A 65-year-old woman is concerned about her risk of fracture as her mother was recently hospitalized for osteoporotic hip fracture. The patient walks her dog for a mile on most days and has no problems with balance or falling. She has a history of hypertension, hyperlipidemia, coronary artery disease, seizure disorder, and gastroesophageal reflux disease. The patient underwent menopause at age 52. She has smoked a pack of cigarettes daily for 24 years but does not drink alcohol. Weight is 56 kg (123.5 lb). Long-term use of which of the following medications may increase this patient's risk of osteoporosis and hip fracture?

Question

A 65-year-old woman is concerned about her risk of fracture as her mother was recently hospitalized for osteoporotic hip fracture.  The patient walks her dog for a mile on most days and has no problems with balance or falling.  She has a history of hypertension, hyperlipidemia, coronary artery disease, seizure disorder, and gastroesophageal reflux disease.  The patient underwent menopause at age 52.  She has smoked a pack of cigarettes daily for 24 years but does not drink alcohol.  Weight is 56 kg (123.5 lb).  Long-term use of which of the following medications may increase this patient's risk of osteoporosis and hip fracture?

Quizplus · Accepted Answer

11ec160b_3c80_383f_9249_594a8ed6b3f5_MD0001_00 Insoluble calcium (eg, calcium carbonate) requires an acidic environment for proper absorption. Strong acid-suppressing medications, such as proton pump inhibitors (eg, omeprazole), may decrease absorption of dietary calcium in the gastrointestinal tract. Long-term use of these medications is associated with an increased risk of osteoporotic fractures. The risk is greatest in older adults in whom calcium absorption is already reduced and in those with other risk factors for osteoporosis (eg, low body weight, smoking). Medications that reduce bone formation (eg, glucocorticoids) can also increase the risk of osteoporosis. Because estrogen plays an important role in bone density, medications that decrease estrogen production (eg, aromatase inhibitors, GnRH agonists) can increase osteoporosis risk. In addition, anticonvulsants that induce the cytochrome P450 system in the liver (eg, phenytoin, carbamazepine) can increase catabolism of vitamin D and lead to lower bone density. Levetiracetam does not induce the P450 enzyme system and has not been shown to negatively affect bone mineral density in adults (Choice C). (Choice A) Statins (eg, atorvastatin) do not increase the risk of osteoporosis, and some studies have noted increased bone density in patients taking these medications. (Choice B) Thiazide diuretics (eg, chlorthalidone, hydrochlorothiazide) increase reabsorption of calcium in the distal renal tubule and are associated with a small decrease in the risk of osteoporosis. (Choice D) Beta blockers (eg, metoprolol) may slightly decrease the risk of osteoporosis, possibly due to increased formation and decreased resorption of bone. (Choice E) Nitrates (eg, nitroglycerin) have been associated in some studies with increased bone density, possibly due to decreased bone turnover. Educational objective: Long-term acid suppression with proton pump inhibitors may be associated with an increased risk of osteoporotic fractures, possibly due to decreased calcium absorption. Other medications associated with an increased risk of osteoporosis include glucocorticoids, aromatase inhibitors, and anticonvulsants that induce cytochrome P450. __________ References: Update on medications with adverse skeletal effects. (http://www.ncbi.nlm.nih.gov/pubmed/21389249) Study of the association between hip fracture and acid-suppressive drug use in a UK primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/24634193) Drug-induced osteoporosis: mechanisms and clinical implications. (http://www.ncbi.nlm.nih.gov/pubmed/20920685)

A 65-Year-Old Woman Is Concerned About Her Risk of Fracture