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Many patients with osteoporosis not screened for vitamin D levels before treatment
AUSTIN, Texas — Three-quarters of men and women veterans seen at the Dayton Veterans Affairs Medical Center assigned osteoporosis medications were not screened for vitamin D levels in the 12 months before initiating therapy.
Researchers suggest that these practices should be improved at the center.
“Vitamin D assessment and treatment for veterans receiving osteoporosis medication need to be improved,” Sonia I. Bennett, MD, MPH, an internal medicine resident at Wright State University Boonshoft School of Medicine in Dayton, told Endocrine Today. “Maintaining adequate vitamin D level is key to prevent bone loss in our veterans, and especially among those receiving osteoporosis medications, as adequate levels enhance the activity of these medications.”
Bennett and colleagues presented data on 253 veterans prescribed various osteoporosis medications from January 2015 to January 2016 at the Dayton VA Medical Center and its outpatient clinics. Researchers sought to determine whether vitamin D levels were checked within 12 months before initiation or at the time of osteoporosis treatment initiation. Therapies prescribed included alendronate, risedronate, ibandronate, calcitonin or raloxifene.
The mean age of the participants at initiation of therapy was 65 years, and 77.1% were men. The most common indication for therapy was osteoporosis (68.8%), followed by osteopenia (24.5%) and osteoporosis prevention (6.3%). Most participants were initially prescribed alendronate (94.5%), followed by risedronate (3.2%), calcitonin (1.6%), raloxifene (0.4%) and ibandronate (0.4%).
Vitamin D levels were checked in the 12 months preceding or at the time of treatment initiation in 24.1% of participants; 42.6% had vitamin D levels greater than 30 ng/mL and 29.5% had vitamin D levels greater than 33 ng/mL.
“We are currently working with the VA pharmacy to get the pop-up reminder to show up when providers order osteoporosis medications,” Bennett said. “Educating primary care providers regarding the significance of assessing vitamin D level with osteoporosis medications is another important step we can take at the Dayton VA Medical Center. Once these steps are implemented, we hope to assess their impact in improving the bone health of our veterans.” – by Amber Cox
Reference:
Bennett S, et al. Abstract #517. Presented at: AACE Annual Scientific and Clinical Congress; May 3-7, 2017; Austin, Texas.
Disclosure: Endocrine Today was unable to confirm any relevant financial disclosures.
Perspective
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This study confirms what every practicing endocrinologist should already know. No drug, no matter how good, can help prevent fractures if there is not an adequate nutritional substrate. The necessary nutritional support includes adequate protein and adequate calcium. Vitamin D is desirable to help with calcium absorption. For those who either synthesize vitamin D through sun exposure or who have sufficient dietary calcium so that they can absorb sufficient calcium without vitamin D-mediated absorption, it may not be necessary to supplement. On the one hand, I am willing to consider that in some patients vitamin D measurement may not be necessary. But, on the other hand, if so large a fraction of patients are not having vitamin D measured, then how many are not having adequate workups prior to starting therapy? The current crisis in osteoporosis care is not limited to patients’ reluctance to take effective drugs, but to providers’ unwillingness to acknowledge the importance of fractures as a health problem and work them up in a comprehensive fashion. Writing a prescription for a medication and recommending calcium and vitamin D supplementation is not sufficient. Our patients deserve better.
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As reported by the authors, in order for any osteoporotic medication to be effective, adequate calcium and vitamin D are required. Daily calcium of 1,000 to 1200 mg, preferably from dietary sources, is what is required along with adequate vitamin D. The Endocrine Society's practice guideline recommends that for maintaining a normal vitamin D status (25-hydroxyvitamin D) above 30 ng/mL, which was considered to be necessary for maximal bone health, at least 1500 to 2000 IUs of vitamin D a day is required. Those who are obese require two to three times more. An effective alternative is 50,000 IUs of vitamin D2 or vitamin D3 once every 2 weeks.
The observation that only 24.1% of veterans had their vitamin D status determined before initiating osteoporosis therapy is not at all unexpected. However, neither the Institute of Medicine nor the Endocrine Society recommend screening everyone for their vitamin D status. It is much more cost effective to simply improve everyone's vitamin D status by following the guidelines proposed by the Endocrine Society.
Before initiating osteoporosis therapy for my patients, I empirically give them 50,000 IUs of vitamin D2 once every 2 weeks with the presumption that they are vitamin D deficient or insufficient. Even if they are vitamin D sufficient, giving this amount of vitamin D will not cause toxicity and is very effective (Demetriou ETW, et al. Endocr Prac. 2012;doi:10.4158/EP11268.OR) I recommend for my patients to initiate their osteoporosis therapy a month after starting the vitamin D supplementation and improving their calcium intake.