A 65-year-old white woman comes to the physician for acute mid-thoracic back pain. Seven days ago, she slipped and fell in her driveway and has had the back pain ever since. The pain is described as deep-seated, boring in quality, and non-radiating, and has not improved with over-the-counter pain medications. Her past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with fluticasone, salmeterol, and ipratropium inhalers, and hypertension treated with lisinopril and hydrochlorothiazide. She has had occasional brief courses of oral glucocorticoids for COPD exacerbations. The patient has a 30-pack-year smoking history and quit approximately 5 years ago. She experienced menopause when she was 48 years old. Her mammogram and Pap smear were negative 6 months ago. Her mother and 2 sisters have osteoporosis. Examination shows tenderness over the mid-thoracic vertebrae. The rest of the examination is unremarkable. The complete blood count, basic metabolic panel, calcium, and phosphorus are within normal limits. Plain radiographs of the thoracic spine reveal a compression fracture in the 10th and 11th vertebrae. Her 25-hydroxyvitamin D level is 25 ng/mL (normal 30-50 ng/mL), and TSH level is 2.1 µU/mL. Bone density at the spine and hip shows a T-score of -2.4 at the lumbar spine and -2.0 at the hip. In addition to optimization of calcium and vitamin D intake, which of the following is the most appropriate intervention for this patient?

Question

A 65-year-old white woman comes to the physician for acute mid-thoracic back pain.  Seven days ago, she slipped and fell in her driveway and has had the back pain ever since.  The pain is described as deep-seated, boring in quality, and non-radiating, and has not improved with over-the-counter pain medications.  Her past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with fluticasone, salmeterol, and ipratropium inhalers, and hypertension treated with lisinopril and hydrochlorothiazide.  She has had occasional brief courses of oral glucocorticoids for COPD exacerbations.  The patient has a 30-pack-year smoking history and quit approximately 5 years ago.  She experienced menopause when she was 48 years old.  Her mammogram and Pap smear were negative 6 months ago.  Her mother and 2 sisters have osteoporosis.  Examination shows tenderness over the mid-thoracic vertebrae.  The rest of the examination is unremarkable.  The complete blood count, basic metabolic panel, calcium, and phosphorus are within normal limits.  Plain radiographs of the thoracic spine reveal a compression fracture in the 10th and 11th vertebrae. Her 25-hydroxyvitamin D level is 25 ng/mL (normal 30-50 ng/mL), and TSH level is 2.1 µU/mL.  Bone density at the spine and hip shows a T-score of -2.4 at the lumbar spine and -2.0 at the hip.  In addition to optimization of calcium and vitamin D intake, which of the following is the most appropriate intervention for this patient?

Quizplus · Accepted Answer

Explanation: The American Association of Clinical Endocrinologists recommends pharmacological therapy for postmenopausal women with T-score <-2.5 or those with a history of low-trauma hip or vertebral fractures regardless of T-score. Another indication for treatment is presence of osteopenia with an elevated 10-year fracture risk based on the Fracture Risk Assessment Tool (FRAX), which predicts fracture risk based on clinical factors for fracture as well as bone mineral density (BMD) at the femoral neck: pharmacologic treatment is recommended when the 10-year calculated probability by FRAX is >20% for major osteoporotic fractures or >3% for a hip fracture. Fracture Risk Assessment Tool (FRAX) Because this patient has a history of low-trauma vertebral fracture, she is a candidate for pharmacologic therapy for osteoporosis regardless of her T-score; serial BMD and T-score measurements are useful in assessing response to therapy. Bisphosphonates are generally the first-line therapy for postmenopausal osteoporosis. Alendronate is a bisphosphonate that improves BMD and lowers fracture risk by decreasing bone resorption. In addition, women with post-menopausal osteoporosis should take supplemental calcium and vitamin D to ensure adequate daily intake (total intake: 1200 mg/day of elemental calcium and 800 IU/day of vitamin D). (Choice B) Similar to bisphosphonates, calcitonin also inhibits bone resorption. However, calcitonin is a weak anti-resorptive agent with very modest efficacy against fracture reduction and is not used as a first-line agent for osteoporosis. (Choice C) Hormone replacement therapy is not recommended as first-line treatment for postmenopausal osteoporosis following the report of the Women's Health Initiative in 2002. The report showed that older women who received a combination of conjugated equine estrogen and medroxyprogesterone had a significantly higher risk of myocardial infarction, stroke, deep-vein thrombosis, pulmonary embolism, and breast cancer. (Choice D) Pharmacologic treatment is necessary due to fragility of vertebral fractures. Supplementation of calcium and vitamin D alone would be suboptimal. (Choice E) Parathyroid hormone fragment (PTH 1-34, teriparatide) is effective in improving bone density and reducing the risk of fractures. However, due to high cost, it is used only as a second-line agent in patients with very high risk of fractures, particularly those in whom bisphosphonate therapy has failed. Educational objective: Pharmacologic therapy for osteoporosis is indicated for patients with a T-score <-2.5 and for those with fragility fractures regardless of bone mineral density. Bisphosphonates are first-line treatment in most cases.

A 65-Year-Old White Woman Comes to the Physician for Acute