Rheumatology Advance Access published online on November 12, 2008
Rheumatology, doi:10.1093/rheumatology/ken430
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Comment on: Hypovitaminosis D among rheumatology outpatients in clinical practice: reply
1Division of Bone Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
Correspondence to:
K. Poole, Division of Bone Research, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital (Box 157), Hills Road, Cambridge CB2 2QQ, UK. E-mail: kenpoole{at}doctors.org.uk
SIR, In response to our finding of widespread hypovitaminosis D in rheumatology outpatients [1], Dr Joshi and colleagues report that a rheumatology patient with unrecognized hypovitaminosis D developed rapid life-threatening hypocalcaemia after intravenous bisphosphonates were administered [2]. Similar complications were reported elsewhere with oral [3] and intravenous bisphosphonates [4, 5]. Serial measurements of bone function tests and calciotropic hormone status in the days immediately after zoledronate infusion were not reported in the landmark HORIZON PFT trial [6] nor a large trial of the drug in Paget's disease [7]. However, in a randomized study, one of us previously identified a marked lowering of serum-corrected calcium during the 5 days after zoledronate infusion in stroke patients with baseline hypovitaminosis D (n = 15) [8]. This occurred despite the concurrent use of combined calcium/vitamin D supplements [8] and in two patients serum calcium had not recovered into the normal range by the 10th day after infusion. Together, these cases highlight the need for clinicians to fully replenish vitamin D in their patients prior to infusing potent intravenous bisphosphonates (which is now our practice in patients with Paget's disease, as well as osteoporosis). Pharmacists must ensure that all clinicians prescribing intravenous bisphosphonates have the necessary ‘tools’ to do this: namely prompt access by prescription to pharmacological (preferably oral) doses of ergocalciferol or cholecalciferol (since the ‘one dose fits all’ regimen of combined oral preparations of calcium and vitamin D is not always effective in vitamin D replenishment [9]). Finally, patients should be advised of the importance of continuing with their calcium and vitamin D supplements after intravenous bisphosphonate infusion.
Disclosure statement: The author has declared no conflicts of interest.
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- Mouyis M, Ostor AJK, Crisp AJ, et al. Hypovitaminosis D among rheumatology outpatients in clinical practice. Rheumatology (2008) 47:1348–51.
[Abstract/Free Full Text] - Joshi A, Price E, Collins D, Williamson L. Comment on: Hypovitaminosis D among rheumatology outpatients in clinical practice. Rheumatology (2008) (in press).
- Whitson HE, Lobaugh B, Lyles KW. Severe hypocalcemia following bisphosphonate treatment in a patient with Paget's disease of bone. Bone (2006) 39:954–8.
- Rosen CJ, Brown S. Severe hypocalcemia after intravenous bisphosphonate therapy in occult vitamin D deficiency. New Engl J Med (2003) 348:1503–4.
[Free Full Text] - Peter R, Mishra V, Fraser WD. Severe hypocalcaemia after being given intravenous bisphosphonate. Br Med J (2004) 328:335–6.
[Free Full Text] - Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. New Engl J Med (2007) 356:1809–22.
[Abstract/Free Full Text] - Reid IR, Miller P, Lyles K, et al. Comparison of a single infusion of zoledronic acid with risedronate for Paget's disease. New Engl J Med (2005) 353:898–908.
[Abstract/Free Full Text] - Yearly zoledronic acid in postmenopausal osteoporosis. New Engl J Med (2007) 357:711–2; author reply 714–5.
[Free Full Text] - Ryan PJ. Vitamin D therapy in clinical practice. One dose does not fit all. Int J Clin Pract (2007) 61:1894–9.[CrossRef][Web of Science][Medline]
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