A 65-year-old woman comes to the office to follow up for osteoporosis, which was diagnosed by a screening bone mineral density scan. The patient was prescribed alendronate, but she stopped taking it due to intense stomach pain from the medication. She saw a television advertisement about raloxifene and is interested in this treatment option. The patient has a history of deep venous thrombosis in her left leg while on an oral contraceptive at age 38 that was treated with several months of heparin. She currently takes medications for hypertension and hyperlipidemia diagnosed after a minor heart attack at age 63. Her mother had breast cancer at age 52 and died from ovarian cancer at age 61. A maternal aunt died from endometrial cancer at age 72. Blood pressure is 125/80 mm Hg, and physical examination is normal. Which of the following is a contraindication to raloxifene in this patient?

Question

A 65-year-old woman comes to the office to follow up for osteoporosis, which was diagnosed by a screening bone mineral density scan.  The patient was prescribed alendronate, but she stopped taking it due to intense stomach pain from the medication.  She saw a television advertisement about raloxifene and is interested in this treatment option.  The patient has a history of deep venous thrombosis in her left leg while on an oral contraceptive at age 38 that was treated with several months of heparin.  She currently takes medications for hypertension and hyperlipidemia diagnosed after a minor heart attack at age 63.  Her mother had breast cancer at age 52 and died from ovarian cancer at age 61.  A maternal aunt died from endometrial cancer at age 72.  Blood pressure is 125/80 mm Hg, and physical examination is normal.  Which of the following is a contraindication to raloxifene in this patient?

Quizplus · Accepted Answer

11ec25c8_d0cb_3d97_bc81_7f2b819ab11d_MD0003_00 Selective estrogen receptor modulators (SERMs) are a class of nonsteroidal compounds that exhibit estrogen agonist and antagonist properties in a tissue-specific fashion. The 2 most frequently used SERMs are raloxifene and tamoxifen. Raloxifene exhibits estrogen agonist activity on the bone and decreases post-menopausal osteoporosis. Although less effective than alendronate, raloxifene is frequently used for osteoporosis management in postmenopausal women who cannot tolerate bisphosphonates or are at high risk for invasive breast cancer. All medicines with estrogen agonist activity, including oral contraceptives, hormone replacement therapy, and all SERMs, increase the risk for venous thromboembolism (VTE). Consequently, current or prior VTE disorders (eg, pulmonary embolism, deep vein thrombosis, retinal vein thrombosis) are contraindications to both raloxifene and tamoxifen use. (Choices A and C) SERMs have estrogen antagonist activity in the breast and decrease the incidence of malignancy. A family history of breast cancer is a potential indication, rather than a contraindication, for raloxifene use. Raloxifene also decreases total and low-density lipoprotein cholesterol levels, although it neither increases nor decreases the risk of coronary heart disease. In contrast, a history of coronary artery disease or estrogen-receptor-positive breast cancer is a contraindication for treatment of menopausal symptoms with hormone replacement therapy (due to unopposed estrogen activity). (Choice B) Raloxifene has estrogen antagonist activity on the uterus and does not increase the risk for endometrial hyperplasia or cancer. As a result, a family history of uterine cancer is not a contraindication to raloxifene use. In contrast, tamoxifen is associated with an increased risk of uterine hyperplasia and cancer. (Choice D) SERMs are not associated with an increased incidence of ovarian cancer. Family history of ovarian cancer is not a contraindication to raloxifene or tamoxifen use. Women at high risk for ovarian cancer can be offered oral contraceptives or, after childbearing is finished, a prophylactic oophorectomy. Educational objective: Raloxifene is a selective estrogen receptor modulator with estrogen antagonist activity in the breast and uterus and agonist activity in the bone. It is used to treat osteoporosis in women at high risk for breast cancer. Contraindications include a history of venous thromboembolism. References: Selective estrogen receptor modulators in clinical practice: a safety overview. (http://www.ncbi.nlm.nih.gov/pubmed/25936229)

A 65-Year-Old Woman Comes to the Office to Follow Up