A 36-year-old white female with systemic lupus erythematosus was seen in your clinic. She has been on prednisone for lupus nephritis for the past year. Decreasing the dose of prednisone below 10 mg per day appears to be associated with an increase in proteinuria. She is currently on no other medications except for birth control pills. She denies any symptoms. She has normal menstrual cycles and is sexually active with one partner. She has no children. Because of a fear of weight gain, she has been restricting dairy products in her diet. She avoids sunlight due to a fear of skin cancer. She is concerned about bone loss secondary to prednisone use. Which of the following should be given to prevent bone loss in this patient?

Question

A 36-year-old white female with systemic lupus erythematosus was seen in your clinic.  She has been on prednisone for lupus nephritis for the past year.  Decreasing the dose of prednisone below 10 mg per day appears to be associated with an increase in proteinuria.  She is currently on no other medications except for birth control pills.  She denies any symptoms.  She has normal menstrual cycles and is sexually active with one partner.  She has no children.  Because of a fear of weight gain, she has been restricting dairy products in her diet.  She avoids sunlight due to a fear of skin cancer.  She is concerned about bone loss secondary to prednisone use.  Which of the following should be given to prevent bone loss in this patient?

Quizplus · Accepted Answer

Explanation: Glucocorticoid use may lead to a low bone mass due to multiple mechanisms. Glucocorticoids decrease calcium absorption from the gut, cause renal calcium wasting, and have a direct anti-anabolic effect on the bone. Furthermore, they suppress the release of gonadotropin-releasing hormone from the hypothalamus, leading to central hypogonadism, which can aggravate bone loss. This patient is on pharmacological doses of glucocorticoids, has a suboptimal intake of calcium and vitamin D because of poor dietary habits, and has limited sunlight exposure. She is at an increased risk for bone loss. Supplementation of calcium and vitamin D is the most reasonable choice to prevent bone loss. Her current use of birth control pills is also likely to protect her from bone loss. (Choice A and B)Alendronate or risedronate is not indicated at this time. Both of these agents are approved by the FDA for treating glucocorticoid-induced osteoporosis. Treatment could be warranted if bone mineral density studies reveal a T score of <-1.5 that continues to rapidly deteriorate. (Choice C)Fluoride causes an increase in the bone mineral density of the vertebral column; however, an abnormal quality of bone and increased fracture rates have been shown when fluoride is used to treat osteoporosis. (Choice D)Calcitonin is a weak anti-resorptive agent that is used as a nasal spray with a dosage of 200 international units per day; other dosages do not seem to work. It is not approved for use in premenopausal patients. Educational Objective: Achieving optimum calcium and vitamin D levels is the best initial step to prevent bone loss due to prolonged glucocorticoid therapy.

A 36-Year-Old White Female with Systemic Lupus Erythematosus Was Seen