BMJ  2005;331 (30 July), doi:10.1136/bmj.331.7511.0-f

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POEM^*

Calcium and vitamin D is effective for preventing first fracture

Question Does supplementation with vitamin D and calcium prevent a first hip fracture or non-vertebral fracture in older people?

Synopsis This meta-analysis combined the results of randomised controlled trials evaluating the role of the combination of calcium and vitamin D₃. The researchers searched three databases for studies evaluating the effect of the combination on hip fractures or non-vertebral fractures, searched reference lists and meeting abstracts, and contacted experts. The researchers did not comment on the quality of the studies other than to note that treatment allocation was masked and all but one used an intention to treat analysis. Two researchers independently extracted the data from the seven studies, which enrolled a total of 9820 people with an average age of 79 years. Patients lived in the community, in housing for the elderly, or in nursing homes, and the majority were women. Hip fracture occurred in a high proportion of patients: 7.3%. The researchers found heterogeneity among the trial results, which was resolved when they separated the studies by dose of vitamin D. Vitamin D 400 IU per day did not prevent fractures, but vitamin D doses of 700-800 IU per day resulted in a significant decrease in hip fractures (5.8% v 7.7%), translating into one less hip fracture for every 50 patients treated for two years (number needed to treat = 50; 95% CI 34 to 109). Similarly, the non-vertebral fracture rate was decreased only by the higher dose, with a number needed to treat of 28 (19 to 49) for at least one year.

Bottom line Supplementation with calcium 1000 mg and vitamin D₃ 800 IU daily decreases the likelihood that older people will experience a first hip fracture or other non-vertebral fracture. The dose of calcium is lower than the 1500 mg daily that is recommended and usually used; the vitamin D dose is higher than the dose usually used in comparison studies with other drugs. These results conflict with two large studies in patients at high risk or with a previous osteoporotic fracture for whom these doses did not decrease the rate of fracture ( BMJ 2005;330: 1003-6[Abstract/Free Full Text] and Lancet 2005;365: 1621-8[CrossRef][ISI][Medline]).

Level of evidence 1a (see www.infopoems.com/levels.html). Systematic reviews (with homogeneity) of randomised controlled trials.

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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[Abstract/Free Full Text].

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^* Patient-Oriented Evidence that Matters. See editorial ( BMJ 2002;325: 983[Free Full Text])

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bmj.com, 29 Jul 2005 [Full text]