A 41-year-old woman comes to the physician because of pain and persistent morning stiffness in both hands. She has had these symptoms for the past six months. She has used ibuprofen and tapering steroids; however, as soon as she stops using the steroids, the stiffness and pain recur. She does not use tobacco, alcohol, or drugs. Examination reveals synovitis in both metacarpophalangeal and proximal interphalangeal joints, bilaterally. Further workup revealed systemic lupus erythematosus. She is started on chronic steroid therapy with prednisone 7.5 mg/day along with hydroxychloroquine. Which of the following is the most appropriate next step in managing this patient?

Question

A 41-year-old woman comes to the physician because of pain and persistent morning stiffness in both hands.  She has had these symptoms for the past six months.  She has used ibuprofen and tapering steroids; however, as soon as she stops using the steroids, the stiffness and pain recur.  She does not use tobacco, alcohol, or drugs.  Examination reveals synovitis in both metacarpophalangeal and proximal interphalangeal joints, bilaterally.  Further workup revealed systemic lupus erythematosus.  She is started on chronic steroid therapy with prednisone 7.5 mg/day along with hydroxychloroquine.  Which of the following is the most appropriate next step in managing this patient?

Quizplus · Accepted Answer

Explanation: Glucocorticoids decrease the intestinal absorption of calcium and increase the calcium excretion in the urine. They also accelerate bone resorption. Treatment should include the administration of supplemental calcium and vitamin D because this therapy has been shown to decrease the rate of bone loss. (Choice A)Patients who are going to be treated with corticosteroids for more than three months (or six months if low doses, i.e., <10 mg/day), should be evaluated with baseline densitometry, and the test should be repeated every year as long as the therapy continues. (Choice B) Bone turnover markers (N-telopeptide) currently have limited utility in the diagnosis of osteoporosis or the selection of candidates for therapy. (Choice D) Calcitonin is used if the bisphosphonates are contraindicated or not tolerated. (Choice E)Bisphosphonates (alendronate) can be added to calcium and vitamin D if the risk of osteoporosis is very high, especially in postmenopausal women. Caution should be exercised when prescribing these to premenopausal women given the possible teratogenic risk. Educational objective: Chronic glucocorticoid therapy increases the risk of osteoporosis. For this reason, it is important to provide the lowest dose of steroids for the shortest duration, and to add vitamin D as well as calcium supplementation to the patient's therapy. Based on the duration of therapy, bone densitometry is indicated for every year. References: The safety of bisphosphonate use in pre-menopausal women on corticosteroids. (http://www.ncbi.nlm.nih.gov/pubmed/19534636) Bone turnover markers: understanding their value in clinical trials and clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/19190842)

A 41-Year-Old Woman Comes to the Physician Because of Pain