The Pharmaceutical Journal
Vol 276 No 7389 p230-231
25 February 2006

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Letters to the Editor

Vitamin D

Vitamin D may benefit women at risk of hip fracture

From Mr P. D. Burrill, MRPharmS

I am concerned that the headline “Vitamin D supplements fail to reduce hip fractures” in The Pharmaceutical Journal of 18 February (p196) may mislead pharmacists, particularly those advising GPs or carrying out medicines use reviews with patients.

There are several pertinent points that readers need to be aware of before rejecting calcium with vitamin D as an intervention to reduce the risk of hip fractures.

· The mean age of the trial participants was 62, with 37 per cent being in the age range 50 to 59 years, and only 17.5 per cent in the range 70 to 79 years. These were healthy postmenopausal women who were generally free of disability, and only 3.5 per cent had osteoporosis (T score below –2.5). Thus they were at low risk of a hip fracture.

· This is reflected in the hip fracture rate in the placebo arm, which was only 0.55 per cent. This was about half the predicted rate and hence affects the power of the study to detect a reduction in the rate of hip fractures.

· Hormone replacement therapy was used by 52 per cent of the women in the study. HRT is an antiresorptive therapy that has been shown to reduce the risk of hip fractures. HRT is no longer recommended for long-term use due to its risks, and its widespread use in this study limits the ability to generalise the results.

· The dose of vitamin D used (400 IU per day) may simply not have been sufficient. Trials that have demonstrated benefits of calcium with vitamin D have used doses of 700–800 IU per day, as highlighted in a recent meta-analysis.¹

· Among women who were adherent (those who took at least 80 per cent of their study medicines), calcium with vitamin D supplementation resulted in a 29 per cent reduction in hip fracture, hazard ratio 0.71 (confidence interval 0.52–0.97). The hazard ratio for hip fracture among the group of women 60 years of age or older was 0.79 (CI 0.64–0.98), a 21 per cent reduction. The authors of the study comment that their findings provide evidence of a positive effect of calcium with vitamin D on bone health in older postmenopausal women.

A full appraisal of this new study taken together with other evidence for the use of calcium with vitamin D should lead us to the conclusion that there are groups of postmenopausal women at higher risk of a hip fracture who can benefit from taking calcium and vitamin D at the right doses.

Peter Burrill
Assistant Director of Public Health (Prescribing and Clinical Effectiveness)
North Derbyshire Public Health Network

Reference

1. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 2005;293:2257–64.

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