Dear Colleagues,
As you will see in this issue, we are featuring an article by prof. Giannini relating to a “real world” Italian experience that demonstrates the utility – in terms of preventing recurring fractures and mortality – of anti-osteoporotic pharmacological treatment in patients suffering fragility fractures, especially if such treatment is associated with calcium and vitamin D supplementation. The results confirm those from the first studies coordinated by Silvano Adami, which were conducted over ten years ago: these showed that specific treatments for osteoporosis were more reliable and even more effective when combined with calcium and vitamin D.
And to think that just in the last few days we have been subjected to media messages that deny the clinical utility of vitamin D supplementation in osteoporotic patients! In my opinion, these messages do a great disservice to the patients themselves, in addition to compromising the credibility of the prescribing doctors. Moreover, such misinformation negatively affects the National Health Service (SSN), both in terms of preventable fractures and of costs for pharmacological treatments, whose effectiveness is compromised.
As I have indeed feared for some time (see my editorial in issue no. 3/4, vol. 1/2018), the uncritical and incompetent interpretation of recent meta-analyses – plagued, as we well know, by numerous biases – have led some to make erroneous conclusions, even in good faith. Specifically, these persons believe that the clinical contribution of vitamin D vis-à-vis musculoskeletal pathologies, and in particular osteoporosis, is irrelevant; they are therefore surprised that so many of the elderly suffering from this condition use these supplements. This skepticism clearly stems from unfamiliarity with the epidemiology of vitamin D deficiency and with the physiopathology of vitamin D, phospho-calcic and bone metabolism.
As is well known, epidemiology has shown a great prevalence of vitamin D deficiency in the elderly; given their physiopathology, this deficiency is justifiable and cannot be counteracted by increased exposure to sunlight, in light of the risks associated with the latter at an advanced age. Moreover, those familiar with the physiopathology of phospho-calcic and bone metabolism know that an important role is played by the frequency of vitamin D deficiency in the pathogenesis of osteoporosis in the elderly, given the related risks of secondary hyperparathyroidism and/or osteomalacia.
Now if the real aim (or prejudice) of this media campaign against vitamin D is to reduce the exorbitant expenses that we incur for vitamin D in Italy, then I am in partial agreement. Indeed I believe – as I stated in a previous editorial – that it is justifiable to attempt to reduce the present costs of vitamin D supplementation (and of monitoring its level) and even “to lower our expectations, particularly with regard to osteoporosis, by improving the suitability of the treatment…” Let me explain myself more carefully.
Lowering our expectations concerning vitamin D, in particular in treating osteoporosis, means admitting that vitamin D alone is not to be considered a suitable treatment for a developed stage of osteoporosis, especially when complicated by fragility fractures. You will certainly have noticed that over the last few years Italy has unfortunately seen a regression in the treatment of osteoporosis, in part because some doctors, for various debatable reasons, have substituted specific treatments for osteoporosis with vitamin D alone. These practitioners evidently forget that in clinical trials the former have demonstrated their clear superiority with respect to supplementation alone. It is sad and embarrassing to see patients in our clinics who believe they are receiving adequate treatment with vitamin D alone, even when they have already suffered two or three fractures!
Then again, even the guidelines of SIOMMMS [1} are not completely reassuring on this point. While stating that “… an adequate supply of calcium and vitamin D represents the necessary precondition for any specific pharmacological treatment” and that “calcium and/or vitamin D deficiency is the most common cause of a failed response to pharmacological treatment of osteoporosis,” they at the same time admit that “… the densitometric effects of vitamin D supplementation are nonetheless on average modest, proportional to the degree of deficiency; they have further only been demonstrated in relation to hip fracture. The anti-fracture effect of vitamin D is modest and has been established only for hip and non-vertebral but not vertebral fractures …”.
The other field in which I believe we can (and must) improve the suitability of treatment with vitamin D is that regarding extra-skeletal pathologies. In light of current scientific evidence, its use in these cases is in fact not always justifiable: this seems to me a valid conclusion with regard, for example, to cardiometabolic disorders. This is indeed the opinion of our colleague prof. Strazzullo, author of the other feature article of this issue. Nonetheless, as is shown by the numerous references which once again support the articles of this issue, there is increasing evidence that confirms the potential beneficial effects of correcting vitamin D deficiency in extra-skeletal contexts: among other considerations, developments in this regard justify the need for a means of keeping readers up to date, such as that provided by our Journal.
I therefore feel that it is necessary that we begin a candid debate with the Health Board Authorities on the costs and benefits of vitamin D supplementation. Otherwise, I fear that someone might “throw the baby out with the bathwater.”
What do you think?
I hope you enjoy reading this issue.