CALCIUM supplements have “very little place in contemporary medical practice”, according to a narrative review published by the MJA that contends that the supplements lack effectiveness in fracture prevention and have potential side effects.

Professor Ian Reid and Associate Professor Mark Boland of the University of Auckland wrote that calcium supplements were not needed in healthy individuals, nor were they required in most people being treated for osteoporosis.

The review also concluded that low doses of vitamin D were safe and played a role in the prevention of osteomalacia in people with specific risk factors, including those with a lack of access to direct sunlight – such as frail older people in nursing homes and people who wore veils – as well as in people with dark skin. The authors said a daily dose of 400–800 IU was usually adequate.

The authors noted that the use of calcium and vitamin D supplements had been controversial, particularly in the past 20 years, “as larger clinical trials have not supported many doctors’ previous clinical practice”. They wrote that major trials in community-dwelling people had not demonstrated a reduced fracture risk with supplementation with either calcium, vitamin D or their combination, but a reduced risk had been shown in a large study in vitamin-D deficient nursing home residents.

In an exclusive podcast, Professor Reid told InSight+ that calcium supplements could cause constipation, bloating and renal stones. He also pointed to a 2017 study he conducted with colleagues that found that calcium supplements resulted in a small increase in the risk of myocardial infarction and, “possibly”, stroke.

“Dietary calcium is relatively safe,” he said. “If you are getting calcium from your diet, it is coming together with protein and fat and so you feel satiety and you don’t binge on it. Supplements are the problem and everyone who has taken or prescribed them knows that people get constipated taking calcium supplements. Calcium is a key part of concrete and sometimes it has that effect on your bowel.”

Professor Reid said that while international authorities had now accepted that routine supplementation of calcium and vitamin D was not required in healthy, community-dwelling older people, they remained firm that supplementation was required alongside treatment for osteoporosis.

“That’s not entirely true,” Professor Reid said. “There are several studies, including a large trial with intravenous bisphosphonates that we published at the end of 2018, which have been done without any calcium supplements and I think there is enough trial evidence that the drugs we commonly used for treating osteoporosis, which is the bisphosphonates, work perfectly well without co-administration of calcium.”

However, Professor Reid noted that calcium and vitamin D supplements should continue to be used in conjunction with some newer osteoporosis medications, such as romosozumab, which inhibited bone resorption and stimulated bone formation.

“There are one or two newer, powerful drugs where it is true that the trials that have been done to date have all been done with calcium and vitamin D supplements,” said Professor Reid, adding that very small numbers of patients were taking these drugs at this time.

“We don’t really know what happens if you use those [drugs] without calcium and vitamin D, so people proceed with caution.”

Professor Markus Seibel, Professor of Medicine at the Concord Clinical School, said the review’s findings were not new.

“The short and the long of all of this is: if your patient is calcium deficient, and only then, supplementation with oral calcium makes sense and has been shown to have beneficial effects on bone health, particularly in the elderly,” said Professor Seibel, who holds the Chair of Endocrinology at the University of Sydney.

Professor Reid said that assay expense and variability meant that vitamin D supplementation was best guided by clinical status.

“For the most part, you can identify who needs vitamin D supplements just from the simple clinical indicators of ‘Are you getting outdoors? Do you have very dark skin? Are you living in a very sunny or non-sunny place? Are you veiled?’”

Professor Peter Ebeling, Professor of Medicine at Monash University, said dietary calcium was more important than calcium supplements and that all patients with serum 25‐hydroxyvitamin D (25(OH)D) levels below 30 nmol/L should be treated with vitamin D supplements.

“I agree daily dosing of 800 IU will be adequate in most people, but most supplements are 1000 IU in Australia, which would be fine too,” he said. “Another alternative would be 7000 IU per week if compliance is a problem; however, in general, higher bolus doses would not be recommended.”


Poll

Calcium supplements have little place in modern medical practice
  • Agree (34%, 51 Votes)
  • Strongly agree (30%, 46 Votes)
  • Jury is still out (24%, 36 Votes)
  • Disagree (9%, 13 Votes)
  • Strongly disagree (4%, 6 Votes)

Total Voters: 152

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9 thoughts on “Calcium and vitamin D supplements. When do we need them?

