Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Recommendations

Introduction

Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of a
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  1. Summary of recommendations
  3. Figures and tables
  4. Appendix A. Process report
  5. Appendix B. Working group
  6. Provided under licence

Evidence statement

A Cochrane review of vitamin D in postmenopausal women and older men concluded that vitamin D alone is unlikely to prevent fractures in the doses and formulations tested so far in older people.7 However, supplements of vitamin D with calcium may prevent hip or any type of fracture.7 A systematic review (SR) specifically assessing older and frailer populations analysed the benefit of vitamin D with and without calcium specifically in frailer residential and community-dwelling elderly.8 Two hundred and two abstracts were reviewed (44 studies fully reviewed). Thirteen publications met the specified eligibility criteria, with a further two studies meeting most eligibility criteria. There were eight studies with discrete residential-care populations. The average daily dosing of vitamin D in residential-care populations ranged from 400 IU to 1000 IU. In the residential-care populations, vitamin D significantly reduced non-vertebral fractures only when combined with calcium, with a relative risk reduction of 28% at three years in the Chapuy study (P <0.01),9 while the other two studies recording non-vertebral fracture rates showed nonsignificant reduction in fractures.10,11 The percentage of patients sustaining non-vertebral fracture ranged from 12% in the active treatment group of the Meyer study to 27% in the placebo group of the Chapuy study. Hip fracture was significantly reduced in the Chapuy study (P <0.02) and was nonsignificantly reduced in the Decalyos II study (P = 0.07).10,11 However, three other studies showed increases in hip fracture rates, although these failed to reach significance.11–13 The percentage of patients sustaining hip fracture in the placebo groups ranged from as low as 5–6% in the Lips and Lyons studies to as high as 16% in the placebo group of the Chapuy study.

Grade: C

Recommendation 27
Calcium and vitamin D supplementation is recommended for the prevention of fracture in the frail elderly and institutionalised elderly. Optimisation of calcium and vitamin D should be the standard of care for this group.

  • Older people are at highest risk of minimal trauma fracture. It is essential to screen for osteoporosis by testing bone mineral density (BMD) in this population (BMD testing is Medicare subsidised for those with risk factors, those older than 70 years of age and those with fragility fracture). Primary prevention of fracture should be the objective.
  • There is a paucity of evidence on strategies to reduce fragility fracture in the elderly.
  • Older individuals have unique needs and differ quite significantly from younger populations in terms of their fragility fracture risk.
  • It is important that clinicians apply a multifactorial and multidisciplinary approach to fracture reduction in elderly people.
  • It is essential to address the triad of osteoporosis, falls risk and reducing the impact of falls in elderly people.
  • Encourage safe mobility and exercise under appropriate supervision. ‘If you don’t use it, you lose it’ applies.
  • A safe environment (extrinsic) and minimising intrinsic factors (comorbidity, medications and polypharmacy) are critical to reducing falls risk.
  • Optimise nutrition, calcium and vitamin D status. Older people are more likely to be deficient due to poor dietary intake, malabsorption or inadequate sun exposure (vitamin D). Supplementation should be considered for most elderly people unless their nutrition, calcium intake and vitamin D status are demonstrated to be sufficient.
  • Choose anti-osteoporosis medications based on patient factors including compliance and persistence factors.
  • Use of hip protectors should be judicious, as it is not possible to abolish the risk of falls and fracture in most elderly people. It should be noted that hip protectors do not work when not used. Compliance is crucial.

The evidence and recommendations for the general population regarding calcium and vitamin D supplementation also apply to the elderly. However, the elderly are a special population due to higher osteoporosis and fracture risk and higher risk of calcium and vitamin D deficiency due to lifestyle factors and frailty. There is good evidence for high prevalence of vitamin D insufficiency in institutionalised and housebound older people and vitamin D supplementation is considered to be standard care in these populations. Calcium intake is often suboptimal, particularly in the elderly (especially institutionalised patients) who may have limitations to dietary intake, absorption and relatively limited sunlight exposure with low vitamin D. Calcium and vitamin D deficiency are especially important and should be optimised in patients with chronic kidney disease and patients on anti-resorptive therapy, with higher risk of hypocalcaemia and secondary hyperparathyroidism. Dietary calcium intake and serum 25-OH D levels should be checked before initiating anti-osteoporosis therapy, with appropriate supplementation to be recommended if calcium intake and/or vitamin D levels are inadequate.1

