A 75-year-old woman comes to the office due to a compression fracture of her tenth thoracic vertebra after slipping in the bathtub. Her medical history is notable for hypertension, hyperlipidemia, type 2 diabetes mellitus, gastroesophageal reflux disease, and stage 4 chronic kidney disease. The patient is compliant with all of her medications, including calcium and vitamin D supplementation.
Laboratory results are as follows:
DXA shows a T-score of −2.0 at the lumbar spine and −1.8 at the femoral neck.
In addition to continuing vitamin D and calcium supplementation, which of the following is the best therapeutic option to decrease this patient's risk of future fractures?

Question

A 75-year-old woman comes to the office due to a compression fracture of her tenth thoracic vertebra after slipping in the bathtub.  Her medical history is notable for hypertension, hyperlipidemia, type 2 diabetes mellitus, gastroesophageal reflux disease, and stage 4 chronic kidney disease.  The patient is compliant with all of her medications, including calcium and vitamin D supplementation.
Laboratory results are as follows:
 DXA shows a T-score of −2.0 at the lumbar spine and −1.8 at the femoral neck.
In addition to continuing vitamin D and calcium supplementation, which of the following is the best therapeutic option to decrease this patient's risk of future fractures?

Quizplus · Accepted Answer

11ec193a_97c3_02ac_853d_f198faa38c4e_MD0002_00 This patient with a thoracic vertebral compression fracture following a ground-level fall (ie, fragility fracture) has clinical osteoporosis (regardless of DXA results). Women with vertebral fracture are at risk for recurrent fracture, with nearly 20% experiencing another fracture within a year. Antiresorptive therapy is appropriate for postmenopausal women with: Osteoporosis on DXA (T-score ≤−2.5)Low trauma hip or vertebral fracture (as in this patient)Osteopenia (T-score between −1 and −2.5) and a 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20% Osteoporosis on DXA (T-score ≤−2.5) Osteoporosis on DXA (T-score ≤−2.5) Low trauma hip or vertebral fracture (as in this patient) Low trauma hip or vertebral fracture (as in this patient) Osteopenia (T-score between −1 and −2.5) and a 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20% Osteopenia (T-score between −1 and −2.5) and a 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20% Most patients are treated with a bisphosphonate (eg, alendronate, risedronate). However, these medications are cleared by the kidneys and are relatively contraindicated in patients with chronic kidney disease (CKD) and creatinine clearance <30-35 mL/min (Choice A). Denosumab is a human monoclonal antibody that inhibits the interaction between RANK and RANK ligand, thereby blocking osteoclast formation. It decreases bone resorption, increases bone mass, and reduces the risk of vertebral, nonvertebral, and hip fracture in postmenopausal women with osteoporosis. It is appropriate for use in patients with CKD; however, calcium levels must be monitored during treatment due to increased risk of hypocalcemia in these patients. (Choice B) Calcitonin may be used to decrease back pain in patients with acute vertebral fracture. However, it has minimal efficacy in fracture prevention. (Choice D) The FRAX assessment tool is an online resource to estimate the risk of fracture, and is used in patients with osteopenia to determine the relative benefit of antiresorptive therapy. This patient has had a vertebral fracture, and treatment is indicated regardless of FRAX score. FRAX assessment tool (Choice E) Teriparatide is a recombinant human parathyroid hormone analog that can increase bone formation and reduce fracture risk. However, it is not recommended as a first-line drug unless osteoporosis is severe (T-score ≤−2.5 with fragility fracture) and is not well studied in patients with CKD. Educational objective: Most patients with osteoporosis are treated with a bisphosphonate. However, these medications are relatively contraindicated in patients with chronic kidney disease (CKD) and creatinine clearance <30-35 mL/min. Denosumab reduces the risk of fracture in postmenopausal women with osteoporosis and is appropriate for use in patients with CKD. __________ References: Denosumab for prevention of fractures in postmenopausal women with osteoporosis. (http://www.ncbi.nlm.nih.gov/pubmed/19671655)

A 75-Year-Old Woman Comes to the Office Due to a Compression