Osteoporosis guidelines mention vitamin D - Jan 2023

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Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians

Amir Qaseem, MD, PhD, MHA; Lauri A. Hicks, DO; Itziar Etxeandia-Ikobaltzeta, PharmD; Tatyana Shamliyan, MD, MS; and Thomas G. Cooney, MD; for the Clinical Guidelines Committee of the American College of Physicians*

Description: This guideline updates the 2017 American College of Physicians (ACP) recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults.

Methods: The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of evidence and graded them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Audience and Patient Population: The audience for this guideline includes all clinicians. The patient population includes adults with primary osteoporosis or low bone mass.

Recommendations

• Recommendation 1a: ACP recommends that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis (strong recommendation; high-certainty evidence).
• Recommendation 1b: ACP suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis (conditional recommendation; low-certainty evidence).
• Recommendation 2a: ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; moderate-certainty evidence).
• Recommendation 2b: ACP suggests that clinicians use the RANK ligand inhibitor (denosumab)as a second-line pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; low-certainty evidence).
• Recommendation 3: ACP suggests that clinicians use the sclerostin inhibitor (romosozumab, moderate-certainty evidence) or recombinant PTH (teriparatide, low-certainty evidence), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture (conditional recommendation).
• Recommendation 4: ACP suggests that clinicians take an individualized approach regarding whether to start pharmacologic treatment with a bisphosphonate in females over the age of 65 with low bone mass (osteopenia) to reduce the risk offractures (conditional recommendation; low-certainty evidence).

Clinical Considerations

• Clinicians should prescribe generic medications if possible ratherthan more expensive brand-name medications.
• Clinicians treating adults with osteoporosis should encourage adherence to recommended treatments and healthy lifestyle modifications, including exercise, and counseling for evaluation and prevention of falls.
• Adequate calcium and vitamin D intake should be part of fracture prevention in all adults with low bone mass or osteoporosis.
• Clinicians should assess baseline risk for fracture based on individualized assessment of bone density, history of fractures, response to prior treatments for osteoporosis, and multiple risk factors for fractures (Appendix Table 3). *There are many available risk assessment tools with varying predictive value, which were not evaluated in the systematic review (34) or in this guideline.
• Current evidence suggests that increasing the duration of bisphosphonate therapy to longer than 3 to 5 years reduces risk for new vertebral fractures but not risk for other fractures (34, 79-81). However, there is increased risk for long-term harms (34). Therefore, clinicians should consider stopping bisphosphonate treatment after 5 years unless the patient has a strong indication fortreatment continuation.
• The decision for a temporary bisphosphonate treatment discontinuation (holiday) and its duration should be individualized and should be based on baseline risk for fractures, type of medication and its half-life in bone, benefits, and harms (higher risk for fracture due to drug discontinuation).
• Females initially treated with an anabolic agent should be offered an antiresorptive agent after discontinuation to preserve gains and because of serious risk for rebound and multiple vertebral fractures (21,69, 70, 82).
• Older adults (for example, those aged >65 years) with osteoporosis may be at increased risk for falls and other adverse events due to polypharmacy or drug interactions. Individualized treatment selection should address contraindications and cautions for drugs indicated to treat osteoporosis based on comorbidities and concomitant medications (Tables 1j and 1k of Supplement Appendix 1) as well as reassessment of other drugs associated with higher risk for falls and fractures.
• There is variable risk for low bone mass in transgender persons based on age at gonadectomy, therapy with sex hormones, distribution of comorbidities, and behavioral risk factors for osteoporosis and fractures. When considering the potential risk for fractures, history of gonadectomy (including age) and sex steroid therapy should be considered in treatment decisions for secondary osteoporosis.

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Bisphosphonates in Vitamin D Life

• Bisphosphonates 4.5 X more likely to work when vitamin D level above 33 ng – Sept 2011
• Osteoporosis treatment with Vitamin D – far healthier and 10X fewer afib events (vs bisphosphonates) – Oct 2018

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Vitamin D Life - Overview Osteoporosis and vitamin D contains

• FACT: Bones need Calcium (this has been known for a very long time)
• FACT: Vitamin D improves Calcium bioavailability (3X ?)
• FACT: Should not take > 750 mg of Calcium if taking lots of vitamin D (Calcium becomes too bio-available)
• FACT: Adding vitamin D via Sun, UV, or supplements increased vitamin D in the blood
• FACT: Vitamin D supplements are very low cost
• FACT: Many trials, studies. reviews, and meta-analysis agree: adding vitamin D reduces osteoporosis
• FACT: Toxic level of vitamin D is about 4X higher than the amount needed to reduce osteoporosis
• FACT: Co-factors help build bones.
• FACT: Vitamin D Receptor can restrict Vitamin D from getting to many tissues, such as bones
• It appears that to TREAT Osteoporosis:
•        Calcium OR vitamin D is ok
•        Calcium + vitamin D is good
•        Calcium + vitamin D + other co-factors is great
•        Low-cost Vitamin D Receptor activators sometimes may be helpful
• CONCLUSION: To PREVENT many diseases, including Osteoporosis, as well as TREAT Osteoporosis
• Category Osteoporosis has 215 items
• Category Bone Health has 307 items

Note: Osteoporosis causes bones to become fragile and prone to fracture
  Osteoarthritis is a disease where damage occurs to the joints at the end of the bones

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Vitamin D Life - Osteoporosis category contains

• 215 items in category - see also Overview Osteoporosis and vitamin D
• Overview Fractures and vitamin D
• Bone - Health 307 items
• Vitamin D Life pages with BONE MINERAL DENSITY or BMD in title 29+ pages
• Search Vitamin D Life for OSTEOPENIA 1740 items as of July 2020
• 13 articles are in both Osteroporosis and Vitamin D Receptor categories
• 9 articles are in both Osteroporosis and Meta-analysis categories
• 20X increase in vitamin D sold and 36 percent decrease in osteoporosis business in Australia – Nov 2013

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Vitamin D Life - Falls and Fractures category contains

• 254 items in FALLS and FRACTURES
• Vitamin D and Calcium cost-effectively reduce falls and fractures – April 2019
• see also Overview Seniors and Vitamin D
  • Overview Fractures and Falls and Vitamin D
  • Overview Fractures and vitamin D
  • Overview Muscles and Vitamin D

Falls

• Fall prevention - Vitamin D is one of the ways - umbrella review Jan 2024
• Deaths due to falls doubled in just a decade (age-adjusted, perhaps decreased vitamin D) – June 2019
• Preventing Falls in Older Adults – Vitamin D combination is the best - JAMA Meta-analysis Nov 2017
• Falls cut in half by 100,000 IU vitamin D monthly - RCT 2016
• Falls reduced by a third if achieved 40 ng level vitamin D– RCT Sept 2018
  • Note: It took 6 months to get to that level. Most trials last only 3 months
• Vitamin D prevents falls – majority of meta-analyses conclude – meta-meta analysis Feb 2015
• Falls reduced by Vitamin D: 13 percent reduction if more than 700 IU – review of 38 trials – Aug 2022

Fracture

• Hip fractures are predicted by 10 factors – low Vitamin D is the biggest – Aug 2023
• Vitamin D and fractures – 24 meta-analyses and counting – Dec 2014
• Low trauma bone fractures in seniors – considering Vitamin D loading dose for all, without testing – Nov 2019
• Vitamin K (any amount and any kind) reduced bone fractures by 24 percent – meta-analysis – May 2019
• 75+ Hip fracture items in Vitamin D Life title   Click here for details