Calcium supplements can increase the risk of renal calculi, particularly if given to individuals with adequate dietary calcium intake or calcium excess states. Calcium supplements can cause abdominal bloating and constipation. One randomised control trial (RCT)2 reported an increase in cardiovascular adverse events with calcium in older postmenopausal women already having adequate dietary intake but not on anti-resorptive therapy. Further research is awaited to clarify this. Toxicity is uncommon with vitamin D, even in high doses. Single doses of up to 500 000 IU are tolerated without causing hypercalcaemia or hypercalciuria. However, higher doses may be associated with a higher risk of falls and fractures.3

  • Serum 25-OH D levels should be checked, optimised and maintained during osteoporosis therapy. • To optimise clinical efficacy, calcium at 500–600 mg per day should be taken in conjunction with vitamin D at  700–800 IU per day.4–6
  • Re-measure serum 25-OH D concentrations after three months of treatment to ensure levels 50–75 nmol/L.
  • In patients with malabsorption or refractory vitamin D deficiency, parenteral vitamin D may be indicated (seek specialist advice).
  • Vitamin D in combination with calcium rather than either alone appears most effective in fracture reduction.
  1. Adami S, Giannini S, Bianchi G, et al. Vitamin D status and response to treatment in post-menopausal osteoporosis. Osteoporos Int 2009;20(2):239–44.
  2. Bolland M, Mason B, Horne A, et al. Calcium supplementation improves lipid profile but does not decrease the incidence of cardiovascular events in postmenopausal women. BMJ 2008;336:262–66.
  3. Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: A randomised controlled trial. JAMA 2010;303(18):1815–22.
  4. Bischoff-Ferrari H, Dawson-Hughes B, Baron J, et al. Calcium intake and hip fracture risk in men and women: A meta-analysis of prospective cohort studies and randomised controlled trials. Am J Clin Nutr 2007;86(6):1780–90.
  5. Boonen S, Lips P, Bouillon R, Bischoff-Ferrari H, Vanderschueren D, Haentjens P. Need for additional calcium to reduce the risk of hip fracture with vitamin D supplementation: Evidence from a comparative meta-analysis of randomised controlled trials. J Clin Endocrinol Metab 2007;92(4):1415–23.
  6. Tang B, Eslick G, Nowson C, et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: A meta-analysis. Lancet 2007;370:632–34.
  7. Avenell A, Mak Jenson CS, O’Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane Database Syst Rev 2014 doi: 10.1002/14651858.CD000227.pub4.
  8. Geddes JAA, Inderjeeth CA. Evidence for the treatment of osteoporosis with vitamin D in residential care and in the community dwelling elderly. BioMed Res Int 2013;2013:463589.
  9. Chapuy MC, Arlot ME, Delmas PD, Meunier PJ. Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women. BMJ 1994;308(6936):1081–82.
  10. Chapuy MC, Pamphile R, Paris E, et al. Combined calcium and vitamin D3 supplementation in elderly women: Confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: The Decalyos II study. Osteoporos Int 2002;13(3):257–64.
  11. Meyer HE, Smedshaug GB, Kvaavik E, et al. Can vitamin D supplementation reduce the risk of fracture in the elderly? A randomised controlled trial. J Bone Miner Res 2002;17(4):709–15.
  12. Lips P, Graafmans WC, Ooms ME, Bezemer PD, Bouter LM. Vitamin D supplementation and fracture incidence in elderly persons: A randomised, placebo-controlled clinical trial. Ann Intern Med 1996;124(4):400–06.
  13. Lyons RA, Johansen A, Brophy S, et al. Preventing fractures among older people living in institutional care: A pragmatic randomised double blind placebo controlled trial of vitamin D supplementation. Osteoporos Int 2007;18(6):811–18.
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