A 75-year-old woman comes to the office for follow-up of osteoporosis. She has been on weekly oral risedronate for the last 2 years and has an adequate daily intake of calcium and vitamin D via diet and oral supplements. However, in the past year the patient has experienced 2 vertebral compression fractures and lost 5.1 cm (2 in) in height. She was evaluated in a fall reduction program, and home safety improvements were implemented. A home health aide assists the patient with her medications and notes that adherence has been excellent. Medical history is notable for a mild stroke 2 years ago with minimal residual deficits.
Vital signs are normal. BMI is 20 kg/m². On examination, the patient appears frail and has a modest thoracic kyphosis. Physical examination is otherwise normal.
Laboratory results show normal blood counts, liver function tests, serum creatinine, alkaline phosphatase, TSH, serum parathyroid hormone, anti-tissue transglutaminase antibody assay, 25-hydroxyvitamin D, and serum protein electrophoresis. 24-hour urine calcium excretion is 290 mg. DXA reveals a T-score of −2.8 in the hip and −3.6 in the spine, which represents a significant (>5%) decrease compared with her last test 2 years ago.
Which of the following is the most appropriate next step in management of this patient's osteoporosis?

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Quizplus · Accepted Answer

11ec193a_9910_438b_853d_95d5837c8055_MD0002_00 This patient has osteoporosis and has received appropriate first-line treatment with a bisphosphonate. However, she has experienced progressive bone loss while on treatment and has severe osteoporosis (T-score ≤−3.5 or T-score ≤−2.5 with a fragility fracture) and recurrent fragility fractures. Benefits of bisphosphonates typically require at least 6-12 months to become apparent, and fractures during this time do not require a change in management. However, significant progression after this period warrants reconsideration of therapeutic options. Patients who have progressive bone loss despite appropriate therapy should be screened for undiagnosed conditions that may contribute to bone loss (eg, hyperthyroidism, hyperparathyroidism, multiple myeloma, malabsorption, liver disease, chronic kidney disease). Teriparatide is a recombinant parathyroid hormone analog that is useful in patients with severe osteoporosis or who fail first-line treatment. It is given by daily subcutaneous injection and can increase bone density and reduce fracture risk. Treatment with teriparatide is typically prescribed for 2 years, after which a bisphosphonate is resumed to preserve gains in bone density. However, there is no evidence of reduced fracture risk with concurrent therapy (Choice B). (Choice A) Raloxifene is a selective estrogen receptor modulator that suppresses bone resorption, improves bone density, and reduces the risk of vertebral fractures. However, it is less effective than bisphosphonates and has not been proven to reduce fractures in combination with a bisphosphonate. In addition, raloxifene is not recommended for patients with increased thromboembolic risk (eg, prior stroke). (Choice C) In randomized trials, hip protectors have not been shown to reduce the risk of hip fractures and are not recommended. (Choice D) Bone turnover markers (eg, urine N-telopeptide) correlate with ongoing bone loss. They can confirm the effectiveness of antiresorptive therapy within 3-6 months, and are useful in patients at increased risk of treatment failure (eg, poor compliance, malabsorption). However, this patient's DXA confirms progressive bone loss, and an N-telopeptide assay would not improve management. Educational objective: Patients with osteoporosis who have progressive bone loss while on bisphosphonate therapy should be evaluated for conditions that can contribute to bone loss and should be considered for a change in treatment regimen. Teriparatide is a recombinant parathyroid hormone analog that can increase bone density and reduce fracture risk in patients with severe osteoporosis or who fail first-line treatment. __________ References: Osteoporosis. (http://www.ncbi.nlm.nih.gov/pubmed/21727287) Spotlight on teriparatide in osteoporosis. (http://www.ncbi.nlm.nih.gov/pubmed/19627171) American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis - 2016. (http://www.ncbi.nlm.nih.gov/pubmed/27662240)

A 75-Year-Old Woman Comes to the Office for Follow-Up of Osteoporosis