1. Sarah Gilfillan, PharmDKelly L. Scolaro, PharmD sarahegil@gmail.comkelly_scolaro@unc.edu

2.  After the lecture, students will be able to:  Assess a patient’s dietary intake of calcium  Understand when to recommend Calcium citrate over Calcium Carbonate  Appropriately counsel a post-menopausal women on recommended calcium intake from diet and supplementation

3.  Low estrogen levels  Increase in bone resorption  Decrease in GI absorption efficiency  Decrease in renal conservation

4.  Elemental Calcium > 1200mg/day  Vitamin D: 800 – 1000 IU/day  25(OH)D level > 30ng/mL  Include calcium and vitamin D in addition to pharmacotherapy (ex. Bisphosphonates)

5.  Calcium intake > 2500mg/day  may increase risk of hypercalcemia and renal impairment  Impair absorption of other minerals (iron, zinc, magnesium, phosphorus)

6. FoodCalcium Milk300mg Low fat yogurt400mg Collard greens300mg Soy milk80-300mg Calcium-fortified CerealUp to 1000mg Calcium-fortified Fruit Juice200-300mg Breakfast bars200-500mg Assess dietary intake before supplementing with calcium Food is the preferred source because often contains other important nutrients

7.  Information about bioavailability is not on the label  Calcium absorption is not the same as milk  In tests, the calcium in soy beverages separated into particulate form (80-90%)  Orange juice performed better at 8-50%  Only 11% of calcium in cow’s milk separates out

8.  Bioavailability  Use of antacids  Number of tablets needed for desired dose  Size of the tablets  Cost

9. Salt % of elemental Calcium Solubility Carbonate40%Insoluble Citrate21%Soluble Phosphate23-29%Insoluble Lactate18%Soluble Gluconate9%Soluble

10. CARBONATE  Most common  Least expensive  Relatively insoluble at high gastric pH  Must enter solution to be absorbed  Well absorbed when taken with meals CITRATE  More expensive (more tablets)  Recommended for:  Use with H2 Blockers or PPIs  Calcium supplement w/o meal

11.  Became popular due to infomercials claiming health benefits due to high concentration in water  Treat or cure cancer, multiple sclerosis, etc  Is simply calcium carbonate  In 2003 a study showed the health of the Okinawans was due to lifestyle  Coral Calcium products may contain excess lead

12.  Constipation  Differentiate from lack of fluid or fiber in diet  Gas  Bloating

13.  Levothyroxine  Separate by 4 hours  Tetracyclines and Quinolones  Take 2 hours before or 4 hours after calcium

14.  Absorption increases from 200mg to 500mg, but does not continue to increase after that  No additional benefit of 1000mg at a time compared to 500mg

16.  Requirements increase with age  Decreased synthesis in the skin  Decreased renal conversion to active form  Intestine less responsive to its effects  Recommendation for adults > 50  800-1000 IU/day

17.  5 – 15 minutes on arms and legs between 10am and 3pm 2-3 times per week  For fair-skinned individuals  Darker skin tones need 5 t0 10 times longer exposure  Wearing SPF 8 or more reduces ability to produce vitamin D by 95%  Lots of research and controversy in this area right now

18.  D2 (ergocalciferol)  Brand: Drisdol ▪ OTC liquid drops ▪ Rx capsules: 50,000 IU  D3 (cholescalciferol)  Multiple strengths and brands OTC  Better at raising and maintaining vitamin D levels  Rocaltrol (calcitriol)  Active form of Vitamin D  Only Rx  Recommended in advanced renal disease

19.  Becoming more popular for bone health  Possibly promotes bone formation and reduces calcium excretion  Warfarin patients:  Do not have to avoid as long as taking the supplement consistently  Monitor INR when stop or start  Ex. Viactiv

20.  Deficiency may increase activity of osteoclasts  Does not improve calcium absorption  Laxative effect may help with constipation associated with calcium supplements

21.  Recent studies suggest NO association with total or non-advanced prostate cancer  But, higher risk of advanced and fatal prostate cancer  Possible mechanism  High calcium levels suppresses vitamin D synthesis  Vitamin D may protect against prostate cancer  No supplementation recommended for men with calcium-rich diet

22. Average 300mg/day from diet (non-dairy sources) 300mg 2 servings of dairy or high-calcium foods600mg Calcium supplement or 3 rd serving of dairy300mg Daily Total1200mg

23. http://www.usp.org/USPVerified/dietarySupplements/