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Osteoporosis


Table 1: Secondary Causes of Osteoporosis Endocrine or Metabolic Causes Nutritional/GI Conditions


• Acromegaly • Alcoholism


• Diabetes mellitus types 1 and 2 • Anorexia nervosa • Growth hormone deficiency • Hypercortisolism • Hyperparthyroidism • Hyperthyroidism • Hypogonadism


• Hypophosphatasia • Porphyria • Pregnancy


• Calcium deficiency • Chronic liver disease


• Total parenteral nutrition • Vitamin D deficiency


Drugs • Antiepileptics


• Aromatase inhibitors • Chemotherapy


• Immunosuppresants


• Malabsorption syndromes/ • Depo-Provera® malnutrition


• Heparin • Lithium


• Proton pump inhibitors • Selective serotonin reuptake inhibitors • Thiazolidinediones • Thyroid hormone


(at supraphysiologic doses) • Warfarin GI = gastrointestinal. Source: Watts, et al., 2010.1


Table 2: Daily Calcium Intakes Recommended by the Institute of Medicine


Age


19–50 51–70 51–70


Sex


Male and female Male


Female 71 and above Male and female RDA


1,000 mg/day 1,000 mg/day 1,200 mg/day 1,200 mg/day


RDA = recommended daily amount. Source: Ross, et al., 2011.5


Upper Limit 2,500 mg/day 2,000 mg/day 2,000 mg/day 2,000 mg/day


• Glucocorticoids


• Gonadotropin-releasing hormone agonists


Collagen Disorders Other


• Ehlers–Danlos syndrome • AIDS/HIV • Homocystinuria due to cystathionine deficiency • Marfan syndrome


• Osteogenesis imperfecta


• Ankylosing spondylitis


• Chronic obstructive pulmonary disease • Gaucher’s disease • Haemophilia • Immobilisation • Major depression • Myeloma


• Organ transplantation • Renal failure


• Renal tubular acidosis • Rheumatoid arthritis • Systemic mastocytosis • Thalassaemia


hospitalisation for a cardiovascular event. No differences were found between the calcium and placebo groups. In addition, there were no differences in the incidence of MI in the two groups.8


The debate over the effect of calcium on cardiovascular disease remains: currently there are insufficient data on the harm of calcium supplementation to change the daily allowances recommended by the Institute of Medicine (IOM), which are shown in Table 2.5


Patients


Table 3: Daily Vitamin D Intakes Recommended by the Institute of Medicine


Age 19–70 Gender RDA Male and female 600 IU/day 20 ng/ml 71 and above Male and female 800 IU/day 20 ng/ml


Serum Level Upper Limit 4,000 IU/day 4,000 IU/day


IU = international unit; RDA = recommended daily amount. Source: Ross, et al., 2011.5


should not receive more than the recommended daily dose, which means that doctors should ask patients about their dietary intake prior to recommending calcium supplementation.


Vitamin D Supplementation


Vitamin D insufficiency has become an increasingly common problem due to lack of exposure to sunlight and lack of dietary sources rich in vitamin D. Currently, 41 % of men and 52 % of women in the US are vitamin D deficient.11


Previously, insufficiency had been defined as


versus placebo. Cardiovascular outcomes were followed as a secondary endpoint. After seven years of follow-up, there was no difference in the number of myocardial infarctions or cerebrovascular events between the groups.10


This study has been


criticised for several reasons: only 50 % of women in the treatment group were taking more than 80 % of the calcium prescribed, and 46 % of the women were already taking calcium supplements prior to randomisation, which may account for the lack of difference at the end of the study. When the study data were re-evaluated, excluding the 46 % of women taking calcium prior to randomisation, there was a statistically significant (p=0.05) increase in clinical MI/stroke in the calcium group.9


This analysis is limited by the low


incidence of cardiovascular events in the WHI trial and by statistically meaningful differences in the baseline characteristics of the members in the placebo and calcium supplementation groups.9


In the randomised, controlled Calcium intake fracture outcome study (CAIFOS) involving 1,460 women, patients were randomised to calcium carbonate 1,200 mg/day or placebo for five years with observational follow-up for an additional 4.5 years.8


25-hydroxyvitamin D (25(OH)D) <30 ng/ml, because this is the level that is associated with maximal suppression of parathyroid hormone (PTH).12


However, in the recent IOM report on dietary reference intakes for calcium and vitamin D, the committee determined that 20 ng/ml is sufficient for 97.5 % of the population, and that levels above 50 ng/ml may have adverse effects.5


The report also states that


600 IU/day of vitamin D is sufficient to enable the general population to reach the goal of 20 ng/ml (the IOM’s recommendations are shown in Table 3).5


These IOM recommendations have led to significant debate on appropriate serum levels of 25(OH)D and appropriate daily dose levels. They may be insufficient in terms of both the recommended daily allowance and the appropriate serum level.13


Several large clinical trials These patients were evaluated for atherosclerotic vascular mortality or time of first 62


have proven that a serum level of 30 ng/l is appropriate. In the UK, 2,686 men and women aged 65–85 were randomised to received vitamin D 100,000 IU every month for five years versus placebo to determine the effect of vitamin D on fracture rates. After five years of follow-up, the treatment group demonstrated an increase in 25(OH)D level from 21 to 29 ng/ml, which led to a statistically significant (p=0.04) decrease in the number of fractures.14


Furthermore, several meta-analyses have demonstrated that the risk of fracture does not decrease until 25(OH)D EUROPEAN ENDOCRINOLOGY


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