Dr. Adrian Lau, Dr. Rowena Ridout, Dr. Claudia Gagnon, Dr. Zahra Bardai, and Dr. Emma Billington.
Recommendations from Osteoporosis Canada Rapid Response Team.

What is a safe amount of alcohol intake? 

The Canadian Centre on Substance Use and Addiction (CCSA) published “Canada’s Guidance on Alcohol and Health: Final Report” in January 2023.  These new 2023 guidelines tell us that there is a continuum of risk for alcohol-related harms.  For healthy individuals, the risk is low with 2 drinks per week, moderate with 3-6 drinks per week, and increasingly high with more than 6 drinks per week.

Previously, Canada’s 2011 “Low-Risk Alcohol Drinking Guidelines” recommended that to reduce our long-term health risks, women should have less than 10 drinks* per week, and men should have less than 15 drinks per week.

How does that relate to my bone health?

CCSA’s new guidelines do not specifically address the relationship between alcohol intake and fractures or osteoporosis. 

Osteoporosis Canada’s guidance with regards to alcohol states: “Research shows an increased risk of osteoporosis for those who regularly consume 3 or more alcoholic drinks per day.  Increased alcohol intake also contributes to increased risk for falls and is often associated with poor nutrition.” (https://osteoporosis.ca/risk-factors/)

Research shows that fracture risk is increased with having 3 or more alcoholic drinks per day.  However, at this time, there are no studies available that provide information on whether lower alcohol intake (2 drinks per week or less), results in a reduced fracture risk.  The relationship between alcohol intake and bone density or osteoporosis is unclear.

What should I do?

Even though an increased risk of fractures was not seen with 2 drinks per day (or 14 drinks per week), we recommend that you discuss these new 2023 CCSA recommendations with your physician to reduce your risk of alcohol-related consequences.

* Note: In Canada, a standard drink is:

·     A bottle of beer (12 oz., 341 ml, 5% alcohol)

·     A bottle of cider (12 oz., 341 ml, 5% alcohol)

·     A glass of wine (5 oz., 142 ml, 12% alcohol)

·     A shot glass of spirits (1.5 oz., 43 ml, 40% alcohol)

Dr. Adrian Lau, Dr. Rowena Ridout, Dr. Claudia Gagnon, Dr. Zahra Bardai, and Dr. Emma Billington.
Recommendations from Osteoporosis Canada Rapid Response Team.

The Canadian Centre on Substance Use and Addiction (CCSA) recently published “Canada’s Guidance on Alcohol and Health: Final Report” (1). 

The key points from CCSA’s guidelines, published in January 2023, are:

• Among healthy individuals, there is a continuum of risk for alcohol-related harms where the risk is:
  • Negligible to low for individuals who consume two standard drinks (see note) or less per week;
  • Moderate for those who consume between three and six standard drinks per week; and
  • Increasingly high for those who consume more than six standard drinks per week.

The 2023 guidelines are an update to the 2011 “Low-Risk Alcohol Drinking Guidelines” (2), which previously recommended:

• Reduce your long-term health risks by drinking no more than:
  • 10 drinks a week for women, with no more than 2 drinks a day most days
  • 15 drinks a week for men, with no more than 3 drinks a day most days

Osteoporosis Canada’s guidance with regards to alcohol was in line with CCSA’s 2011 guidelines.  It states, “Research shows an increased risk of osteoporosis for those who regularly consume 3 or more alcoholic drinks per day.  Increased alcohol intake also contributes to increased risk for falls and is often associated with poor nutrition.” (3)

This recommendation stemmed from the results of a study by Kanis et. al. in 2005 (4), which analyzed the results of three prospective cohorts, including The Canadian Multicentre Osteoporosis Study (CaMOS).  It observed that there was no significant increase in the risk of osteoporotic or hip fractures when daily alcohol intake was 2 units or less.   At this time, there are no studies available that provide any information on whether lower alcohol intake (2 drinks per week or less), results in a reduced fracture risk.  The Fracture Risk Assessment Tool (FRAX) (5), a commonly used tool in clinical practice endorsed by Osteoporosis Canada (6,7), considers daily alcohol consumption of 3 or more units to be a risk factor for fractures, as its modelling is based on data from Kanis et. al. (4).  

