A 74-year-old woman comes to the emergency department due to left hip pain and inability to walk after a fall. She is being treated by her primary care provider for various medical conditions including hypertension, congestive heart failure, chronic atrial fibrillation, type 2 diabetes mellitus, trigeminal neuralgia, depression, and gastroesophageal reflux disease. On examination, the left leg is shorter than the right and externally rotated. She is not able to move the left hip. An imaging study confirms acute femoral neck fracture. Her bone density, measured by quantitative x-ray densitometry, is consistent with osteoporosis. Which of the following drugs, had it been used as part of the medical regimen, would have had a beneficial effect on calcium homeostasis and reduced this patient's fracture risk?

Question

A 74-year-old woman comes to the emergency department due to left hip pain and inability to walk after a fall.  She is being treated by her primary care provider for various medical conditions including hypertension, congestive heart failure, chronic atrial fibrillation, type 2 diabetes mellitus, trigeminal neuralgia, depression, and gastroesophageal reflux disease.  On examination, the left leg is shorter than the right and externally rotated.  She is not able to move the left hip.  An imaging study confirms acute femoral neck fracture.  Her bone density, measured by quantitative x-ray densitometry, is consistent with osteoporosis.  Which of the following drugs, had it been used as part of the medical regimen, would have had a beneficial effect on calcium homeostasis and reduced this patient's fracture risk?

Quizplus · Accepted Answer

11ec160b_3c82_5b23_9249_4f92e49ab08f_MD0001_00 Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) are indicated for treatment of patients with hypertension, including those who also have diabetes mellitus. Although thiazides can cause a small increase in blood glucose, this effect is often not clinically significant and substantially outweighed by their blood pressure-lowering benefits. Thiazides inhibit the Na-Cl cotransporter in the distal convoluted tubule, leading to decreased sodium reabsorption. Thiazides also cause peripheral vasodilation, resulting in reduced peripheral vascular resistance. In addition, thiazide diuretics increase calcium reabsorption in the distal tubule. Studies have shown that use of thiazides is associated with higher bone mineral density and reduced fracture risk, and many experts recommend them for treatment of hypertension in patients who are at risk for osteoporosis. Increased calcium reabsorption also causes hypocalciuria, which may prevent recurrent renal stones in some patients. (Choice A) Several antiepileptic drugs (eg, phenytoin, carbamazepine, phenobarbital) are associated with decreased bone mineral density and increased risk of osteoporosis. (Choice B) Diltiazem is a calcium channel blocker that is indicated for treatment of hypertension. It is also used for rate control in patients with atrial fibrillation. It has no significant effect on serum calcium levels, bone density, or fracture risk. (Choice C) Escitalopram is a selective serotonin reuptake inhibitor (SSRI) indicated for treatment of depression and generalized anxiety disorder. SSRIs are associated with a small decrease in bone density; their effect on fracture risk has not been well studied. (Choice D) Furosemide is a loop diuretic used to treat congestive heart failure (CHF). It causes an increase in urinary calcium loss that may worsen osteoporosis. (Choice F) Lansoprazole is a proton pump inhibitor (PPI) used to treat gastroesophageal reflux and peptic ulcer. PPIs inhibit the enzyme H-K-ATPase on gastric parietal cells and reduce gastric acid secretion. PPIs also decrease calcium and magnesium absorption, and long-term use is associated with an increased risk of osteoporosis. (Choice G) Metformin suppresses hepatic gluconeogenesis and increases insulin sensitivity and peripheral glucose uptake. It has no significant effect on osteoporosis risk. (Choice H) Spironolactone is an aldosterone inhibitor used to treat CHF. Spironolactone can cause hyperkalemia, but it does not have a significant effect on calcium homeostasis. Educational objective: Thiazide diuretics increase calcium absorption in the distal convoluted tubules within the nephron. Thiazides are associated with increased bone mineral density and are recommended for treatment of hypertension in patients at risk for osteoporosis. Loop diuretics increase urinary calcium loss. __________ References: 7B.10: Thiazide diuretics and fracture-risk among hypertensive patients. Results from the Swedish primary care cardiovascular database (SPCCD). (http://www.ncbi.nlm.nih.gov/pubmed/26102978)

A 74-Year-Old Woman Comes to the Emergency Department Due to Left