77 Etidronate, however, does not reduce vertebral or non

The modest increases in BMD with increased calcium intake are smaller than observed with weak anti resorptive agents such as etidronate76 and raloxifene.77 Etidronate, however, does not reduce vertebral or non vertebral fractures, and raloxifene reduces vertebral but not non vertebral fractures.78 In contrast, potent anti resorptive agents such as alendronate, zoledronate, and denosumab increase BMD by 6 9% at the spine and 5 6% at the hip over three years.79 80 81 82 These changes are associated with reductions of 44 70% in vertebral fracture, 35 41% in hip fracture, and 15 25% in non vertebral fractures.78 The magnitude of fracture reduction predicted by the small increases in BMD we observed with increased calcium intake are also consistent with the findings of our systematic review of calcium supplements and fracture.10 We observed small (The large number of randomised controlled trials that studied increased calcium intake and BMD and the consistency of the results across different populations in studies using higher or lower doses of calcium and in studies of dietary calcium sources or calcium supplements does not reveal any obvious gaps in the evidence. Any future trials conducted should have a strong rationale as to why the results are likely to differ from the large body of existing trial evidence. It is usually recommended that anti resorptive agents are co prescribed with calcium and vitamin D, although randomised controlled trials of such agents have shown reductions in risk of fracture83 84 85 and the expected increases in BMD64 86 87 88 without the co administration of calcium and vitamin D.

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