamin D is beneficial for the prevention or treatment of frailty in older adults.
Login for details - Generalized anxiety disorder (GAD).  A small clinical study suggests that vitamin D may modestly improve anxiety in patients with GAD.
Login for details - Hematopoietic stem cell transplant (HSCT).  It is unclear if oral vitamin D is beneficial for improving outcomes in patients receiving HSCT.
Login for details - Hepatitis C.  Low levels of vitamin D have been associated with an inadequate response to hepatitis C therapy. Adding vitamin D to standard therapy for hepatitis C may improve viral response, especially in specific genotypes.
Login for details - HIV/AIDS.  It is unclear if oral vitamin D is beneficial for improving bone mineral density (BMD) in children and young adults with HIV.
Login for details - Hyperlipidemia.  Although population research has found that higher vitamin D levels are associated with improved lipid levels, it is unclear if vitamin D supplementation is beneficial.
Login for details - Hyperthyroidism.  Oral vitamin D has only been evaluated in combination with other ingredients; its effect when used alone is unclear.
Login for details - Hypothyroidism.  It is unclear if vitamin D is beneficial in the treatment of subclinical hypothyroidism.
Login for details - Ichthyosis.  It is unclear if oral vitamin D is beneficial in patients with inherited ichthyosis.
Login for details - IgA vasculitis.  It is unclear if oral alfacalcidol is beneficial in children with IgA vasculitis.
Login for details - Irritable bowel syndrome (IBS).  It is unclear if oral vitamin D is beneficial for IBS; the available research is conflicting.
Login for details - Kidney transplant.  It is unclear if oral cholecalciferol is beneficial for improving allograft function or preventing non-skeletal complications in kidney transplant recipients.
Login for details - Kidney transplant-related bone loss.  Oral vitamin D might be beneficial for preventing bone loss associated with kidney transplantation.
Login for details - Impaired glucose tolerance (prediabetes).  Taking vitamin D might slow prediabetes progression to diabetes in people with low baseline levels of vitamin D or in people achieving high levels of vitamin D following supplementation. It is unclear if vitamin D supplementation is beneficial in people with prediabetes and sufficient vitamin D levels.
Login for details - Infant development.  It is unclear if giving oral vitamin D in doses above the recommended dietary allowance during infancy is beneficial for improving neurodevelopment. It is also unclear if oral vitamin D during pregnancy is beneficial for improving cognitive development in the offspring.
Login for details - Infertility.  It is unclear if oral or intramuscular vitamin D is beneficial in females with infertility.
Login for details - Lung cancer.  It is unclear if oral vitamin D prevents lung cancer or improves lung cancer prognosis.
Login for details - Low birth weight.  It is unclear if oral vitamin D can reduce the risk for low birth weight; the available evidence is conflicting.
Login for details - Male infertility.  It is unclear if oral cholecalciferol is beneficial in males with infertility.
Login for details - Melanoma.  It is unclear if oral vitamin D is beneficial in patients with melanoma.
Login for details - Metabolic syndrome.  It is unclear if oral vitamin D is beneficial for preventing or treating metabolic syndrome.
Login for details - Migraine headache.  It is unclear if oral vitamin D reduces the frequency of migraine.
Login for details - Multiple sclerosis (MS).  Although vitamin D supplementation has been linked with a lower risk of developing MS, taking oral vitamin D supplements does not seem to reduce MS relapses.
Login for details - Muscle strength.  It is unclear if oral vitamin D improves muscle strength in middle aged or older adults with low or sufficient levels of vitamin D. The available research is conflicting.
Login for details - Myalgia.  It is unclear if oral vitamin D is beneficial for reducing myalgia associated with obesity.
Login for details - Myelodysplastic syndromes.  It is unclear if oral vitamin D is beneficial for patients with myelodysplastic syndromes.
Login for details - Nonalcoholic fatty liver disease (NAFLD).  It is unclear if oral or intramuscular vitamin D is beneficial in children or adults with NAFLD.
Login for details - Nonmelanoma skin cancer.  It is unclear if oral vitamin D is beneficial for preventing keratinocyte carcinomas.
