Metabolic effects of thiazide and 1,25-(OH)₂ vitamin D in postmenopausal osteoporosis

It was previously shown that the stimulation of intestinal calcium absorption by exogenous 25-hydroxyvitamin D (25-OHD) in postmenopausal women with osteoporosis was attenuated when thiazide was added, probably due to the suppression of endogenous synthesis of 1,25-(OH)₂ vitamin D (1,25-(OH)₂D). To test whether the above attenuation could be averted if exogenous 1,25-(OH)₂D replaced 25-OHD, 10 women with postmenopausal osteoporosis participated in a three-phase study comprising control (pretreatment), treatment with 1,25-(OH)₂D 0.5 μg/day for 4 weeks, and combined 1,25-(OH)₂D and trichlormethiazide (TZ) 2 mg/day for 4 weeks. The 1,25-(OH)₂D treatment significantly increased serum 1,25-(OH)₂D from 60±7.2 (SD) to 154±48 pmol/1, fractional intestinal calcium absorption (α) from 0.386 ±0.055 to 0.613±0.081, and urinary calcium from 3.7±0.8 to 6.6±1.9 mmol/day. Addition of TZ significantly reduced urinary calcium from 6.6±1.9 to 4.8±1.3 mmol/day, without changing α (0.613±0.081 to 0.584±0.070), serum calcium or 1,25-(OH)₂D (154±48 to 154±38 pmol/1). Thus, estimated calcium balance (absorbed minus urinary calcium, increased marginally to +5.6 mmol/day on 1,25-(OH)₂D alone (p=0.028) and significantly to +6.8 mmol/day on 1,25-(OH)₂D+TZ, from the control value of +4.0 mmol/day. Seven patients who were treated long-term with combined 1,25-(OH)₂D and TZ for 11-29 months maintained their a (0.593±0.099) and a marginally more positive estimated calcium balance (+6.4 mmol/day, p=0.025 from the control phase). Moreover, there was a stability of bone density of radial shaft, femoral neck, and lumbar spine. In conclusion, when exogenous 1,25-(OH)₂D is provided, TZ does not lower serum 1,25-(OH)₂D and α in patients with postmenopausal osteoporosis. Thus, the hypocalciuric action of TZ may lead to improved calcium balance and may potentially attenuate further bone loss.