A 65-year-old man comes to the physician to follow up polymyalgia rheumatica with giant cell arteritis. He was started on 60 mg/day of prednisone 6 weeks ago and has been tapered to 20 mg/day. The patient has been taking 1,200 mg/day of supplemental calcium as well as 800 IU/day of vitamin D. He has no visual symptoms. His morning shoulder stiffness and aches have dissipated, and he feels well overall. Blood pressure is 136/84 mm Hg and pulse is 72/min. His weight is 77 kg (169.4 lb), an increase from 72 kg (158.4 lb) 2 months ago. The patient has no temporal artery tenderness. The remainder of his physical examination is within normal limits. Laboratory results are as follows:

Dual-energy x-ray absorptiometry reveals a T-score of −1.3 at the lumbar spine and −1.2 at the femoral neck. Which of the following is the best next step in preventing fragility fractures in this patient?

Question

A 65-year-old man comes to the physician to follow up polymyalgia rheumatica with giant cell arteritis.  He was started on 60 mg/day of prednisone 6 weeks ago and has been tapered to 20 mg/day.  The patient has been taking 1,200 mg/day of supplemental calcium as well as 800 IU/day of vitamin D.  He has no visual symptoms.  His morning shoulder stiffness and aches have dissipated, and he feels well overall.  Blood pressure is 136/84 mm Hg and pulse is 72/min.  His weight is 77 kg (169.4 lb), an increase from 72 kg (158.4 lb) 2 months ago.  The patient has no temporal artery tenderness.  The remainder of his physical examination is within normal limits.  Laboratory results are as follows:

Dual-energy x-ray absorptiometry reveals a T-score of −1.3 at the lumbar spine and −1.2 at the femoral neck.  Which of the following is the best next step in preventing fragility fractures in this patient?

Quizplus · Accepted Answer

11ec193a_991b_8d46_853d_494cda3620f5_MD0002_00 Giant cell arteritis is a chronic disease; most patients require a minimum of 9 months to 1 year of glucocorticoid therapy, and some patients need lifelong treatment to prevent relapse. Patients receiving glucocorticoids at >7.5 mg/day for >3 months have a significantly increased risk for glucocorticoid-induced osteoporosis and fragility fractures. Steroid-induced osteoporosis often results in fragility fractures at higher bone mineral density readings than in postmenopausal osteoporosis. This patient has additional risk due to age >50 years and baseline osteopenia (T-score between −1.0 and −2.5). Current guidelines recommend that all men age >50 and postmenopausal women taking >7.5 mg/day of prednisone for an anticipated course >3 months should be started on bisphosphonates as initial therapy. Alendronate and risedronate are preferred. Parathyroid hormone (eg, teriparatide) is a second-line agent used in patients who cannot tolerate bisphosphonates. Bisphosphonates are also recommended for patients with a 10-year fracture risk >20%, regardless of the anticipated dose or duration of glucocorticoid use. Evidence to guide management of men age <50 and premenopausal women is limited, and care should be individualized. 10-year fracture risk (Choice A) Calcitonin attenuates lumbar bone density loss but has not been reported to decrease fracture risk. It is not recommended for prevention of steroid-induced osteoporosis. (Choice B) Although guidelines recommend daily weight-bearing exercise, along with adequate intake of calcium and vitamin D to prevent bone loss and muscle atrophy, these therapies alone usually are not sufficient to prevent steroid-induced osteoporosis. (Choice C) Denosumab is a monoclonal antibody directed against the osteoclast-activating factor that increases bone mineral density and reduces fragility fractures. However, there is insufficient data to support its use in this setting. (Choice D) Repeat bone density testing may be considered for patients at risk for glucocorticoid-induced osteoporosis, though the benefits and optimal schedule are debated. This patient warrants bisphosphonate therapy now and should not wait for repeat testing. Educational objective: Men age >50 and postmenopausal women expected to receive corticosteroids at >7.5 mg/day for >3 months are candidates for osteoporosis prevention therapy. Bisphosphonates are preferred in most patients. __________ References: Recent recommendations on steroid-induced osteoporosis: more targeted, but more complicated. (http://www.ncbi.nlm.nih.gov/pubmed/23376917)

A 65-Year-Old Man Comes to the Physician to Follow Up