Login for details - Obesity.  The evidence for the use of oral vitamin D in obesity is conflicting and unclear.
Login for details - Orthostatic hypotension.  It is unclear if oral vitamin D is beneficial for prevention of orthostatic hypotension.
Login for details - Osteoarthritis.  It is unclear if oral vitamin D is beneficial for osteoarthritis.
Login for details - Otitis media.  It is unclear if oral vitamin D is beneficial in patients with otitis media.
Login for details - Overactive bladder.  It is unclear if oral vitamin D is beneficial for overactive bladder.
Login for details - Overall mortality.  Taking oral vitamin D alone does not seem to reduce mortality; however, there is some evidence that taking certain forms of vitamin D with calcium might have a modest benefit.
Login for details - Pain (chronic).  It is unclear if oral vitamin D is beneficial for chronic pain.
Login for details - Parkinson disease.  It is unclear if oral vitamin D is beneficial for this condition.
Login for details - Periodontitis.  It is unclear if oral vitamin D is beneficial for periodontal disease.
Login for details - Physical performance.  It is unclear if oral vitamin D improves muscle strength in elderly adults.
Login for details - Pneumonia.  High-dose oral vitamin D does not reduce pneumonia severity in children.
Login for details - Polycystic ovary syndrome (PCOS).  Oral vitamin D has mostly been evaluated in combination with calcium; its effect when used alone is unclear.
Login for details - Post-stroke fatigue.  It is unclear if oral vitamin D is beneficial for post-stroke fatigue.
Login for details - Pre-eclampsia.  It is unclear if oral vitamin D during pregnancy is beneficial for pre-eclampsia prevention.
Login for details - Pregnancy-induced hypertension.  It is unclear if oral vitamin D is beneficial for patients with gestational hypertension.
Login for details - Premenstrual syndrome (PMS).  It is unclear if oral vitamin D is beneficial in patients with PMS.
Login for details - Preterm labor.  It is unclear if oral vitamin D is beneficial for preterm labor.
Login for details - Rheumatoid arthritis (RA).  Small clinical studies suggest that oral vitamin D may not improve symptoms in patients with RA.
Login for details - Sarcopenia.  It is unclear if oral vitamin D is beneficial in older adults with sarcopenia.
Login for details - Schizophrenia.  It is unclear if oral vitamin D is beneficial for schizophrenia.
Login for details - Seasonal affective disorder (SAD).  One small study suggests that a large dose of oral vitamin D can improve symptoms of SAD.
Login for details - Seborrheic keratosis.  It is unclear if topical vitamin D analogues improve symptoms of seborrheic keratosis.
Login for details - Sexual dysfunction.  One small study suggests that injecting a large dose of vitamin D might improve sexual function.
Login for details - Sickle cell disease.  One small study suggests that oral vitamin D reduces pain and improves quality of life in children with sickle cell disease with vitamin D insufficiency or deficiency.
Login for details - Small for gestational age (SGA).  It is unclear if oral vitamin D can reduce the risk for SGA births; the available evidence is conflicting.
Login for details - Statin-induced myalgia.  It is unclear if oral vitamin D is beneficial for patients with statin-induced myalgia.
Login for details - Stroke.  Although low vitamin D levels are associated with higher risk of stroke, taking vitamin D supplements does not seem to reduce stroke risk.
Login for details - Sunburn. Login for details
- Systemic lupus erythematosus (SLE).  It is unclear if oral vitamin D is beneficial in patients with SLE.
Login for details - Ulcerative colitis.  Limited evidence suggests that vitamin D may be beneficial in patients with ulcerative colitis.
Login for details - Upper respiratory tract infection (URTI).  It is unclear if oral vitamin D is beneficial for dementia.
Login for details - Urinary incontinence.  Limited evidence suggests that vitamin D may be beneficial in middle-aged, but not older, adults with urinary incontinence.
Login for details - Urticaria.  It is unclear if oral vitamin D is beneficial for the prevention or treatment of urticaria.
Login for details - Uterine fibroids.  It is unclear if oral vitamin D is beneficial for preventing the recurrence of uterine fibroids.