  1. Anonymous says:

    Unfortunately, Calcium – Vit D has often been overlooked as a treatment for muscle cramping. The research is usually done for bone loss (Osteopenia or Osteoporosis) but never considered in patients who have chronic muscle cramping. Muscles can not relax without sufficient Calcium!

  2. Gabrielle McMullin says:

    There is also a powerful study that showed that Calcium and Vitamin D treatment increases cardiovascular disease and mortality from this.

  3. Dr Celine M Aranjo says:

    Are we ignoring physiology here? Bone requires many raw materials, one of these is Calcium, another is Vit D. Parathyroid glands secrete Calcitonin which regulates the blood levels of Calcium when signals are sent from bone. When Serum Calcium is low (muscle cramps/infantile seizures/tetany) calcitonin mobilises calcium from bone for essential homeostasis. This mobilisation of calcium from bone, requires re-calcification if osteoporosis (osteopenia/rickets) is to be prevented This is done by calcitonin by taking serum calcium and depositing it into bony matrix.Thus re-modelling of bone should be a healthy on-going process, which in cases of inadequate calcium and Vit D intake is lacking.

  4. Anonymous says:

    High time to see a review article by two experts that once again proves that Calcium and Vitamin D supplements have no reasonable place in current medicine – apart from rare new adjunct therapies. Sad to see is is rounded off with a paragraph by an author not associated with this research, that is know to have been defending Vitamin D and Calcium supplements in the face of new evidence proving their lack of efficacy and highlighting safety-doubts. Receiving research-funding from their manufacturer through Osteoporosis Australia or similar bodies without offering a declaration of conflict of interest in this article does not increase the scientific accountability of those ‘closing words’.

  5. Dr Scott says:

    The article mentions that only if you are “calcium deficient” then supplementation makes sense. How is calcium deficiency diagnosed? It is certainly not based on serum calcium as that is tightly regulated by PTH. Realistically you need to do a “metabolic bone study” which measures calcium excretion, PTH, vit D and bone turnover markers to determine if you are calcium deficient. It has been my anecdotal experience that patients often have evidence of calcium deficiency on this test when being treated with denosumab (Prolia). Denosumab is the most commonly prescribed osteoporosis medication on the PBS so why is that not mentioned here? I understand bisphosphonates don’t require it but why no mention of if calcium supplementation is required for denosumab?

  6. Anonymous says:

    I prescribe both calcium and vitamin D supplementation for my patients receiving Prolia. I would tend to avoid calcium supplementation in otherwise healthy adults. Vitamin D deficiency is underestimated in Australia and many adults would benefit from supplementation of 1000 in daily.

  7. Anonymous says:

    Wonderful: yet another review-article proving the uselessness of Calcium and Vitamin D supplementation, and Dr Anonymous eagerly admitting that s/he still ‘prescribes both calcium and vitamin D supplementation’, going even further and recommending from the obscurity of anonymity and scientific absurdity to claim contrary to all best available evidence that ‘many adults would benefit from supplementation of 1000 IU daily’.

    Why not make the name of this anonymous yet presumably medical contributor public for the ignorance and refusal to follow best medical evidence, instead aligning with vested interests of supplements manufacturers, disregarding even RACGP recommendations, as per mandatory reporting requirements, not adhering to best medical practice and putting patients at risk?

  8. Paul Burke says:

    Why would any Publication print any Medical opinions from ANONYMOUS contributors.
    makes the Publication good only for Toilet Paper

  9. Prof Gary Wittert says:

    The contention that calcium supplements have “no place” is inherently ridiculous. There are unequivocally circumstances when they are both required and beneficial. That is not the same as a recommendation for “routine” calcium supplementation for the prevention or management of postmenopausal osteoporosis. And now that time is made available by not having to talk about calcium supplements, let’s use that productively to advocate for healthy eating (fresh whole foods including dairy) and both aerobic and resistance exercise.

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