A 55-year-old girl is evaluated for a new-patient go to. Medical historical past is important for an consuming dysfunction. Though she has maintained a traditional weight for the previous 20 years, she notes that previous to that point her weight would fluctuate in a variety correlating with BMIs of 17 to 19. She has in any other case been wholesome and presently feels nicely. She is postmenopausal and a never-smoker. Household historical past is important for postmenopausal osteoporosis in her mom. Her drugs are over-the-counter calcium and vitamin D dietary supplements.
On bodily examination, temperature is 36.three °C (97.three °F), blood strain is 137/81 mm Hg, pulse price is 76/min, and respiration price is 11/min. BMI is 21. She has gentle thoracic kyphosis however no skeletal tenderness. The rest of the examination is unremarkable.
Outcomes of laboratory research are important for a serum calcium degree of 9.1 mg/dL (2.three mmol/L) and 25-hydroxyvitamin D degree of 40 ng/mL (99.eight nmol/L); thyroid perform research are regular.
Twin-energy x-ray absorptiometry (DEXA) scan exhibits T-scores of –1.eight within the femoral neck and –1.9 within the lumbar backbone. Ten-year fracture danger utilizing the Fracture Danger Evaluation Instrument (FRAX) is 6.9% for main osteoporotic fracture and zero.7% for hip fracture. Plain radiographs of the backbone present no proof of compression fracture.
Which of the next is essentially the most applicable administration of this affected person?
A. Start raloxifene
B. Repeat DEXA scan in 2 years
C. Change calcium with cholecalciferol
D. Begin bisphosphonate remedy
MKSAP Reply and Critique
The proper reply is B. Repeat DEXA scan in 2 years.
A repeat dual-energy x-ray absorptiometry (DEXA) scan ought to be repeated in 2 years on this affected person with low bone mass and comparatively low 10-year fracture danger. The Fracture Danger Evaluation Instrument (FRAX) calculator defines the 10-year fracture danger for sufferers with T-scores within the −1.zero to −2.5 ranges. The FRAX calculator incorporates a number of danger elements together with intercourse, fracture historical past, femoral neck bone mineral density, glucocorticoid use, smoking, BMI, age, and alcohol consumption to find out projected fracture danger. If the chance of main osteoporotic fracture is larger than or equal to 20% or the chance of hip fracture is larger than or equal to three%, then the affected person’s profit from remedy exceeds the chance, and he or she ought to be supplied therapy. Due to her historical past of low physique weight and restricted dietary consumption through the time of improvement of peak bone mass, she is at elevated danger for low bone mass or osteoporosis and is subsequently an applicable candidate for early screening. Her DEXA scan exhibits low bone mass. Backbone movie exhibits no proof of fracture. Moreover, her calcium and vitamin D ranges are regular. Persevering with way of life actions (similar to maximizing weight-bearing train and avoidance of tobacco or extreme alcohol) along with calcium and vitamin D supplementation is suitable administration of this affected person.
Raloxifene is a selective estrogen receptor modulator (SERM) that may be a therapy possibility for ladies with osteoporosis as a result of it has been proven to extend bone mineral density and scale back the chance of vertebral (however not nonvertebral) fractures. Nonetheless, raloxifene can be related to an elevated danger of thromboembolic occasions and vasomotor signs. There’s restricted information supporting use of raloxifene or different SERMs for treating sufferers with low bone mass, though some tips advocate contemplating therapy in sufferers with low bone mass and 10-year fracture danger decided by the FRAX calculator of better than or equal to 20% for a significant osteoporotic fracture or better than or equal to three% for hip fracture. Raloxifene would subsequently not be applicable remedy for this affected person.
Cholecalciferol (Dthree), a metabolite of vitamin D, is usually used to complement low serum vitamin D ranges in sufferers with vitamin D deficiency. This affected person has regular serum vitamin D ranges; subsequently, there isn’t a indication for therapy with vitamin D metabolites.
Bisphosphonates are thought-about first-line remedy for osteoporosis, though they aren’t used routinely in girls with low bone mass. Much like the usage of SERM remedy, tips advocate consideration of therapy with a bisphosphonate for low bone mass provided that there may be 10-year fracture danger decided by the FRAX calculator of better than or equal to 20% for a significant osteoporotic fracture or better than or equal to three% for hip fracture.
- Therapy for low bone mass in postmenopausal girls entails way of life modification (maximizing weight-bearing train and avoidance of tobacco or extreme alcohol) and vitamin D and calcium supplementation; the necessity for pharmacologic remedy relies on the 10-year estimated fracture danger (≥20% for a significant osteoporotic fracture or ≥three% for hip fracture).
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