Module 6 Discussion Calcium Supplementation in Patient with a Bone Disease

Module 6 Discussion

Calcium Supplementation in Patient with a Bone Disease

Calcium intake, whether through diet or supplementation helps to maintain skeletal integrity and normal calcium levels. After ingestion, calcium should be absorbed through the intestines. If not absorbed properly, it may lead to secondary hyperparathyroidism and increased calcium resorption from the bones, which can increase the risk of fractures due to bone loss (Verbeke et al., 2023).

A common bone disease associated with calcium deficiency is osteoporosis, which can affect the elderly as well as individuals with nutritional deficiencies. Calcium supplements may cause gastrointestinal issues with long-term use (Verbeke et al., 2023). Other adverse effects include cardiovascular events and renal calculi. To prevent these complications and avoid hypercalcemia, healthcare providers initially typically recommend obtaining calcium from dietary sources. If maintaining normocalcemia through diet alone is not possible, calcium supplements may then be recommended, often alongside vitamin D to help with proper absorption (Kraus et al., 2024; Verbeke et al., 2023).

Postmenopausal Woman with History of Hip Fracture

This 59-year-old woman has several risk factors for potential bone disease including being postmenopausal, a t-score of -2.3, a history of hip fracture, and family history of osteoporosis. A t-score helps to interpret the measurements of bone mineral density (BMD). A score between -2.5 and -1.0 indicates low bone mass. Given her age, clinical history, and test results, she should be recommended for pharmacologic treatment. Fortunately, she is already taking calcium and vitamin D supplements, which help reduce the risk of fractures and support BMD.

Before initiating pharmacotherapy, the provider should assess whether she is meeting her daily calcium and vitamin D requirements by reviewing her nutritional intake and the dosage of her supplements. She should consume 1200mg of calcium and 800 to 1000 IU of vitamin D daily. Calcium sources include dairy products, leafy green vegetables, and salmon. Vitamin D can be obtained from sunlight exposure, fortified milk, and egg yolks. Individuals her age typically ingest 600 to 700mg of calcium daily through diet, so the remaining amount should be supplemented. However, supplements should be limited to 500 to 600 mg of calcium per dose and no more than 4,000 IU of vitamin D daily to prevent hypercalciuria, hypercalcemia, and cardiovascular events (Chisholm-Burns et al., 2022).

Bisphosphonates are typically the drug of choice due to their ability to decrease bone resorption. Within this class, alendronate 5 mg daily or 35 mg once weekly orally appears to be an appropriate option for this patient due to its high binding affinity to bone and its ability to prevent postmenopausal osteoporosis. She should be educated on proper administration, including taking the tablet whole with 6 to 8 oz of water on an empty stomach. Additionally, the patient must be informed of the importance of remaining upright for at least 30 minutes after administration to prevent esophageal irritation. Possible side effects include mild to severe gastrointestinal (GI) symptoms, musculoskeletal pain, osteonecrosis of the jaw, and atypical femoral fractures. Patients should follow up every 1 to 2 years for a DXA scan and should be evaluated for adverse effects and progression of osteoporosis, such as loss of height, physical deformity, and new low-trauma fractures (Chisholm-Burns et al., 2022).

Gout

For this 45-year-old man coming in with left knee pain, there are several risk factors for gout including being a male, drinking alcohol, having hypertension, and taking diuretics such as hydrochlorothiazide. The provider should also assess what he ate for dinner and his usual diet. The individual may be experiencing a gout flare up. Gout is a form of inflammatory arthritis that can be very painful. A flare up results from the immune system reacting to the breakdown of urate crystals. These crystals are made up of uric acid, which is a byproduct of purine metabolism. Purine accumulation may occur due to the natural breakdown of cells, impaired excretion from chronic kidney disease, or a purine-rich diet (Bussell, 2024).

Non-pharmacologic interventions that should be encouraged include avoiding foods high in purines, avoiding alcohol, increasing vitamin C intake, drinking at least two liters of water a day, immobilizing the affected area, and topical application of ice to reduce swelling and pain (Bussell, 2024; Chisholm-Burns et al., 2022).

Regarding pharmacotherapeutic options, first-line therapies to consider include NSAIDS, glucocorticoids, and colchicine. According to Chisholm-Burns et al. (2022), “selection depends on the number of joints affected, presence/absence of infection, clinician/patient preference, prior response, and patient factors such as comorbidities and renal function” (p. 981). NSAIDs such as naproxen, indomethacin, and sulindac may be prescribed at the higher end of the therapeutic range to relieve pain and reduce inflammation. Due to the high dose, treatment duration should be limited. It is typically recommended that NSAID use be discontinued 24 hours after pain is relieved. Adverse effects may include peptic ulcers, fluid retention, and renal impairment. NSAIDs are contraindicated in individuals with a history of these adverse effects, as well as those taking anticoagulants and those with heart failure. While taking NSAIDs, patients should monitor for new epigastric pain, bloody or black stools, hematuria, dyspnea, swelling, and dizziness (Chisholm-Burns et al., 2022).

At this time, the patient would not be a candidate for urate lowering therapies (ULT), as this is his first gout flare. Candidates for ULT are individuals who have experienced two or more flares ups within a 12-month period. Pharmacologic options for ULT include febuxostat, probenecid, and allopurinol. Allopurinol, 100 mg orally once daily, is often the drug of choice to lower serum uric acid (SUA) levels to below 6 mg/dL. Patients should be informed of potential adverse effects, including nausea, fever, and rash. While on ULT, SUA levels should be rechecked every 2 to 5 weeks (Chisholm-Burns et al., 2022).

Reference

Bussell, G. (2024). Gout and your diet. Journal of General Practice Nursing, 10(4), 34–39. https://doi.org/https://research.ebsco.com/c/b3no5h/viewer/pdf/a5zasibdif

Chisholm-Burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., Bookstaver, P.B. (2022). Pharmacotherapy: Principles and practices (6^th edition).  McGraw-Hill Education.

Kraus, D. A., Medibach, A., Behanova, M., Kocijan, A., Haschka, J., Zwerina, J., & Kocijan, R. (2024). Nutritional behavior of patients with bone diseases: A cross-sectional study from Austria. Nutrients, 16(12), 1920. https://doi.org/10.3390/nu16121920

Verbeke, J., Laurent, M. R., & Matthys, C. (2023). Development and validation of an eight-item calcium screener to assess daily calcium intake of patients with osteoporosis in clinical practice. European Journal of Clinical Nutrition, 78(4), 301–306. https://doi.org/10.1038/s41430-023-01390-9