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Evidence summaries

Calcium and Vitamin D for Corticosteroid-Induced Osteoporosis

Calcium and vitamin D appear to prevent bone loss at the lumbar spine and forearm in corticosteroid-treated patients. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 5 studies with a total of 274 subjects taking systemic corticosteroids for various underlying conditions. Calcium plus vitamin D was associated with increase in lumbar spine bone mineral density at 1 year (WMD 2.63, 95% CI 0.74 to 4.53; 3 studies, n=152) and distal radius bone mineral density at 1 year (WMD 2.49, 95% CI 0.62 to 4.36; 3 studies, n=110) The other outcome measures (femoral neck bone mass, fracture incidence, biochemical markers of bone resorption) were not significantly different.

Another systematic review 2 included 21 RCTs with a total of 1 260 subjects. The meta-analysis included 9 comparisons of vitamin D plus calcium versus no therapy or placebo. The effect size for bone mineral density (BMD) was 0.60 (95% CI 0.34 to 0.85). The pooled effect size for Vitamin D plus calcium versus calcium alone was 0.43 (95% CI 0.04 to 0.82). The pooled effect size for incidence of fractures was -0.89 (95% CI -1.90 to 0.12). The effect size of bisphosphonates versus vitamin D plus calcium was 0.57 (95% CI 0.09 to 1.05) in favour of bisphosphonates.

The 2017 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 3 conditionally recommends optimizing calcium intake (1 000-1 200 mg/day) and vitamin D intake (600-800 IU/day) as well as lifestyle modifications (a balanced diet, maintaining weight in the recommended range, smoking cessation, regular weight-bearing or resistance training exercise, limiting alcohol intake to 1-2 alcoholic beverages/day) for all patients receiving glucocorticoid (GC) treatment. There are concerns about the potential harms of calcium and vitamin D supplementation with regard to cardiovascular risks. Optimizing calcium intake, however, may be even more important in GC-treated patients because of the increase in urinary calcium excretion during GC use. For this reason, the guidelines suggest optimizing dietary intake of calcium. More research about the benefits and harms of supplemental calcium and vitamin D in GC-treated patients is needed.

Comment: The quality of evidence is downgraded by sparse data. Direct evidence of fracture prevention is very limited.

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    References

    • Homik J, Suarez-Almazor ME, Shea B et al. Calcium and vitamin D for corticosteroid-induced osteoporosis. Cochrane Database Syst Rev 2000;(2):CD000952. [PubMed]
    • Amin S, LaValley MP, Simms RW, Felson DT. The role of vitamin D in corticosteroid-induced osteoporosis: a meta-analytic approach. Arthritis Rheum 1999 Aug;42(8):1740-51. [PubMed]
    • Buckley L, Guyatt G, Fink HA, et al. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Care Res (Hoboken) 2017;69(8):1095-1110 [PubMed]

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