Does taking vitamin D supplements reduce fall-related fractures among geriatric

patients?

Mohamad BeydounKim KirkpatrickJeffrey Oboite

Rafael Otero De Santiago

Patient caseMC is a 68 y/o caucasian female who lives at villages of Homeland apartments alone. She comes to the pharmacy to pick up her medications and asked the pharmacist a question regarding vitamin D supplements. A close friend of hers recently had a fall-related fracture and has her worried. She has heard that vitamin D can help lower your chances of falls and fractures and wants to know if vitamin D would be beneficial for her in the future.

Home Medications:● Escitalopram 10mg PO QD● Metoprolol Succinate 25mg PO QD● Simvastatin 10mg PO QD● Albuterol 1-2 puffs every 4-6 hrs PRN

PMH:● Depression● Hypertension● Hyperlipidemia● Asthma

Vitamin D1

• Vitamin D is a fat-soluble vitamin• Function

• Promotes calcium absorption in the gut

• Maintains adequate serum calcium and phosphate concentrations

• Bone growth and bone remodeling

• With calcium - helps protect older adults from osteoporosis

• Vitamin D sources• UV B radiation (sun)• Fatty fish (salmon, tuna)• Cod liver oil• Beef liver• Cheese• Milk

Drug interactionsSteroids (prednisone)Weight loss drug (Orlistat)Cholesterol lowering drug

(cholestyramine)AEDs (phenytoin and phenobarbital)

Vitamin D1,2

• Supplement Form

• D2 - ergocalciferol

• D3 - cholecalciferol

Fall-related fractures3

• 1 out of 3 older people fall each year.

• 1 out of 5 falls causes serious injuries such as broken bone or head injury.

• Each year over 700,000 people are hospitalized because of fall related injuries like head injury or hip fractures

• Falling once makes people afraid of falling again so they would decrease their daily activities making their bones more fragile.

• Falling once double your chances of falling again.

Centers for Disease Control and Preventionhttp://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html (Accessed 2016 April 5)

Geriatric population4,5

• “Baby Boomers”• Define as people ≥ 65 y/o• Growing population• At high risk for falls because

of comorbidities or medications

• Fall-related fractures can be very complicate in this population

• Increase mortality rateEldercare Workforce Alliance http://www.eldercareworkforce.org/research/issue-briefs/research:america-solution-jobs-crisis-better-care-for-older-adults/ (Accessed 2016 April 5)

Inclusion and Exclusion criteriaInclusion

• Clinical trials • Population ≥ 60 y/o• Fractures as an outcome• Vitamin D dietary

supplementation• Sample size ≥ 100• No year restriction

Exclusion• Secondary literature• Population < 59 y/o• Studies with bone mineral

density as the only outcome• Studies with falls as the only

outcome• Sample size < 99

Search Strategy - PubMed

Filters: english language, human subjects, clinical trials, aged 65+ years

MeSH: “Vitamin D” + “Bone fractures” + “Accidental falls”

218 articles

22 articles

Applied our inclusion and exclusion criteria 5articles

Search Strategy - Trip Database

Applied our inclusion and exclusion criteria

P: Geriatric, I: Vitamin D, C: (blank), O: Bone fracture

112 articles

2articles

Search Strategy - Medline

English language

Vitamin D AND Geriatric AND Falls AND Fractures (TX All Text)

36 articles

22articles

Applied our inclusion and exclusion criteria/ Excluded duplicates

0articles

POEM P Geriatric population

I Vitamin D dietary supplementation

C No vitamin D dietary supplementation or Placebo

O Incidence of fall-related fractures

Article #1

Can Vitamin D Supplementation Reduce the Risk of Fracture in the Elderly? A Randomized Controlled Trial

Meyer et al. Can Vitamin D Supplementation Reduce the Risk of Fracture in the Elderly? A

Randomized Controlled Trial. Journal of Bone and mineral research. 2002. Vol 17, Num 4: 709-15.

Meyer et al.6

P Patients >75 y/o with a life expectancy of more than half a year, able to take their medications and not permanently bedridden

I 400 IU of vitamin D3 daily

C Placebo

O Effectiveness of vitamin D in the prevention of fractures in the elderly people

T 2 years

S Doubled-blinded randomized controlled trial

Results6

Results6

Limitations of the study6

• 761 patients discontinued the treatment after and average treatment period of 10 months.

• High percentage of females (75%)• High percentage of patients had a history of hip

fractures (30%).• The study was done in the city with the highest

incidence rates of hip fractures ever reported internationally.

• Both groups were receiving vitamin A and calcium.• No vitamin D adverse effects were reported• Possible reporting bias

Clinical Implications6

• Vitamin D group, compared with the controlled group, did not show any significant benefit in the prevention of hip fractures and/or nonvertebral fractures.

