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Three Part Question

In [elderly patients with osteoporosis] is [calcium and vitamin D3 required] for [prevention of future osteoporotic fractures]?

Clinical Scenario

Mrs. S, a 72-year-old female retired piano teacher presented to the AECC clinic with a 30-year history of upper cervical stiffness. She has had a history of corticosteroid use and had early menopause. Mrs. S has also not had any HRT. Cervical series of x-rays were taken, which showed generalised osteopaenia throughout the cervical spine. Mrs. S was referred for a DXA bone scan, which revealed a bone density of 2.2SD (standard deviation) below normal. Mrs. S is being treated with general mobilisation and myofascial therapy of the cervical spine. She asks your advice on whether supplements could be beneficial.

Search Strategy

Medline, using Pub Med interface.
Using RCT limits. 'calcium' AND 'vitamin D3'– 361 articles. (calcium AND vitamin D3) AND osteoporosis – 127 articles. (calcium AND vitamin D3 AND osteoporosis) AND elderly AND osteoporotic fracture prevention – 7 articles.

Search Outcome

3 relevant articles.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Larsen ER et al 2004 Denmark	9605 patients aged 66 and over (mean age 74.0 years).5771 were women and 3834 were men.1g Calcium and 10mg (400 IU) Vitamin D3 given to 4957 (Active participation – 50.3%).Suggestions of improving domestic environment given to 5063 (Active participation – 46.4%).	RCT (3)	Fracture incidence rate among male and female patients offered the calcium and vitamin D3 program.	16% reduction (0.84;Cl, 0.72-0.98; p<0.025).	Study was only carried out in an northern European region known to be deficient in vitamin D3.
			Experienced at least one osteoporotic fracture.	656 (women, 543 fractures; 30.3 per 1000 years. Men, 113 fractures; 9.6 per 1000 years). RR, 3.1; p<0.0001.

Comment(s)

The recent RCT (Larsen et al) was the largest study to evaluate the effect of calcium and vitamin D3. Although the RCT was carried out in a northern European region known to be deficient in vitamin D3, the results obtained show the positive effects for calcium and vitamin D3. Further research is certainly needed and may include southern European countries. The RCT (Meyers et al) conducted a few years before was a double-blinded study, but had a number of weaknesses that would have possibly affected the results. The low dosage and source of vitamin D given, created too many variables in this study. Cod liver oil was used as the source and as it is rich in both vitamin D and A, it has been suggested for a long time that a high intake of vitamin A is harmful for skeletal health. This study did however find that vitamin D3 alone produced no fracture preventing effect. The third RCT is concerned with calcitriol. It has shown that this supplement can possibly cause an increase in fracture rate. However, studies with a larger number of individuals and a more accurate BMD detection are needed to prove this.

Clinical Bottom Line

Although the evidence is limited, calcium and vitamin D3 supplements may be beneficial in the prevention of osteoporotic fractures in the elderly. The efficacy of calcitriol remains unproven as a single agent for the treatment of osteoporosis.

References

1. Larsen, E.R., Mosekilde. L. and Foldspang, A. Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study. . Journal of Bone and Mineral Research. Mar;19(3):370-8. 2004. Mar;19(3):370-8.