Vitamin D plus calcium supplementation might not reduce the risk of hip fracture in unselected community-dwelling adults > 50 years old

EBM Focus - Volume 13, Issue 3

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Reference: JAMA 2017 Dec 26;318(24):2466 (level 2 [mid-level] evidence)

  • Supplementation with vitamin D (≥ 1,000 units/day) plus calcium (1,000-1,200 mg/day) is recommended in community-dwelling adults ≥ 65 years old to reduce risk of fractures and falls.
  • A systematic review comparing supplementation with vitamin D at ≥ 800 units/day plus calcium ≥ 1,000 mg/day to placebo or no treatment found no significant difference in risk of hip fracture (RR 1.06, 95% CI 0.74-1.51, incident hip fracture in 1.3%) in an analysis of 5 trials with 9,566 unselected community-dwelling adults > 50 years old.
  • Vitamin D plus calcium supplementation was not found to be associated with a reduced risk of hip fracture. Definitive conclusions, however, are precluded by the wide confidence interval for the risk ratio.

In order to reduce the risk of fracture and falls in older adults living in institutionalized settings and community-dwelling adults ≥ 65 years old, the American Geriatrics Society Workgroup on Vitamin D Supplementation suggests supplementation with ≥ 1,000 units/day (25 mcg/day) vitamin D plus calcium commonly given at 1,000-1,200 mg/day (J Am Geriatr Soc 2014). A recent systematic review was conducted to evaluate the potential benefit of supplementation to prevent fractures in community-dwelling adults. This review included 33 randomized trials comparing supplementation with vitamin D plus calcium, vitamin D alone, or calcium alone vs. placebo or no treatment in 51,145 community-dwelling adults > 50 years old with or without osteoporosis (trials in patients with corticosteroid-induced osteoporosis were excluded). The dose and frequency of supplementation varied across the trials, as well as duration of treatment which ranged from 3 months to 7 years.

Comparing vitamin D plus calcium supplementation to control, there was no significant difference in risk of hip fracture (risk ratio [RR] 1.09, 95% CI 0.85-1.39) in an analysis of 7 trials with 17,927 patients in which incident hip fracture occurred in 1.4% of patients. Consistent results were observed (RR 1.06, 95% CI 0.74-1.51) in an analysis limited to 5 trials evaluating 9,566 patients who took vitamin D at ≥ 800 units/day (20 mcg/day) plus calcium ≥ 1,000 mg/day (incident hip fracture in 1.3%). A nonsignificant increase in hip fracture risk was associated with vitamin D supplementation alone (RR 1.21, 95% CI 0.99-1.47) in an analysis of 9 trials with 20,672 patients (incident hip fracture in 1.9%) and with calcium supplementation alone (RR 1.53, 95% CI 0.97-2.42) in an analysis of 14 trials with 6,703 patients (incident hip fracture in 2%).

The results of this systematic review suggest that vitamin D plus calcium supplementation might not reduce the risk of hip fracture in unselected community-dwelling adults > 50 years old. In the analysis of trials in which patients took vitamin D at ≥ 800 units/day (20 mcg/day) plus calcium ≥ 1,000 mg/day, the risk ratio for hip fracture associated with combined supplementation had a wide confidence interval that includes the possibility of benefit or harm. Therefore, it is unclear what effect combined supplementation at doses close to the recommended levels has on the risk of hip fracture. The wide confidence interval may reflect the inclusion of a population with potentially highly variable clinical characteristics, as the osteoporotic status and baseline 25-hydroxyvitamin D concentrations were not known for most patients. In addition, the treatment durations in the analysis of the higher supplementation doses ranged from 1 to 5 years indicating that some treatment durations may not have been long enough to have an effect on hip fracture risk. In summary, the results of this analysis do not provide definitive evidence in conflict with the consensus recommendation from the American Geriatrics Society Workgroup on Vitamin D Supplementation in Older Adults.

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