Calcium Supplementation for 67-Year-Old with Hip Fracture
For a 67-year-old patient with a history of hip fracture, recommend 1000-1200 mg of calcium daily combined with 800 IU of vitamin D3, focusing primarily on dietary sources and using supplements only to reach the total target dose. 1
Evidence-Based Rationale
The most recent EULAR guidelines (2021) specifically address post-fracture patients and recommend discussing calcium and vitamin D intake with patients who have experienced osteoporotic fractures, focusing on actual versus recommended intake levels. 1 Importantly, while vitamin D (800 IU) and calcium (1000 mg) supplementation appeared generally ineffective in preventing future fractures in older people with a history of osteoporotic fracture, adequate nutrition remains essential for bone health and overall recovery. 1
Specific Dosing Recommendations
Calcium Intake
- Target total daily calcium: 1000-1200 mg from all sources (diet plus supplements) 1, 2
- Prioritize dietary sources first: calcium-rich foods should be the foundation 1
- Use supplements only to bridge the gap between dietary intake and target dose 1
- If using supplements, divide doses: take no more than 500-600 mg at a time for optimal absorption 3
Vitamin D Supplementation
- Recommended dose: 800 IU daily of vitamin D3 (cholecalciferol) 1, 4
- Higher doses (≥800 IU) show better efficacy than lower doses for fracture prevention in older adults 1
- Target serum 25(OH)D levels of at least 30 ng/mL (75 nmol/L) 3
Critical Context: Understanding the Evidence Limitations
Important caveat: The evidence shows that calcium and vitamin D supplementation does NOT significantly reduce the risk of subsequent fractures in patients who have already had a hip fracture. 1, 5 The landmark RECORD trial of 5,292 elderly post-fracture patients found no significant reduction in new fractures with 800 IU vitamin D3 plus 1000 mg calcium (HR 0.94,95% CI 0.81-1.09). 5
However, supplementation remains recommended because:
- It supports bone health and reduces secondary hyperparathyroidism 6
- It may reduce fall risk (48% relative risk reduction in some studies) 7
- It's required when prescribing bisphosphonates or other osteoporosis medications 2
- Adequate nutrition is fundamental to post-fracture recovery 1
Practical Implementation
Assessment Steps
- Calculate current dietary calcium intake before prescribing supplements 1
- Check baseline vitamin D level (25-hydroxyvitamin D) 3
- Screen for contraindications: history of kidney stones, hypercalcemia, or renal insufficiency 1
Monitoring
- Recheck vitamin D levels after 3-6 months of supplementation to ensure adequacy 3
- Watch for gastrointestinal side effects from calcium supplements (common reason for discontinuation) 5
Common Pitfalls to Avoid
- Don't rely solely on supplements for fracture prevention - this patient needs comprehensive osteoporosis evaluation and likely pharmacologic therapy (bisphosphonates, denosumab, etc.) 1, 2
- Don't prescribe calcium alone - always combine with vitamin D for optimal effect 4
- Don't exceed 1000-1200 mg total calcium daily - higher doses increase kidney stone risk (NNH = 273) without additional benefit 1
- Don't use doses lower than 800 IU vitamin D - 400 IU or less is ineffective 1, 8
- Don't forget to address other fracture risk factors: smoking cessation, alcohol reduction, fall prevention strategies, and structured exercise programs 1
Integration with Osteoporosis Treatment
If prescribing bisphosphonates (like alendronate), calcium and vitamin D supplementation is mandatory if dietary intake is inadequate. 2 The patient should take calcium and vitamin D at different times from the bisphosphonate to avoid interference with absorption. 2
Adjunctive Interventions
Beyond supplementation, this patient requires: