What are the implications of initiating vitamin D and calcium supplementation in a patient with chronic myasthenia gravis (MG) undergoing steroid treatment?

From the Guidelines

For patients with chronic myasthenia gravis on steroid treatment, I recommend starting vitamin D (800-1000 IU daily) and calcium supplementation (1000-1200 mg daily, divided into two doses) to prevent steroid-induced osteoporosis, as supported by the most recent guidelines 1. This preventive regimen should begin concurrently with steroid therapy and continue throughout the duration of steroid treatment.

• Calcium citrate is often better absorbed than calcium carbonate, especially for older adults or those on acid-reducing medications.
• For vitamin D, cholecalciferol (vitamin D3) is preferred over ergocalciferol (vitamin D2) due to better bioavailability, as noted in previous studies 1. These supplements help prevent steroid-induced osteoporosis, a common complication of long-term corticosteroid use in myasthenia gravis treatment.
• Steroids reduce calcium absorption from the gut and increase calcium excretion through the kidneys, leading to bone mineral density loss.
• This bone loss occurs most rapidly in the first 3-6 months of steroid therapy, making early supplementation crucial, as recommended by guidelines for monitoring bone health in patients on corticosteroids 1. Consider baseline bone density testing before starting steroids and periodic monitoring during treatment.
• If the patient has risk factors for osteoporosis (such as advanced age, female gender, or history of fractures), additional bone-protective medications like bisphosphonates might be warranted.

From the Research

Starting Vitamin D and Calcium for Chronic Myasthenia and Steroid Treatment

• The use of vitamin D and calcium in patients with chronic myasthenia and steroid treatment is primarily focused on preventing corticosteroid-induced osteoporosis, as evidenced by studies such as 2 and 3.
• Corticosteroid-induced osteoporosis is a serious disorder that results in significant long-term morbidity, with increased bone resorption caused by decreased calcium absorption and increased urinary calcium excretion leading to secondary hyperparathyroidism 2.
• Calcium prophylaxis alone, when patients start corticosteroids, is associated with rapid rates of spinal bone loss and offers only partial protection from corticosteroid-induced spinal bone loss 2.
• The combination of calcium and vitamin D therapy may help maintain bone mass at the spine and hip throughout treatment in patients who have used chronic corticosteroids, as shown in studies such as 2 and 4.
• However, calcium and vitamin D therapy appears to be less effective than other agents in the prevention of corticosteroid-induced bone loss, and activated vitamin D may be of greater benefit 2.
• Other studies, such as 3, have compared the efficacy of different treatments, including alendronate, calcitriol, and simple vitamin D, in preventing and treating glucocorticoid-induced bone loss.
• The results of these studies suggest that alendronate may be superior to calcium and vitamin D in preventing glucocorticoid-induced bone loss, but that calcium and vitamin D can still be useful adjunctive therapies 3.
• Additionally, studies such as 5 have investigated the effects of high-intensity interval training and vitamin D supplementation on bone metabolism among women diagnosed with osteoporosis, and found that the combination of HIIT and vitamin D supplementation may be a strategic option to prevent BMD reduction with aging or to slow demineralization.
• Overall, the evidence suggests that vitamin D and calcium can be useful in preventing and treating corticosteroid-induced osteoporosis, but that other treatments, such as bisphosphonates, may be more effective in certain cases 2, 4, 3.