Endocrinology Metabolism

Calcium in osteoporotic patients

Management and Treatment of the Disease

Should I prescribe calcium for my patient with osteoporosis? If so, how much?

Need for calcium: Modern studies of osteoporosis treatment have included calcium (and vitamin D) with the pharmacologic treatment. There is a little evidence that calcium plus vitamin D has a minor salutary effect on fracture risk. So, in general calcium is good for bones.

How much? The Institute of Medicine (IOM) recommended that most adults ingest 1000-1200 mg of calcium daily. This is the total elemental calcium from diet and supplements if necessary. The American diet has more calcium than thought previously, probably because more foods are fortified with calcium. Nonetheless it is still somewhat difficult to obtain adequate calcium without ingesting dairy foods. For those patients who are lactose intolerant, lactase tablets are readily available.

Is more calcium better? No. The gut can only absorb about 500 mg of elemental at any one time. Higher than 1200 mg of calcium daily may increase the risk of kidney stones, although in some cases a really low oral calcium intake can actually lead to more stones. So, we suggest following the IOM guidelines on calcium intake.

My patient with osteoporosis likes coral calcium. Is this better? What about chocolate calcium chews?

Some more exotic calcium preparations may contain lead and/or arsenic. Therefore, plain calcium carbonate or calcium citrate should be used from a reliable source. Calcium carbonate should be taken with meals because stomach acid is needed for absorption. The chocolate chews are generally okay, but remember that more is not necessarily better.

Is calcium safe for that osteoporosis patient with declining renal function?

In patients with end-stage renal disease (CKD 5 on dialysis), calcium-containing phosphate binders were associated with more coronary artery calcification than sevelamer, which does not contain calcium. Extrapolating to those with declining renal function with aging (and with increasing fracture risk with aging) is difficult. More study is needed to determine if those osteoporosis patients with CKD 3 or 4 should ingest lower amounts of calcium than those with more normal renal function, although no problems were seen in most osteoporosis studies that included subjects with CKD 3 or 4.

If there is evidence of coronary calcification in renal failure patients taking calcium, what about the reports that calcium supplementation increases cardiovascular risk in all adults?

There is some evidence to support and discount a deleterious effect of calcium ingestion on blood vessels. It is not easy to find an answer that will satisfy both sides of this debate. For now, we suggest following the IOM recommendations that most adults need 1000 to 1200 mg of elemental calcium daily.

The most recent reviews of calcium and cardiovascular risk have failed to show a deleterious effect. Thus, most experts agree with the IOM plan. Patients with osteoporosis need calcium and for most people this means 1000 to 1200 mg of elemental calcium, preferably in the diet, each day.

Is magnesium helpful for osteoporosis?

The role of magnesium in osteoporosis is not established. It is interesting that a drug class, the proton pump inhibitors, is associated with both increased fracture risk and hypomagnesemia. Nonetheless, a connection between the two outcomes has not been established.

The cathartic effect of magnesium may neutralize the constipating effect of calcium. Thus, taking both calcium and magnesium - often available together - is appealing.

If the patient has a co-existing disease or medication use, how will that effect your treatment decision?

Tell the user when to switch if it appears the treatment is not proving effective and what to consider switching to.

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