J.R. is a 66 y.o. female who was seen in the E.D. after a fall at home. J.R. reports, “I tripped on the rug and fell to the floor with my arms out.” The forearm appears swollen and ecchymotic (bruised). The patient reports a “throbbing” pain, with an 8/10 rating. The patient has no significant medical history, nor does she take any daily medications.  She has smoked 1ppd of cigarettes x 25 yrs and drinks 2-4 glasses of wine each night.  She reports, “I don’t do as much as I used to, my hips and feet are always achy, it’s tough getting old.”

Diagnosis

X-Ray confirms a distal radial fracture, and the patient is casted.

During follow up with her PCP J.R. is evaluated for post-menopausal osteoporosis. Evaluation includes history, physical, and lab work-up.

•         Biochemistry profile (especially calcium, phosphorous, albumin, total protein, creatinine, liver enzymes including alkaline phosphatase, electrolytes)

•         25-hydroxyvitamin D

•         Complete blood count

•         Urinary calcium excretion

A diagnosis is made based on the World Health Organization’s diagnostic thresholds for low bone mass and osteoporosis based on bone mineral density measurements that are compared with a young adult reference population.

Other diseases that should be considered as a cause of osteoporosis, or ruled out, before a postmenopausal associated etiology is determined: rheumatoid arthritis, celiac disease, hyperthyroidism, inflammatory bowel disease, liver disease, hyperparathyroidism, hypogonadism, myeloma, vascular diseases, cancer metastases.

The following medications may cause osteoporosis; heparin, coumadin, glucocorticoids, lithium, methotrexate, anticonvulsants, cyclophosphamide, cyclosporine. Benzodiazepines are associated with an increase fall risk, and subsequent increase risk of fracture.

Osteoporosis is a disease where bone tissue is normally mineralized but the mass or density of bone is decreased. Specifically, the trabecular structural integrity is impaired. The rate of bone resorption begins exceeding formation after approximately age 30, the time of peak bone mass.  In women, this process is accelerated after the first years of menopause and continues throughout the postmenopausal years. There are multiple contributory factors in the development of osteoporosis. Post menopausal osteoporosis is most likely related to changes in osteoprotegerin (aka osteoclastogenesis inhibitory factor), inadequate dietary intake of calcium (calcium absorption in the intestine decreases with age), deficient vitamin D, decreased magnesium, lack of exercise, decreased estrogen levels, and family history.

Risk Factors

·         Female

·         White or Asian Ethnicity

·         Post-menopausal

·         Smoking

·         Alcohol & Caffeine consumption

·         Low body weight is a predictor of low bone mineral density

·         Low Calcium and Vitamin D intake

Decreased visual acuity and prolonged immobility increase risk of fall and subsequent fracture.

Treatment

Non- pharmacological management includes; dietary intervention, calcium, vitamin D, smoking cessation, moderate ETOH consumption, exercise, home fall hazard assessment.

Patients who would benefit from drug therapy are those at the highest risk of fracture based on their bone mineral density and clinical risk factors.

The FRAX (Fracture Risk Assessment) Tool, developed by the WHO can be used as a guideline in determining if pharmacological therapy is appropriate.

Drugs typical used include:

Biphosphonates; Alendronate or Risderonate are currently considered first line therapy.

If biphosphates cannot be tolerated then a Selective Estrogen Receptor Modulator (SERM) can be used. Raloxifene is a first choice in this drug class.

PTH therapy is recommended for severe osteoporosis when biphosphates and SERMS cannot be tolerated.

Estrogen/Progestin therapy is no longer considered best practice due to an increased risk of breast cancer, stroke, DVT, and CAD.

Case created by Jaime Records, 2011.