A 66-year-old woman comes to the office to review the results of her recent DXA scan of the hips and spine. She has a history of essential hypertension, osteoarthritis, and acid reflux disease. Current medications include lisinopril, omeprazole, and acetaminophen as needed. She has never smoked and has no history of fractures or falls.
Height is 165 cm (5 ft 5 in) and weight is 70 kg (154.3 lb).
Laboratory testing, including renal function, electrolytes, TSH, and parathyroid hormone level, is normal.
Results of the DXA scan are as follows:
Which of the following is the most appropriate next step in management of this patient?

Question

A 66-year-old woman comes to the office to review the results of her recent DXA scan of the hips and spine.  She has a history of essential hypertension, osteoarthritis, and acid reflux disease.  Current medications include lisinopril, omeprazole, and acetaminophen as needed.  She has never smoked and has no history of fractures or falls.
Height is 165 cm (5 ft 5 in) and weight is 70 kg (154.3 lb).
Laboratory testing, including renal function, electrolytes, TSH, and parathyroid hormone level, is normal.
Results of the DXA scan are as follows:
 Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97cd_d82f_853d_e1b80230a5bc_MD0002_00 This patient is at risk for osteoporosis based on age and female sex. In addition, she takes omeprazole, which can increase bone loss. Osteoporosis screening is recommended for women age >65 and younger women who have additional risk factors for osteoporosis. The World Health Organization and the International Society for Clinical Densitometry define osteopenia as a T score of −1.1 to −2.4 and osteoporosis as a T score <−2.5. In the lumbar spine, the average bone density at L1-L4 should be used rather than bone density at individual vertebrae. The final diagnostic interpretation is based on the lowest T score at the lumbar spine and either hip (total proximal femur or femoral neck). This patient has a lowest T score of −2.9 (at the left hip) and therefore meets diagnostic criteria for osteoporosis rather than osteopenia (Choice B). (Choice A) Fracture risk estimated with the FRAX risk assessment tool can be used to guide management in patients age >50 who have osteopenia and have not previously taken specific therapy for osteoporosis. This patient has osteoporosis, and treatment (eg, bisphosphonate therapy) is indicated even without calculation of a FRAX score. FRAX risk assessment tool (Choice D) Peripheral bone density (eg, calcaneus, forearm) is not recommended for routine use due to lack of standardization but can be considered in certain circumstances, such as morbid obesity (exceeding the weight limit of the DXA machine) or metal implants in the spine or hips (eg, joint replacements). In addition, forearm measurement is recommended in primary hyperparathyroidism, in which bone loss is more pronounced in cortical rather than cancellous bone. (Choice E) Z scores are used to compare an individual's bone density with others the same age and can identify abnormal bone loss that is disproportionate to that expected from aging. Z scores are useful for fracture risk estimation in young premenopausal women or in children but are less helpful in postmenopausal women. Educational objective: Osteopenia is defined as a T score of −1.1 to −2.4 and osteoporosis as a T score <−2.5. Diagnostic interpretation is based on the lowest T score at the lumbar spine (average bone density at L1-L4) and either hip. < __________ References: Screening, diagnosis and treatment of osteoporosis: a brief review. (http://www.ncbi.nlm.nih.gov/pubmed/25568654) What is the utility of distal forearm DXA in primary hyperparathyroidism? (http://www.ncbi.nlm.nih.gov/pubmed/22258698)

A 66-Year-Old Woman Comes to the Office to Review the Results