Login for details - Vaginal atrophy.  It is unclear if oral vitamin D is beneficial for vaginal atrophy. There is limited evidence on the topical use of vitamin D in vaginal atrophy in postmenopausal adults or patients taking tamoxifen.
Login for details - Vertigo.  Vitamin D with calcium might reduce positional vertigo. It is unclear if the benefit is from vitamin D, calcium, or the combination.
Login for details - Vitiligo. Login for details
- Warts. Login for details
When taken by mouth: Vitamin D is likely safe when taken in recommended amounts. Most people don't experience side effects with vitamin D, unless too much is taken. Some side effects of taking too much vitamin D include weakness, dry mouth, nausea, vomiting, and others. Taking vitamin D for long periods of time in doses higher than 4000 IU (100 mcg) daily is possibly unsafe and may cause very high levels of calcium in the blood.
Special Precautions & Warnings:
Pregnancy and breast-feeding: Vitamin D is likely safe during pregnancy and breast-feeding when used in daily amounts below 4000 IU (100 mcg). Do not use higher doses unless instructed by your healthcare provider. Vitamin D is possibly unsafe when used in higher amounts during pregnancy or while breast-feeding. Using higher doses might cause harm to the infant.Children: Vitamin D is likely safe in children when taken by mouth in recommended amounts. But it is possibly unsafe to take vitamin D in higher doses, long-term. Infants from 0-6 months should not take more than 1000 IU (25 mcg) daily. Infants aged 6-12 months should not take more than 1500 IU (37.5 mcg) daily. Children aged 1-3 years should not take more than 2500 IU (62.5 mcg) daily. Children aged 4-8 years should not take more than 3000 IU (75 mcg) daily. Children aged 9 years and older should not take more than 4000 IU (100 mcg) daily.
Hardening of the arteries (atherosclerosis): Taking vitamin D could make this condition worse, especially in people with kidney disease.
A type of fungal infection called histoplasmosis: Vitamin D might increase calcium levels in people with histoplasmosis. This could lead to kidney stones and other problems. Use vitamin D cautiously.
High levels of calcium in the blood: Taking vitamin D could make this condition worse.
Over-active parathyroid gland (hyperparathyroidism): Vitamin D might increase calcium levels in people with hyperparathyroidism. Use vitamin D cautiously.
Lymphoma: Vitamin D might increase calcium levels in people with lymphoma. This could lead to kidney stones and other problems. Use vitamin D cautiously.
Kidney disease: Vitamin D might increase calcium levels and increase the risk of "hardening of the arteries" in people with serious kidney disease. Calcium levels should be monitored carefully in people with kidney disease.
A disease that causes swelling (inflammation) in body organs, usually the lungs or lymph nodes (sarcoidosis): Vitamin D might increase calcium levels in people with sarcoidosis. This could lead to kidney stones and other problems. Use vitamin D cautiously.
Tuberculosis: Vitamin D might increase calcium levels in people with tuberculosis. This could lead to kidney stones and other problems. Use vitamin D cautiously.
Aluminum
Interaction Rating=Moderate Be cautious with this combination.
Aluminum is found in most antacids. Vitamin D can increase how much aluminum the body absorbs. This interaction might be a problem for people with kidney disease. Take vitamin D two hours before, or four hours after antacids.
Atorvastatin (Lipitor)
Interaction Rating=Moderate Be cautious with this combination.
Vitamin D might decrease how much atorvastatin the body absorbs. Taking vitamin D with atorvastatin might decrease the effects of atorvastatin.
Calcipotriene (Dovonex)
Interaction Rating=Moderate Be cautious with this combination.
Taking vitamin D along with calcipotriene might increase the effects and side effects of calcipotriene.
Digoxin (Lanoxin)
Interaction Rating=Moderate Be cautious with this combination.
Taking vitamin D along with digoxin might increase the effects and side effects of digoxin. If you are taking digoxin, talk to your doctor before taking vitamin D supplements.
Diltiazem (Cardizem, others)
Interaction Rating=Moderate Be cautious with this combination.
Vitamin D helps your body absorb calcium. Calcium can affect the heart. Diltiazem can also affect the heart. Taking large amounts of vitamin D along with diltiazem might decrease the effects of diltiazem.
