What vitamin D supplementation is recommended for patients with osteoporosis taking Evinity?

Vitamin D Supplementation with Evenity (Romosozumab)

Direct Recommendation

All patients taking Evenity for osteoporosis should receive 1,000-1,200 mg of calcium daily (from all sources) and 800-1,000 IU of vitamin D daily, with target serum 25(OH)D levels of at least 30 ng/mL (75 nmol/L). 1, 2

Rationale for Supplementation

• Adequate calcium and vitamin D are essential when using any bone-modifying agent, including Evenity, to optimize therapeutic response and prevent secondary hyperparathyroidism 3
• Vitamin D sufficiency is necessary for maximizing intestinal calcium absorption and bone mineralization during anabolic therapy 4, 5
• Patients with documented osteoporosis requiring Evenity need supplementation regardless of serum calcium levels, as normal serum calcium does not reflect total body calcium stores or bone health status 1

Specific Dosing Protocol

Standard Supplementation

• Calcium: 1,000-1,200 mg daily from all sources (diet plus supplements) 3, 1
• Vitamin D: 800-1,000 IU daily 3, 1
• Divide calcium doses into no more than 500-600 mg per dose for optimal absorption 1, 2

Target Serum Levels

• Minimum adequate 25(OH)D level: 20 ng/mL (50 nmol/L) 1, 6
• Optimal level for bone health: 30 ng/mL (75 nmol/L) or higher 3, 1, 6
• Higher doses of vitamin D (≥800 IU/day) reduce hip fracture risk by 30% and non-vertebral fracture risk by 14% in adults 65+ years 1, 2

Correcting Vitamin D Deficiency Before or During Evenity

If 25(OH)D < 20 ng/mL (Deficiency)

• Initial correction: Ergocalciferol (vitamin D2) 50,000 IU weekly for 8 weeks 3, 6
• Alternative: Add 1,000 IU daily to current intake if levels are 20-30 ng/mL 3
• Recheck 25(OH)D level after 3 months 3, 1
• Maintenance: 800-1,000 IU daily after correction 6

If 25(OH)D 20-30 ng/mL (Insufficiency)

• Add 1,000 IU vitamin D daily to current intake 3
• Recheck level in 3 months 3

Practical Implementation

Calcium Formulation Selection

• Calcium carbonate (40% elemental calcium): Take with meals, 500 mg twice daily 1
• Calcium citrate (21% elemental calcium): Preferred for patients on proton pump inhibitors or with reduced gastric acid; can be taken without food 1, 2

Vitamin D Formulation

• Vitamin D3 (cholecalciferol) is preferred over vitamin D2 (ergocalciferol) for maintenance therapy, particularly with intermittent dosing 3, 6
• Both forms are acceptable for daily dosing 3

Monitoring Requirements

• Check baseline 25(OH)D level before starting Evenity if not recently measured 3, 1
• Recheck 25(OH)D after 3 months of supplementation 3, 1
• Monitor serum calcium and phosphorus at least every 3 months during treatment 3
• Consider 24-hour urinary calcium in patients with history of kidney stones 1

Critical Pitfalls to Avoid

Inadequate Dosing

• Doses of 400 IU or less of vitamin D with 1,000 mg or less of calcium show no net benefit for fracture prevention 1, 2
• Many patients require more than the standard 800 IU daily and should be repleted based on serum 25(OH)D levels 3

Over-Supplementation

• Calculate dietary calcium intake first before adding supplements 1, 2
• Maximum total calcium should not exceed 2,000-2,500 mg daily to minimize kidney stone risk 1
• Vitamin D toxicity is uncommon but may occur with daily doses >50,000 IU producing 25(OH)D levels >150 ng/mL 3

Absorption Issues

• Never give calcium in single large doses; split into 500-600 mg portions 1, 2
• Take calcium carbonate with meals for optimal absorption 1
• Consider calcium citrate for patients with achlorhydria or on acid-suppressing medications 1, 2

Special Considerations

High-Risk Populations

• Elderly or institutionalized patients: 800 IU vitamin D daily without baseline testing may be appropriate 6
• Dark-skinned or veiled individuals with limited sun exposure: May require supplementation without baseline measurement 2, 6
• Patients on concurrent glucocorticoids: Require 800-1,000 mg calcium and 800 IU vitamin D daily throughout steroid treatment 1, 2

Safety Profile

• Calcium with or without vitamin D has no relationship to cardiovascular disease, cerebrovascular disease, or all-cause mortality in generally healthy adults (moderate-quality evidence) 1, 2
• Calcium supplementation increases kidney stone risk: 1 case per 273 women supplemented over 7 years 1, 2
• Dietary calcium is preferred over supplements when possible, as it carries lower kidney stone risk 1, 2

Essential Lifestyle Modifications

• Weight-bearing and resistance exercise should accompany supplementation 3, 1, 2
• Smoking cessation is essential 3, 1, 2
• Limit alcohol consumption to 1-2 drinks per day 3, 1
• Avoid excessive caffeine intake 1, 2