The association between alcohol intake and bone density or osteoporosis is less clear.  A meta-analysis by Godos et. al.(8), showed that consumption of up to two drinks per day was correlated with higher lumbar and femoral neck bone mineral density (BMD) values, while up to one drink was correlated with higher hip BMD compared to no alcohol consumption.  On the other hand, a meta-analysis by Cheraghi et. al. (9) found that those consuming 0.5 to 1 alcoholic beverages per day had 1.38 times the risk of developing osteoporosis, while those consuming 1 to 2 per day had 1.34 times the risk of developing osteoporosis.  Certainly, there are limitations of meta-analyses of observational studies.  As well, BMD alone may not be the best indicator of overall bone health.

Although CCSA’s new guidelines (1) suggest that consuming more than 2 alcoholic drinks per week is associated with an increased risk of alcohol-related consequences, they did not specifically address the amount of alcohol intake that is associated with fractures or other bone-related consequences.  Their research found that 3 to 6 standard drinks per week was associated with an increased risk of several types of cancer, while 7 or more was associated with an increased risk of heart disease or stroke.

Even though an increased risk of fractures was not seen with 2 drinks per day (or 14 drinks per week), we recommend that individuals discuss the new 2023 CCSA recommendations with their physicians, to review their targets on alcohol consumption to reduce the risk of alcohol-related consequences.

Note: In Canada (10), a standard drink is 17.05 millilitres or 13.45 grams of pure alcohol, which is the equivalent of:

·     A bottle of beer (12 oz., 341 ml, 5% alcohol)

·     A bottle of cider (12 oz., 341 ml, 5% alcohol)

·     A glass of wine (5 oz., 142 ml, 12% alcohol)

·     A shot glass of spirits (1.5 oz., 43 ml, 40% alcohol)

References:

1. Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A. et. al.  The Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. (2023). Canada’s Guidance on Alcohol and Health: Final Report. Ottawa, Ont.: Canadian Centre on Substance Use and Addiction.
2. Butt, P., Beirness, D., Gliksman, L., Paradis, C., & Stockwell, T. (2011). Alcohol and health in Canada: A summary of evidence and guidelines for low-risk drinking. Ottawa, Ont.: Canadian Centre on Substance Abuse.
3. https://osteoporosis.ca/risk-factors/
4. Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H & Tenenhouse A.  Alcohol intake as a risk factor for fracture.  (2005). Osteoporosis International.  16: 737–742
5. https://frax.shef.ac.uk/FRAX/index.aspx
6. Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. (2010). CMAJ. 182:1864–73.
7. Lentle B, Cheung AM, Hanley DA, et al. Osteoporosis Canada 2010 Guidelines for the Assessment of Fracture Risk.  (2011). Can Assoc Radiol J. 62(4): 243–250.
8. Godos J, Giampieri F, Chisari E, Micek A, Paladino N, Forbes-Hernández TY, Quiles JL, Battino M, La Vignera S, Musumeci G, et al.  Alcohol Consumption, Bone Mineral Density, and Risk of Osteoporotic Fractures: A Dose–Response Meta-Analysis. (2022). International Journal of Environmental Research and Public Health. 19:1515.
9. Cheraghia Z, Doosti-Iranib A, Almasi-Hashianid A, Baigie V, Mansourniaf N, Etminang M, Mansourniah MA.  The effect of alcohol on osteoporosis: A systematic review and meta-analysis.  (2019). Drug and Alcohol Dependence. 197:197-202.
10. https://www.canada.ca/en/health-canada/services/substance-use/alcohol/low-risk-alcohol-drinking-guidelines.html

Recommendations from Osteoporosis Canada Rapid Response Team

We are aware of the recent study by Dr. Meryl Leboff that concluded vitamin D3 supplementation of 2000 IU daily does not significantly lower the risk of fractures among generally healthy midlife and older adults. It is important to note that the study’s results and recommendations do not apply to individuals who have osteoporosis, previous fragility fractures or are at risk of severe vitamin D deficiency.

