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Frequently asked questions

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Yes. Although a few studies have raised questions on the subject, there are no known contraindications. It should be mentioned that studies that have associated cardiovascular diseases with calcium intake were highly criticized for reason for a lack of statistical validity and solid database. In fact, most published studies are meta-analysis that used research which main goal was not to measure cardiovascular risk. However, comprehensive epidemiological studies have not found any association. One of them, taken from the Nurse Health Study, has observed the calcium intake of nearly 25,000 women over a period of 25 years. This study has not shown any relationship between the intake of supplements and the risk of CV or stroke. (See Calcium Supplement Intake and risk of cardiovascular disease in women, Osteoporosis International, May 2014.)

Yes, there are many interactions. Most of these products should be taken four (4) hours apart (before and after):
Levothyroxine

– Iron

– Antibiotics (quinolones, ciprofloxacin or Cipro, levofloxacin, norfloxacin or Noroxin and ofloxacin). Tetracyclines: doxycycline, minocycline and tetracycline.

-Antiepileptic drug, phenytoin (Dilantin), carbamazepine, phenobarbitol and primidone

-Bisphosphonates: intake at least 30 minutes apart, preferably more.

Because measuring serum concentrations of 25-OH vitamin D is costly (generally $12.00 to $15.00), it is not recommended in all patients. As you will soon see the notice on the vitamin D level result sheets that you will require, it is not recommended to measure vitamin D levels in all patients. Since most North Americans suffer from vitamin D deficiency and that supplementation is cost-effective, it is preferable to supplement everyone in vitamin D. Serum concentration of 25-OH vitamin D should be measured only in patients with specific problems (i.e. hyperparathyroidism, osteoporosis, bariatric surgery, etc.) following a three-month supplementation regimen.

To have an effect at the bone level, the target level of 25-OH D is set at 75 nmol/L, and most experts will maintain it below 125 nmol/L.

Since the Mantra Pharma launch of the combined elemental calcium 500 mg and 1000 UI of vitamin D, there is no reason to give vitamin D separately (except in certain cases).

No, as requirements vary according to age and diseases, but it appears that they also differ according to race. Certain studies seem to indicate that people of Asian descent have a lower requirement than that of Caucasians, and people of African descent have a higher requirement. However, because of a lack of large-scale studies to confirm these statistics, and in the interest of simplification, the recommended intake is the same for all (with some adjustments according to age).

ALL MCal calcium supplements are reimbursed by the RAMQ.

MCAL D400, MCAL D800, MCAL D1000 calcium carbonate and chewable MCAL D400 and MCAL D1000 are reimbursed by the RAMQ system.

As for Liquid MCal Citrate, it is processed and reimbursed like exceptional medications by using the VA-138 code.

MCal tablets are formulated to be as brittle as possible. This formula does not depend in any way on the type of calcium used, but rather on the manufacturing methods. Mantra Pharma uses as few binding agents as possible (which allows to form the calcium in a tablet). This way, tablets dissolve faster once in the stomach. As the first limiting step for proper calcium absorption is the dissolution and solubilization, MCal tablets are generally better tolerated than most tablets on the market. It is, however, very important to ensure tablet intake with food to maximize dissolution of the calcium and its absorption.

Patients who do not tolerate calcium carbonate very well may turn to the new Liquid MCal Citrate formulation. Because citrate offers a more efficient solubility than calcium, not only it is generally better tolerated, but also better absorbed.

If your patient has a poor dietary calcium intake, the use of a supplement can be an « insurance policy » to maximize the chances that the bones obtain all they need to ensure healthy development. Because the bone metabolism is one of the slowest system of the human body, the effects are not immediate. Considering that it takes nearly 10 years for the body to form the quantity of bones of a human skeleton, we understand why it is difficult to conduct a study long enough to provide proper assessment. What’s more, there are several other parameters which should be monitored in the studies that are difficult to control (vitamin D, exercise, protein intake, salt). However, experts agree to say that supplementation to compensate for loss of calcium is a step that can easily be taken to optimize bone remodeling.

Throughout their lives, all human beings should optimize their calcium intake. As for children and teenagers, a supplement would allow for optimal formation of the “bone capital” and for adults, it would reduce the net loss of the bone density. In Canada, calcium intake is highly promoted, especially after the age of 50 because of the increased risk of osteoporosis and fractures after that age. It is therefore some kind of last-minute prevention. A lifelong adequate intake of calcium is the best way to ensure optimal bone health and reduce the risk of fractures when aging.

CALCIUM INTAKE OF CANADIANS

Age Recommended daily intake Percentage of Canadians with a lack of calcium in their diet
1-3 years 700 mg 3%

 

4-8 years 1000 mg 23%

 

9-18 years 1300 mg Boys: 33 % to 44%

Girls: 67% to 70%

Adults 1000 -1200 mg Men: 26% to 80%, according to the age group

Women: 48% to 87%, according to the age group

The North American population often lacks in vitamin D, and to ensure optimal bone formation, vitamin D alone cannot optimize the bone metabolism. In fact, because most people do not consume enough calcium, calcium will often be the limiting element, even with an optimal vitamin D. Let’s not forget what osteoblasts set on the collagen matrix to form the bone; it is the calcium. Vitamin D is a very important vector to maximize bone absorption (and possibly the binding) but is not what “composes” the bone?

The estimated requirement is 1000 mg (19-49 years) and 1200 mg (+50 years). To date, there is no difference in calcium requirements between men and women. If your patient consumes more than three (3) portions of milk products daily, it is therefore unnecessary to supplement. In most people, calcium intake of more than 1000-1200 mg will not be absorbed at the intestine level or may eventually be excreted through the kidneys.

As most North Americans do not consume enough calcium to meet sufficient requirements and optimize the bone formation, many people will need to take daily calcium supplements.

Yes. In certain cases, some of your patients may need more calcium than average. This is often the case in patients who suffer from malabsorption syndromes and bariatric surgery patients. A PTH that is above the normal level with a normalized 25-OH vitamin D and normal renal function may be an indication of insufficient calcium absorption.

Calcium requirements are the same for everyone. To provide enough calcium for most patients to absorb enough and allow the osteoblast to bind enough calcium to bone matrix, one should consume 1200 mg daily (+50 years) elemental calcium. Requirements for a patient who suffers from osteoporosis is therefore generally the same. However, it is even more important for these patients to maximize their intake to slow down the reduction of the bone density. In cases of patients under treatment, it is particularly important to have maximum intake since there is a need to maximize the bone formation with a sufficient calcium intake, while ensuring that the calcium intake is adequate to prevent any potential risk of hypocalcemia. As osteoporosis medication reduces bone resorption, less calcium coming from the bone end up in the bloodstream. This is particularly important for high-efficiency products, such as denosumab. In certain cases, your patient may need a calcium intake that exceeds general recommendations.