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Guidelines for Assessing, Preventing and Treating Low Bone Density in HIV

June/July 2015

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The Importance of Vitamin D

Vitamin D helps people absorb calcium from their diet and has an important impact on bone and muscle health. Furthermore, many medicines used to treat osteoporosis work best when vitamin D levels in the blood are at least 75 nmol/L. The team stated that it is important for patients to achieve the target level of vitamin D (in their blood) before therapy for low bone density is prescribed.


Vitamin D Dosing

When a patient's blood concentration of vitamin D is greater than 75 nmol/L, the team says that 1,000 IU/day of vitamin D3 should be sufficient to maintain this concentration.

For patients whose blood levels are between 50 and 70 nmol/L, the team says that 2,000 IU/day of vitamin D3 should help to raise these levels to the target of approximately 75 nmol/L. However, the team notes that doctors may need to "consider a more aggressive replacement strategy" if patients have any of the following conditions or features:

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  • hyperparathyroidism
  • osteomalacia
  • malabsorption
  • obesity
  • taking medicines that affect the production of vitamin D

Higher doses of vitamin D need to be considered because patients with any of these conditions may take longer to reach the target concentration of 75 nmol/L of vitamin D in their blood.

For patients whose blood levels are between 37.5 and 50 nmol/L, the team recommends higher doses, such as the following:

  • 50,000 IU/week of vitamin D2 or D3 for between eight and 12 consecutive weeks (or "the equivalent of 6,000 IU/day of vitamin D3").

Again, the team cautions that doctors may need to "consider a more aggressive replacement strategy" if patients have any of the previously listed conditions or features.


A Checklist

Prior to initiating therapy for low bone density, the team encourages doctors to screen their patients for potential causes of low bone density, including the following:

  • low levels of vitamin D in the blood
  • elevated levels of parathyroid hormone in the blood
  • higher-than-normal levels of thyroid hormone in the blood
  • lower-than-normal levels of testosterone in both men and women
  • Cushing syndrome (a disorder where the body produces too much of the hormone cortisol)
  • kidney disorders
  • some cancers
  • some gastrointestinal disorders

For more information about vitamin D, its forms, sources and recommendations by specialists, see Treatment Update 185.

A future issue of TreatmentUpdate will have more information on vitamin D.

Additionally, the team asks doctors to avoid prescribing certain medicines that are associated with thinning bones, such as the following, "if appropriate alternatives are available":

  • anti-seizure drugs
  • proton pump inhibitors (used to reduce stomach acidity)
  • certain antidiabetic drugs called glitazones
  • corticosteroids


Specific Therapy for Low Bone Density

The team recommends one of the following medicines for treating low bone density:

  • alendronate (Fosamax, Fosavance) -- 70 mg once weekly by mouth, accompanied by calcium carbonate 1,000 mg/day and vitamin D3 400 IU/day
  • zoledronic acid (Aclasta, Zometa) -- 5 mg administered intravenously once yearly

The team states that treatment with these drugs needs to be individualized; that is, treatment should be reviewed after the first three to five years of administration. The reasons for this period of reassessment are to assess changes in bone density and fracture risk and to screen for the possibility of rare side effects such as osteonecrosis of the jaw and fracture of the thigh bone. For more information about these potential side effects, see Understanding the risk/benefit of bone drugs.

There are other medicines that could be used for the therapy of osteopenia or osteoporosis; however, the team did not provide detailed recommendations about them.


Effectiveness

The team mentions several ways to assess whether therapy has been successful (these assessments have been validated with thousands of HIV-negative people):

  • lack of new fractures or signs/symptoms of new fractures
  • maintaining height (less than a 1-cm decrease)
  • either no decrease or an increase in bone density in the hip and spine when assessed by DEXA scans
  • reduction in the level of proteins in the blood or urine that are associated with thinning bones (these may only be available from research laboratories)

If the recommended therapies do not work, the team suggests that doctors refer patients to a specialist.


References

  1. Brown TT, Hoy J, Borderi M, et al. Recommendations for evaluation and management of bone disease in HIV. Clinical Infectious Diseases. 2015 Apr 15;60(8):1242-51.
  2. Hileman CO, Labbato DE, Storer NJ, et al. Is bone loss linked to chronic inflammation in antiretroviral-naive HIV-infected adults? A 48-week matched cohort study. AIDS. 2014 Jul 31;28(12):1759-67.
  3. Kooij KW, Wit FW, Bisschop PH, et al. Low bone mineral density in patients with well-suppressed HIV infection: association with body weight, smoking, and prior advanced HIV disease. Journal of Infectious Diseases. 2015 Feb 15;211(4):539-48.
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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication TreatmentUpdate. Visit CATIE's Web site to find out more about their activities, publications and services.
 

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