Osteoporosis Canada encourages individuals with osteoporosis to continue taking their current vitamin D supplementation.  Vitamin D helps build stronger bones by increasing the absorption of calcium. It also improves the function of muscles, which can improve your balance and decrease the likelihood of falling and suffering a fracture.

If you have osteoporosis, discuss your vitamin D requirements with your health care professionals before making any changes to your routine.

Dr. Adrian Lau, Dr. Rowena Ridout, Dr. Claudia Gagnon, Dr. Zahra Bardai, Dr. Emma Billington and Dr. Wendy Ward.

Recommendations from Osteoporosis Canada Rapid Response Team.

LeBoff and colleagues (1) recently published the results of an ancillary study of the Vitamin D and Omega-3 Trial (VITAL), concluding that Vitamin D3 supplementation of 2000 IU daily did not result in a significantly lower risk of fractures than placebo among generally healthy midlife and older adults.

In an editorial in response to these results, Cummings and Rosen (2) suggest that “providers should stop screening for 25-hydroxyvitamin D levels or recommending vitamin D supplements, and people should stop taking vitamin D supplements to prevent major diseases or extend life”.

These articles have raised concerns in the osteoporosis community, amongst health care professionals, patients, and caregivers.  Should patients with osteoporosis or previous fragility fractures continue their vitamin D3 supplementation?  Should their vitamin D levels be checked?

An individual’s medical risk of conditions in which vitamin D monitoring and supplementation may be of benefit should be carefully evaluated.

It is important to note that the participants in this study were representative of the general American population and thus results and recommendations may or may not be applicable to patients with osteoporosis, previous fractures, or those at risk of severe vitamin D deficiency.  At baseline, only about 10% of the study participants had previous fragility fractures, and less than 5% were on osteoporosis medications.    

About 42% of participants were already on vitamin D supplementation prior to the initiation of the study.  If participants were randomized to the placebo group (as opposed to the vitamin D 2000 IU group), they were allowed to continue their vitamin D supplementation, up to 800 IU daily.  Of note, the baseline 25-hydroxyvitamin D level of participants was 30 ng/ml, or 75 nmol/L, which is in target as per our current guidelines.  While vitamin D was not shown to prevent fractures in this study group, this effect of vitamin D supplementation cannot be generalized to patients with osteoporosis given their higher risk of fractures.

What should we do about Vitamin D testing?

The screening of 25-hydroxyvitamin D levels in the general population is currently not recommended (3).  However, there may be specific situations where vitamin D testing may be of clinical use.  These include patients with co-morbidities which affect vitamin D absorption and metabolism, where testing may help identify significantly low 25-hydroxyvitamin D levels, and facilitate correct dosing of vitamin D supplementation.  These co-morbidities include malabsorptive disease, renal disease, living in institutionalized settings, and taking certain medications which may affect vitamin D metabolism.  Screening lab tests may also be useful prior to the initiation of anti-resorptive agents for osteoporosis, as low 25-hydroxyvitamin D levels may be a risk factor for hypocalcemia.

What should we do about Vitamin D supplementation?

We encourage our patients with osteoporosis to continue with their current vitamin D supplementation, as per the current Osteoporosis Canada Guidelines (4), and according to their personal clinical needs.  As few foods contain vitamin D, Health Canada recommends that all Canadians over age 50 take 400 IU of vitamin D per day (5).  Also, most pharmacotherapy trials provided participants with a minimum of 400 IU of vitamin D per day.  Patients should discuss their vitamin D requirements with their health care professionals before making any changes to their routines.