Medications changed by the liver (Cytochrome P450 3A4 (CYP3A4) substrates)
Interaction Rating=Minor Be watchful with this combination.
Some medications are changed and broken down by the liver. Vitamin D might change how quickly the liver breaks down these medications. This could change the effects and side effects of these medications.
Verapamil (Calan, others)
Interaction Rating=Moderate Be cautious with this combination.
Vitamin D helps the body absorb calcium. Calcium can affect the heart. Verapamil can also affect the heart. Do not take large amounts of vitamin D if you are taking verapamil.
Water pills (Thiazide diuretics)
Interaction Rating=Moderate Be cautious with this combination.
Vitamin D helps the body absorb calcium. Some "water pills" increase the amount of calcium in the body. Taking large amounts of vitamin D along with some "water pills" might cause too much calcium in the body. This could cause serious side effects, including kidney problems.
Calcium: Taking vitamin D along with calcium increases absorption of calcium. This might increase the risk of calcium levels becoming too high in some people.
Magnesium: Taking vitamin D can raise the level of magnesium in people who have low magnesium and low vitamin D levels. This doesn't seem to be a concern for people with normal magnesium levels.
Vitamin D can be taken with or without food. But taking it with food increases how much vitamin D the body absorbs. Also, vitamin D can increase how much calcium the body absorbs from food.
Vitamin D is an essential nutrient. Fish, eggs, and fortified milk are good sources of vitamin D. The amount that should be consumed on a daily basis is called the recommended dietary allowance (RDA). The RDA is 600 IU (15 mcg) daily for people 1-70 years of age and 800 IU (20 mcg) daily for those 71 years and older. While pregnant and breastfeeding, the RDA is 600 IU (15 mcg) daily. In children, the RDA depends on age. Vitamin D is also made in the skin after sun exposure. Spending 15-30 minutes in the sun each day should be enough to maintain normal vitamin D levels for most people.
Most people should not consume more than 4000 IU daily unless under the care of a healthcare provider. Speak with a healthcare provider to find out what dose might be best for a specific condition.
Alfacalcidol: 1-alpha-hydroxycholecalciferol, 1-alpha-hydroxycholécalciférol, 1 alpha (OH)D3.
Calcifediol: 25-HCC, 25-hydroxycholecalciferol, 25-hydroxycholécalciferol , 25-hydroxyvitamin D3, 25-hydroxyvitamine D3, 25-OHCC, 25-OHD3, Calcifédiol.
Calcipotriene : Calcipotriène, Calcipotriol.
Calcitriol: 1,25-DHCC, 1,25-dihydroxycholecalciferol, 1,25-dihydroxycholécalciférol, 1,25-dihydroxyvitamin D3, 1,25-dihydroxyvitamine D3, 1,25-diOHC, 1,25(OH)2D3, Eldecalcitol.
Cholecalciferol: 7-déhydrocholestérol Activé, Activated 7-dehydrocholesterol, Cholécalciférol, Colecalciferol, Colécalciférol, Vitamin D3.
Dihydrotachysterol: DHT, Dihydrotachystérol, dihydrotachysterol 2, dichysterol, Vitamine D3.
Ergocalciferol: Activated Ergosterol, Calciferol, Ergocalciférol, Ergocalciferolum, Ergostérol Activé, Ergostérol Irradié, Irradiated Ergosterol, Viosterol, Viostérol, Vitamin D2, Vitamine D2.
Paricalcitol: 19-nor-1,25-dihydroxyvitamin D2, 19-nor-1,25-dihydroxyvitamine D2, Paracalcin.
Vitamina D, Vitamine D.
Information on this website is for informational use only and is not intended to replace professional medical advice, diagnosis, or treatment. While evidence-based, it is not guaranteed to be error-free and is not intended to meet any particular user’s needs or requirements or to cover all possible uses, safety concerns, interactions, outcomes, or adverse effects. Always check with your doctor or other medical professional before making healthcare decisions (including taking any medication) and do not delay or disregard seeking medical advice or treatment based on any information displayed on this website.
© TRC Healthcare 2023. All rights reserved. Use and/or distribution is permitted only pursuant to a valid license or other permission from TRC Healthcare.