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What type of calcium and vitamin D supplementation should I prescribe?

 

A) Patients with osteoporosis require an adequate intake of vitamin D. Vitamin D enhances the intestinal absorption of calcium and low vitamin D levels are associated with impaired calcium absorption and a consequent rise in PTH. This can lead to excessive bone resorption.

Most patients with osteoporosis require approximately 800 IU of vitamin D and 1200-1500mg elemental calcium daily. This is especially important if they are on bisphosphonate therapy. There are a variety of preparations available containing a combination of calcium and vitamin D3. It is important that patients are prescribed a combined calcium and vitamin D preparation, rather than a single calcium supplement as it is the vitamin D component which is most important. Although multivitamin preparations are available, most contain only 400 IU vitamin D which is inadequate.

Some patients find chewable tablets unpalatable, however there are a number of preparations available in a drinkable or capletform and in a variety of flavours. Patients should be prescribed the equivalent of calcichew D3 forte 2 tablets daily. Tablet forms of calcium and vitamin D medications bought across the counter are rarely adequately absorbed-this is the reason that prescribed medications are available as chews or drink formulations

1) CalcichewD3 forte

chewable tablets (lemon flavoured)

1 tablet contains calcium 500mg and vitamin D 400 IU

 

2) Adcal D3

Chewable tablets (lemon or tutti frutti flavour) or effervescent tablets (lemon flavoured)

1 tablet contains calcium 600mg and vitamin D 400 IU

 

3) Cacit D3

effervescent granules (lemon flavoured)

1 sachet contains calcium 500mg and vitamin D 440 IU

 

4) Calceos

chewable tablets (lemon flavoured)

1 tablet contains calcium 500mg and vitamin D 400 IU

 

5)fovit D3

powder (lemon flavoured)

1 sachet contains calcium 1.2mg and vitamin D 800 IU

 

6)Natecal D3

chewable tablets (aniseed, peppermint and molasses flavoured)

1 tablet contains calcium 600mg and vitamin D 400 IU

 

7) Calcitriol 250mg

Cholecalciferol (vitamin D3) require hydroxylation by the kidney to the active form. In patients with severe renal impairment the hydroxylated derivative Calcitriol may be prescribed. Side effects include hypercalcaemia and monthly monitoring of calcium is required.

 

B) How do I obtain IM ergocalciferol

Sometimes we recommend IM ergocalciferol in patients where either absorption of vitamin D or compliance is an issue. IM ergocalciferol can be freely prescribed on a GP10 and obtained by community pharmacies directly from pharmaceutical wholesalers as for any other drug.

We would suggest contacting your community pharmacist to ascertain availability prior to issuing the prescription as there have been some problems with supply from the wholesalers but these appear to have been resolved.

Ergocalciferol is only available in packs of 10 at an approximate cost of 85. However, there is a system whereby the pharmacy can claim reimbursement for the full cost of the box against a prescription for only 1 dose. If there were any future prescriptions, payment would not be made for (the other 9) doses already claimed for.

The manufacturer recommends that plastic syringes should not be used to administer ergocalciferol as the bung in the syringe can swell up, making the plunger difficult to push. However, we have found no problems using plastic syringes if the ergocalciferol is drawn up and given without delay.

If pharmacies are experiencing problems obtaining IM vitamin D we suggest they go direct to the manufacturer: UCB Pharma

UCB Pharma

208 Bath Rd

Slough

Berks SL1 3WE

Tele: 01753 447544

Fax: 01753 447604

 

C) Is Denosumab suitable for use in Primary Care?

Denosumab is available and funded for use in Primary Care in Grampian after advice from a secondary care physician.