Oxfordshire

Clinical Commissioning Group

Osteoporosis, Calcium and Vitamin D update

The current guidelines for OP are on the OCCG intranet site here. The current formulary for medication for Osteoporosis (OP) and the supplementation of Calcium and Vit. D is under discussion with the OCCG prescribing group, but I thought it might be useful to send you an update from the expert GP, Dr. Sally Hope.Some of her comments are below and I think you will find them very helpful for day to day practice.More information will follow, so keep an eye on the G.P. Bulletin.

  1. The NICE guideline on supplements for people at high risk of Vit. D deficiency [Nov 2014] says ALL housebound/elderly [>65 yrs.] should have Vit. D supplements.

So we then have the problem of should GPs be prescribing them or not? Only Boots and Holland &Barrett have what they say on the tin (others have between 10-210% of stated dose under a food licence).

In the OUH osteoporosis clinic, it is found thatpeople take OTC preps but still don't become Vit. D replete which is a waste of everyone's time and money.

  1. The NICE OP guideline says that ALL patients MUST be calcium and Vit. D replete for any of the other bone strengthening medicines to work i.e. bisphosphonates, denosumab or IV zol or teriparatide.
  1. Most people HATE taking calcium + Vit. D tabs [too gritty/chewy/sweettaste/constipation/headaches etc. etc., difficult as they bind other meds, 'not enough time in day'etc.] so either don't take them or don't take TWO/d but just manage ONE resulting in under treatment) which is a waste of time and money once again. For this reason in people who simply refuse to drink more milk I advise CAlci-D which is cheapest for NHS and only 1/day. NB calcichewD3 is more expensive so add these alternatives to Scriptswitch.
  1. Most people in care homes are calcium deficient so please keep this on the radar when visiting/assessing them. A pint of milk a day would sort this out.
  1. Other patients who are calcium deficient are usually only too pleased to drink 1 pt. milk/day (or rice/hemp/soya/goat/coconut milk if lactose intolerant) and NOT take the nasty calcium tabs but they do need to take Vit D tabs.
  1. The Edinburgh Calcium Calculator is a useful tool to download and works out how much dietary calcium one is actually having, and one can titrate the diets accordingly

A patient needs >700 mg dietary calcium/day + 800 - 1000 iu Vit. D/day [usually)

If the Vit D is stopped you become deficient in 6 weeks so maintenance is vital.

  1. Howeverwomen taking SUFFICIENT dietary calcium AND 1000 mgs calcium supplements may have too much calcium, with a 40% increased risk of MI and CVA. (Prof Ian Reid's Meta-analysis of WHI [US] study). So drinking milk + OTC Vit. D for OP may be a better solution to be discussed with patients.
  1. A NEW Vit. D (InVitaD3 800 iu)is 30% cheaper than Fultium and halal and olive oil based [not peanut like fultium]. Consider adding this to Scriptswitch as well.

Dr Shelley Hayles (OCCG Planned Care) Jan. 2017