Osteoporosis management clinical scenario
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Osteoporosis Management: Clinical scenario. Status. Medical History. Medical History. Women, 49 y Asymptomatic - BMD T-scores: -2.7. Menopause: 45y Mother : hip fracture at age of 79 y. Further examination? . Spinal X-ray? . Normal . Rx?. Vertebral fx . Case 1. Yes

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Osteoporosis Management: Clinical scenario

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Osteoporosis management clinical scenario

Osteoporosis Management:Clinical scenario


Case 1

Status

Medical History

Medical History

  • Women, 49 y

  • Asymptomatic

  • - BMD T-scores: -2.7

  • Menopause: 45y

  • Mother : hip fracture

  • at age of 79 y

Further examination?

Spinal X-ray?

Normal

Rx?

Vertebral fx

Case 1

Yes

Differentiation: Secondary osteoporosis

(Hypogonadism, thyroidism…)

Yes

Maybe asymptomatic vertebral fracture

(deformity)

No

Because the risk for the patient sustaining

a fracture in the next 10 y is low

Yes

Because the risk for a subsequent fx

is high

Anti-resorption

(alendronate, risedronate or raloxifene)

Rx?


Case 2

Status

Medical History

Medical History

  • Women, 55 y

  • Asymptomatic

  • - BMD T-scores: -1.5

  • Normal

Further examination?

Spinal X-ray?

Normal

Rx?

Rx?

Vertebral fx

Case 2

NO

Considerable when having more

clinical evidence

No

Because the risk for the patient sustaining

a fracture in the next 10 y is low

  • Adequate calcium dietary, vitamin D

  • Icrease weight-bearing exercise

  • Prevent falls

  • Very low or ultra-low HRT or oral bisphosphonates can be considered

Yes

Because the risk for a subsequent fx

is high

Anti-resorption

(alendronate, risedronate or raloxifene)

Rx?


Case 3

Case 3

Status

Medical History

  • Women, 65 y

  • Frequent back pain

  • - HRT: undesired

  • Menaupause: 50y

  • Lose ht: 8cm

  • Prior fx (distal radius)

Yes

Measure BMD

Further examination?

Yes

Maybe vertebral fracture (back pain)

Spinal X-ray?

  • Depend

  • Osteoporosis: YES

  • Non-osteoporosis: NO

Normal

Rx?

Anti-resorption

(alendronate, risedronate or raloxifene)

Rx?

Vertebral fx

Yes


Case 4

Case 4

Status

Medical History

  • Men, 80 y

  • Arrival with hip fracture

  • (fall from standing height)

  • Difficult to keep balance when standing

  • Susceptible to fall

NO

Further examination?

NO

Apparently Clinical features

Spinal X-ray?

Normal

Rx?

Rx?

Anti-resorption

(alendronate, risedronate or raloxifene)

Vertebral fx


Osteoporosis management clinical scenario

Case 5

Status

Medical History

  • Never use HRT

  • Had asthma since childhood, current medications: b.i.d. steroid inhale+ glucocorticosteroid 5-6 times/y for 2-6 wk for exacerbations.

  • Diagnosed with a seizure disorder at aged 20y, currently well controlled with Phenytoin 300mg/d.

  • Currently use multivitamin daily

  • No history of osteoporotic fracture.

  • Surgical menopause five years previously

  • Women, 45 y, teacher

  • No height loss.

  • Body weight at average of age group.

  • Expiratory wheeze noted.

  • BP: 140/82

  • BMD T-scores: -2.6

  • Lab test results:

    • sCa: 8.9 (normal: 8.6-10.2)

    • normal CBC

    • normal cholesterol

    • 24-hour urine calcium: 50 mg

    • 25 OH vitaminD:8ng/mL (normal: > 20).


Osteoporosis management clinical scenario

Case 5

Comments

Summary

  • BMD much lower than expected level for her age

  • Several risk factors for secondary osteoporosis:

    • early surgical menopause

    • chronic exposure to anticonvulsants

    • corticosteroids use

  • Vitamin D defficiency + seizure  high risk of fall

This case is a timely reminder that not all low bone density is simple osteoporosis. Several potential causes of secondary osteoporosis needed to be addressed before she could be treated successfully for

Further examination?

  • HRT is suitable

  • Bisphosphonates

Rx?

NO


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