References

1. LeBoff MS, Chou SH, Ratliff KA, Cook NR, Khurana B, Kim E, Cawthon PM, Bauer DC, Black D, Gallagher JC, Lee I, Buring JE, Manson JE.  Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults.  New England Journal of Medicine. 2022;387(4):299-309.
2. Cummings SR and Rosen C. VITAL Findings — A Decisive Verdict on Vitamin D Supplementation.  New England Journal of Medicine.  2022;387(4):368-370.
3. Lindblad AJ, Garrison S, McCormack J.  Testing vitamin D levels.  Canadian Family Physician. 2014;60(4):351.
4. Papaioannou A, Morin S, Cheung AM, Atkinson S, Brown JP, Feldman S, David A. Hanley DA, Hodsman A, Jamal SA, Kaiser SM, Kvern B, Siminoski D, Leslie WD.  2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary.  CMAJ.  2010;182(17):1864-1873.
5. https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/vitamins-minerals/vitamin-calcium-updated-dietary-reference-intakes-nutrition.html

Dr. Aliya Khan, Dr. Heather Frame, Dr. Claudia Gagnon, Dr. Rowena Ridout, Dr. Lianne Tile and Dr. Sandra Kim

Recommendations from Osteoporosis Canada Rapid Response Team

Osteoporosis is a chronic condition which requires consistent pharmacologic intervention. There is currently no evidence that osteoporosis therapy increases the risk or the severity of COVID-19 infections. With the exception of bisphosphonates, which have long-term skeletal retention, cessation of osteoporosis drug therapy is associated with bone loss and an increased risk of fracture (1, 2). Thus it is important to not stop osteoporosis therapy or delay the dose of medication without consulting your physician.

The COVID -19 vaccine is given intramuscularly and may result in a mild flu like reaction as well as a local injection site reaction. This has been documented with both the adenovirus vector-based vaccine as well as the mRNA-based vaccine (3, 4). Since intravenous zoledronate or injected denosumab or romosozumab medications may also result in a flu like reaction or local injection site reaction, it is advisable that these medications not be administered at the same time as the COVID-19 vaccine. An interval of one week between infusion of the intravenous bisphosphonate zoledronate and COVID-19 vaccination is recommended. An interval of 4-7 days between subcutaneous administration of denosumab or romosozumab and the COVID-19 vaccination is recommended. As teriparatide is administered daily subcutaneously, it can be continued if it is well tolerated and has not resulted in any local injection site reactions. Osteoporosis Canada recommends administration of teriparatide in the abdominal wall or the thigh and not in the same location as the COVID-19 vaccine. Oral bisphosphonates and raloxifene can be continued without any delay in their administration. These recommendations are consistent with the joint recommendations made by the ASMBR, AACE, Endocrine Society, ECTS, IOF and NOF.

Osteoporosis Canada emphasizes the importance of close adherence to the dosing regimens of all osteoporosis medications to ensure optimal skeletal health.

References:

1. Tsourdi E, Zillikens MC, Meier C, et al. Fracture risk and management of discontinuation of denosumab therapy: a systematic review and position statement by ECTS. J Clin Endocrinol Metab. 2020; doi: 10.1210/clinem/dgaa756 [Epub ahead of print)
2. Napoli N, Elderkin AL, Kiel DP, Khosla S. Managing fragility fractures during the COVID-19 pandemic. Nat Rev Endocrinol. 2020;16(9):467-8.
3. Zhu FC, Li YH, Guan XH, et al. Safety, tolerability, and immunogenicity of a recombinant adenovirus type-5 vectored COVID-19 vaccine: a dose-escalation, open-label, non-randomised, first-in-human trial. Lancet. 2020;395(10240):1845-54.
4. Baden LR, El Sahly HM, Essink B, et al. Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine. N Engl J Med. 2021;384(5):403-16.