• There was no difference in mortality between the control group and the vitamin D group

Article #2

Vitamin D Supplementation and Fracture in Elderly Persons: A Randomized, Placebo-Controlled Clinical Trial

Lips et al. Vitamin D Supplementation and Fracture in Elderly Persons: A Randomized, Placebo-

Controlled Trial. Ann Intern Med. 1996. 124: 400-406.

Lips et al.7

P Patients ≥ 70 y/o

I 4000 IU of vitamin D3 daily

C Placebo

O Hip and peripheral bone fractures

T 4 years

S Doubled-blinded randomized controlled trial

Results7

Results7

• Kaplan-Meier display of cumulative proportion of participants with first hip fracture

Limitations of the study7

• Additional medications taken during the study were not reported

• Baseline chronic disease states were not reported• Frailer elderly persons refrained from participation

• Subgroup analysis may reveal confounding variables• Vitamin D3 4000 IU daily does not reduce incidence of

bone fracture in Dutch elderly population

Clinical Implications7

Article #3Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial

Sanders et al. Annual High-Dose Oral Vitamin D

and Falls and Fractures in Older WomenA Randomized Controlled Trial. JAMA. 2010;

303(18): 1815-22

Sanders et al.8

P Women >70 y/o with a high risk of hip fracture

I 500,000 IU of vitamin D3 orally once a year

C Placebo

O Falls and fractures

T 4 years

S Double-blinded, placebo-controlled randomized trial

Results8

Results8

Results8

Limitations of the study8

• Possible reporting bias• Self-reported falls • Only radiologically confirmed fractures were

reported in the study • Baseline characteristics obtained through questionnaire • Patient population • Possible confounding

Clinical Implications8

• Vitamin D resulted in higher incidence of falls and provided no benefit in reduction of fractures

Article #4 Vitamin D supplementation and the prevention of fractures and falls: results of a randomised trial in elderly people in residential accommodation

Law et al. Vitamin D supplementation and the prevention of fractures and falls:

results of a randomised trial in elderly people in residential accommodation. Age

and ageing. 2006; 35: 482-486

Law et al.9

P Patients > 60 y/o not currently taking vitamin D, calcium, or other drugs that can increase bone density.

I 1100 IU of vitamin D2 daily

C No vitamin D (no placebo)

O Nonvertebral fractures, hip fractures and falls

T 10 months

S Randomized controlled trial of cluster design

Results9

Limitations of the study9

• Possible selection bias since data on ineligible patients was not provided.

• 10 months long• No blinding• No placebo• Follow up was only 6 or 12 months

Clinical Implications9

• There was no reduction in the incidence of fractures or falls in the vitamin D-treated group.

• Indeed, the incidence of fractures was directionally higher in the treated group (3.6%) than in the control group (2.6%), but this was not statistically significant.

• There was no evidence to support vitamin D supplementation and the prevention of fall-related fractures.

Overview/Assessment

Articles Conclusions

Meyer et al.1 (2002) No benefit

Lips et al.2 (1996) No benefit

Sanders et al.3 (2010) Increased falls risk

Law et al.4 (2006) No benefit

Limitations of our systematic review• Possible reporting bias

• No discontinuation of other medications or supplements• 80% of the participants in our studies were females• Dose of vitamin D were different

RecommendationShould MC start vitamin D dietary supplementation for the prevention of fall-related fractures?

MC would not benefit from taking vitamin D supplements for the prevention of fall-related fractures

References1. National Institutes of Health https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/#en1(Accessed 2016 April 5)2. GlobalRPh http://www.globalrph.com/2008/vitamin_d_synthesis.gif(Accessed 2016 April 5)3. Centers for Disease Control and Prevention http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html(Accessed 2016

April 5) 4. World Health Organization http://www.who.int/healthinfo/survey/ageingdefnolder/en/(Accessed 2016 April 5)5. Eldercare Workforce Alliance http://www.eldercareworkforce.org/research/issue-briefs/research:america-solution-jobs-crisis-

better-care-for-older-adults/(Accessed 2016 April 2016 5)6. Meyer et al. Can Vitamin D Supplementation Reduce the Risk of Fracture in the Elderly? A Randomized Controlled Trial. JJ

Bone Miner Res. 2002. Vol 17, Num 4: 709-15.7. Lips et al. Vitamin D Supplementation and Fracture in Elderly Persons: A Randomized, Placebo-Controlled Trial. Ann Intern

Med. 1996. 124: 400-4068. Sanders et al. Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women A Randomized Controlled Trial.

JAMA. 2010; 303(18): 1815-229. Law et al. Vitamin D supplementation and the prevention of fractures and falls: results of a randomised trial in elderly people in

residential accommodation. Age Ageing. 2006; 35: 482-486

Questions