Download Calcium Supplementation in Postmenopausal Women

Sarah Gilfillan, PharmD
[email protected]
Kelly L. Scolaro, PharmD
[email protected]
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After the lecture, students will be able to:
 Assess a patient’s dietary intake of calcium
 Understand when to recommend Calcium citrate
over Calcium Carbonate
 Appropriately counsel a post-menopausal women
on recommended calcium intake from diet and
supplementation
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Low estrogen levels
 Increase in bone resorption
 Decrease in GI absorption efficiency
 Decrease in renal conservation
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Elemental Calcium > 1200mg/day
Vitamin D: 800 – 1000 IU/day
 25(OH)D level > 30ng/mL
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Include calcium and vitamin D in addition to
pharmacotherapy (ex. Bisphosphonates)
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Calcium intake > 2500mg/day
 may increase risk of hypercalcemia and renal
impairment
 Impair absorption of other minerals (iron, zinc,
magnesium, phosphorus)
Food
Calcium
Milk
Low fat yogurt
Collard greens
Soy milk
300mg
400mg
300mg
80-300mg
Calcium-fortified Cereal
Calcium-fortified Fruit Juice
Breakfast bars
Up to 1000mg
200-300mg
200-500mg
•Assess dietary intake before supplementing with calcium
•Food is the preferred source because often contains
other important nutrients
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Information about bioavailability is not on the
label
Calcium absorption is not the same as milk
In tests, the calcium in soy beverages
separated into particulate form (80-90%)
Orange juice performed better at 8-50%
Only 11% of calcium in cow’s milk separates
out
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Bioavailability
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Use of antacids
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Number of tablets needed for desired dose
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Size of the tablets
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Cost
Salt
Carbonate
Citrate
Phosphate
Lactate
Gluconate
% of elemental
Calcium
40%
21%
23-29%
18%
9%
Solubility
Insoluble
Soluble
Insoluble
Soluble
Soluble
CARBONATE
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Most common
Least expensive
Relatively insoluble at high
gastric pH
 Must enter solution to be
absorbed
Well absorbed when taken
with meals
CITRATE
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More expensive (more
tablets)
Recommended for:
 Use with H2 Blockers or
PPIs
 Calcium supplement w/o
meal
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Became popular due to infomercials claiming health
benefits due to high concentration in water
 Treat or cure cancer, multiple sclerosis, etc
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Is simply calcium carbonate
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In 2003 a study showed the health of the Okinawans
was due to lifestyle
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Coral Calcium products may contain excess lead
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Constipation
 Differentiate from lack of fluid or fiber in diet
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Gas
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Bloating
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Levothyroxine
 Separate by 4 hours
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Tetracyclines and Quinolones
 Take 2 hours before or 4 hours after calcium
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Absorption increases from 200mg to 500mg,
but does not continue to increase after that
 No additional benefit of 1000mg at a time
compared to 500mg
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Requirements increase with age
 Decreased synthesis in the skin
 Decreased renal conversion to active form
 Intestine less responsive to its effects
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Recommendation for adults > 50
 800-1000 IU/day
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5 – 15 minutes on arms and legs between
10am and 3pm 2-3 times per week
 For fair-skinned individuals
 Darker skin tones need 5 t0 10 times longer
exposure
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Wearing SPF 8 or more reduces ability to
produce vitamin D by 95%
Lots of research and controversy in this area
right now
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D2 (ergocalciferol)
 Brand: Drisdol
▪ OTC liquid drops
▪ Rx capsules: 50,000 IU
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D3 (cholescalciferol)
 Multiple strengths and brands OTC
 Better at raising and maintaining vitamin D levels
Rocaltrol (calcitriol)
 Active form of Vitamin D
 Only Rx
 Recommended in advanced renal disease
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Becoming more popular for bone health
Possibly promotes bone formation and
reduces calcium excretion
Warfarin patients:
 Do not have to avoid as long as taking the
supplement consistently
 Monitor INR when stop or start
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Ex. Viactiv
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Deficiency may increase activity of
osteoclasts
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Does not improve calcium absorption
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Laxative effect may help with constipation
associated with calcium supplements
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Recent studies suggest NO association with
total or non-advanced prostate cancer
 But, higher risk of advanced and fatal prostate
cancer
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Possible mechanism
 High calcium levels suppresses vitamin D
synthesis
 Vitamin D may protect against prostate cancer
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No supplementation recommended for men
with calcium-rich diet
Average 300mg/day from diet (non-dairy 300mg
sources)
2 servings of dairy or high-calcium foods 600mg
Calcium supplement or 3rd serving of dairy 300mg
Daily Total
1200mg
http://www.usp.org/USPVerified/dietarySupplements/