Nonpharmacologic Therapy and Calcium/Vitamin d Supplements

The use of nonpharmacologic therapy, such as diet, exercise, and vitamin supplements, is essential in preventing and treating osteoporosis. Women should consume a high intake of foods rich in calcium (e.g., low-fat dairy products) and vitamin D. Fortified milk, orange juice, cereals, and fish are examples of foods high in vitamin D. Exposure to sunlight, approximately 15 minutes daily, increases vitamin D synthesis in the body, leading to increased concentrations.⁷ Women with osteoporosis need to include at least 30 minutes of either aerobic or weight-bearing and muscle-strengthening exercise three times per week in their routine. Additionally, other modifiable risk factors need to be evaluated, such as smoking cessation, reducing alcohol intake, and incorporating vegetables and fruits into a daily diet.² Fall prevention is equally important. The risk of falls can be minimized by regularly monitoring vision and hearing, clearing indoor and outdoor walkways, and limiting the use of medications that can affect balance, such as sedatives, anticholinergics, benzodiazepines, tricyclic antidepressants, and antihypertensives that cause hypotension.⁷ 

The NOF recommends at least 1,200 mg elemental calcium/day for postmenopausal women over 50 years of age and 800 to 1,000 IU/day for vitamin D in women 50 years of age and older.² In addition, on November 30, 2010, the Institute of Medicine (IOM) released recommendations for the appropriate amount of calcium and vitamin D intake.¹⁸ The recommendations, which are based on data from more than 1,000 studies, concluded that appropriate levels of vitamin D and calcium are essential for bone growth and development. However, these supplements have no impact on other disease states, such as cancer, cardiovascular disease, or diabetes.

The amount of daily calcium required is based on the quantity of elemental calcium in each product. Maximal absorption of calcium occurs at 500 to 600 mg per dose.¹ Calcium supplementation should be divided throughout the day, usually twice daily, to achieve maximal absorption. Each OTC product has varying amounts of calcium and vitamin D. In general, calcium carbonate products have a higher percentage of elemental calcium (TABLE 7).¹⁹ Common side effects are constipation, bloating, and flatulence. These products should be separated from certain medications such as iron, tetracyclines, and fluoroquinolones, because they can interfere with absorption.⁷

Conclusion and the Pharmacist’s Role

The best way to treat osteoporosis is to prevent its occurrence. Modification of risk factors is imperative, and pharmacists can play a large role in this area. Pharmacists can counsel patients—especially women, who are at an increased risk for osteoporosis—to increase their intake of foods and drinks rich in calcium and vitamin D; offer strategies to quit smoking; encourage 30 minutes of weight-bearing and muscle-strengthening exercise at least three times per week; and, most importantly, recommend appropriate calcium and vitamin D supplementation and any required prescription medications for osteoporosis. Pharmacists can determine the best therapeutic option for patients based on efficacy, tolerable adverse effects, contraindications, and medication adherence. Patients require counseling on proper dosing, administration, and adverse effects to promote the safe use and monitoring of medications for osteoporosis. Medication adherence and monitoring of BMD by central DXA is critical to reduce fracture risk and progression of osteoporosis. Refer to for useful online resources for patients and pharmacists regarding osteoporosis management.