Osteoporosis

Case history: 68-year-old white

woman
Presents to accident and emergency
department with right wrist pain,
swelling, and displacement following
a fall onto outstretched hand on the
stairs at home

History
Past medical history asthma since
childhood (treated with corticosteroids aged
5055), gastric ulcer aged 45, menopause
age 59, left wrist fracture aged 67
Family history stroke in sister aged 65, hip
fracture in mother aged 78. Mother
diagnosed with osteoporosis
Social history lives alone, 2 children,
retired, smokes 5 cigarettes per day,
occasional alcohol, takes no exercise, fully
mobile and able to complete all ADLs
(activities of daily living)

Examination
On examination wrist displaced, swollen,
no open wound
No loss of sensation or vascular compromise
X-ray Colles fracture of distal radius
present
N.B. The most common osteoporotic fractures
are vertebrae, wrists, and hips. Lifetime risk
of fracture in white women is 20% for spine,
15% for wrist, and 18% for hip. There is an
exponential increase in fracture over 50
years

Further issues for you to consider...

How can further fractures be prevented?
Bisphosphonates are the most commonly
used treatment, but how useful are they?
Are there any non-pharmacological
treatments that would help?
Which of these options are most
appropriate for this particular person?
How strong is the evidence for these
options?

Bisphosphonates

Categorisati
on of
effectivenes
s for each
bisphosphon
ate we cover

Clinical
question

Different
bisphosphonates
for which we
have searched
for systematic
review or
randomised
control trial
evidence
Click on the drug of interest to see the evidence base for the
benefits and harms

Individual medicine
Thinking about this person:
Past medical history previous fracture,
postmenopausal, corticosteroid use, gastric
ulcer
We can see from the review that alendronate,
(and other bisphosphonates) are associated
with gastric ulcers and erosions
Therefore, we should consider other options,
but remember as well that this is not a
contraindication, but a caution about their use

Family history stroke (raloxifene may

increase stroke risk)
What would be better?

Using Clinical Evidence to help answer the

patients questions
Questions your patient has
Several friends take HRT and have recommended
this should she do the same?
At present, she does not take any regular
exercise, but wonders whether this is important.
She has heard that exercise strengthens the
bones, but is worried about having a fall and
getting another fracture
Since the diagnosis she has been taking calcium
and vitamin D supplements as she hoped these
would reduce her fracture risk are these a good
use of money and are they harmful in any way?

Conclusions
Risks of HRT outweigh the benefits
We dont know if exercise is beneficial
Monotherapy with calcium or vitamin
D has not been shown to reduce
fractures
Bisphosphonates are effective but are
associated with gastric ulcers
Raloxifene increases stroke risk

 Audrey is a 45-year-old female with heavy periods

that are becoming increasingly irregular. She and her
partner currently use condoms but she wonders if
this is necessary (she thinks its unlikely that she
could become pregnant at her age). She is healthy
with no history of hypertension and she doesnt
smoke. Some of her friends are using the birth
control pill to regulate their periods (and sometimes
to avoid their periods altogether!) but she wonders if
this is safe. She had used the pill in the past with no
problems but stopped taking it because she thought
that she had to stop taking it when she turned 35.

 Who can take the OC?

Is menstrual suppression with the pill safe?
Whats the risk of venous
thromboembolism (VTE) among OC users?
Should women be screened prior to
starting the OC?
Is the Pill associated with an increased risk
of cancer?
Role of anti retroviral agents in OC users!

an older gentlemen named Crandle

and he comes to you with spiking
back pain. On exam, he has loss in his
arms and legs, loss of motor function.
You suspect metastatic cancer of the
prostate to the SPINE. What are the
classes of drugs you will be asked to
master for this MOST COMMONLY
diagnosed cancer in the US