#18 Osteoporosis, bone health and the calcium, vitamin D controversy.

November 7, 2016 | By Matthew Watto, MD

On this episode, we got served! Endocrinologist, Dr. Pauline Camacho, current president of AACE and Professor of Medicine at Loyola University Chicago makes it rain clinical pearls as she schools us on the use of calcium, Vitamin D, bisphosphonate therapy and drug holidays. This is a must listen for anyone treating osteoporosis. Make sure to check out the new 2016 AACE guidelines, which include infographics for patients and their easy to use algorithm.

Clinical Pearls:

Vitamin D

1. Vitamin D for postmenopausal osteoporosis prevention (women > 50 yo)
   1. Optimum Vit D level between 30-50 ng/ml recommend
   2. Check PTH if Vit D is very low
   3. If secondary hyperparathyroidism then treat until PTH normalizes
   4. Usual dose is Vit D2 or D3 1000 to 2000 IU daily
   5. Weekly dosing may be required for loading
   6. Vit D3 preferred if malabsorption (e.g. post gastric bypass)
2. Vitamin D2 or D3 50,000 IU dosed monthly or biweekly is probably safe despite trials suggesting increased falls^2-3

Calcium

1. Calcium recommended total daily intake through diet +/- supplements
   1. postmenopausal women 1200 mg daily
   2. Men 1000 mg
2. Calcium citrate has better absorption, especially in the elderly or those on PPI

Osteoporosis and drug therapy

1. AACE’s four criteria for diagnosis osteoporosis
   1. T-score -2.5 or below in the lumbar spine, femoral neck, total, and/or 33% (one-third) radius
   2. Low-trauma spine or hip fracture (regardless of BMD)
   3. Osteopenia or low bone mass (T-score between -1 and -2.5) with a fragility fracture of proximal humerus, pelvis, or possibly distal forearm
   4. Low bone mass or osteopenia and high FRAX® fracture probability based on country-specific thresholds
2. Bisphosphonate therapy
   1. Treat for 5-10 years with oral or 3-6 years with IV bisphosphonates
   2. High fracture risk: elderly patients or those with hx of fracture then consider IV agents 1st line (zoledronic acid, denosumab, teriparatide)
3. Therapy is successful if:
   1. Stable bone mineral density (BMD)
   2. Increasing BMD
   3. Diminishing levels bone turnover markers (e.g. N-terminal and C-terminal cross-linked telopeptides)⁴
4. Therapy is a failure if:
   1. Significant or progressive loss of BMD (using a reliable machine)
   2. Fracture occurs
5. Drug holiday may last several years, but ends if:
   1. Fracture occurs
   2. BMD declines significantly
   3. Rising bone turnover markers (telopeptides)
6. After drug holiday the clock resets. Meaning patient may start another full treatment course with bisphosphonate, denosumab or teriparatide
7. After a hip fracture
   1. Check Vit D level and replete
   2. Start bisphosphonate once Vit D level corrected (usually takes 2-3 months)
8. Routine testing of BMD is recommended for men >70 yo
   1. If you can get it covered!

Disclosures:
Dr. Camacho did not report any relevant financial disclosures.

1. Make recommendations for daily intake of vitamin D, recognize appropriate levels, and treat secondary hyperparathyroidism
2. Ensure adequate calcium intake through diet and/or supplementation and counsel patients on risks and benefits
3. Select appropriate bone preserving therapy, treatment course, and learn to monitor for treatment failure
4. Identify appropriate timing of drug holidays and reinitiation of drug therapy 

Links from the show:

1. Hot off the press! 2016 AACE Guidelines for postmenopausal osteoporosis https://www.aace.com/files/final-appendix-sept-7.pdf
2. Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline RCT JAMA Int Med Jan 2016
3. Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women JAMA 2010
4. Eastell R et al. Bone turnover markers and bone mineral density response with risedronate therapy: relationship with fracture risk and patient adherence. J Bone Miner Res. 2011 Jul;26(7):1662-9. doi: 10.1002/jbmr.342. 

Further recommended reading:

1. Calcium intake and bone mineral density: systematic review and meta-analysis
2. Calcium intake and risk of fracture: systematic review
3. Dr. Camacho responds to reader response about physiologic norm for Vit D level http://ajcn.nutrition.org/content/101/2/413.2.full.pdf
4. Dr. Camacho’s review article on prediction of fracture risk from Jul 2015 https://www.ncbi.nlm.nih.gov/pubmed/26236988
5. Differing Vit D levels by latitude challenge idea of a physiologic norm https://www.ncbi.nlm.nih.gov/pubmed/25008852
6. VITAL Study for Vit D and Omega 3 fatty acids for prevention of cancer, heart attack and stroke http://www.vitalstudy.org