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Chapter 49. Osteoporosis

SD is a 55-year-old woman with no significant past medical history. However, she currently smokes one pack per day and drinks alcohol socially (two beers every other week). She attends a health fair and learns her T-score is –1.5 using a peripheral bone density device. She does not currently take any medications, vitamins, or supplements. Which statement represents the best course of action for the patient?

a. SD has osteopenia and should be started on alendronate 70 mg PO every week.

b. SD should be advised to quit smoking and to have her bone mineral density (BMD) checked again in 2 years.

c. SD should be started on teriparatide 20 μg subcutaneous (SubQ) daily to rebuild her bone mass to normal levels.

d. SD should be started on calcium 1200 mg PO daily and vitamin D 800 IU PO daily.

Answer d is correct. SD is not currently taking calcium or vitamin D per Institute of Medicine guidelines. Though this may or may not fully explain her low BMD score, it is the most logical starting point to minimize the risk of developing osteoporosis. She should also be referred to for further testing (ie, central dual energy x-ray absorptiometry [DXA]). Assessing BMD using a peripheral bone density device is a good screening tool, but central DXA is considered the gold standard for diagnosis.

Answer a is incorrect. It is unknown if SD does or does not have osteopenia based on the WHO guidelines, as a peripheral bone density device cannot be used for diagnostic purposes. Therefore, a more thorough assessment needs to be done before initiating a bisphosphonate at this point. Furthermore, if a bisphosphonate is ultimately deemed appropriate, the "prevention" dose of alendronate is 5 mg PO daily or 35 mg PO every week.

Answer b is incorrect. It should be recommended that SD go for a more thorough assessment (ie, Central DXA) and be advised to quit smoking, as active or previous smoking is a risk factor.

Answer c is incorrect. Teriparatide is recommended for patients with (severe) osteoporosis and high risk of fracture. SD should be referred to for further assessment to determine her diagnosis based on WHO guidelines.

JR is a 68-year-old white man who presents to the emergency department with a hip fracture after falling out of bed. He is 5 ft 8 in and weighs 133 lb. His medical history includes rheumatoid arthritis, currently treated with prednisone 10 mg PO daily (× 2 years), methotrexate 15 mg PO weekly (× 2 years), and folic acid 1 mg PO daily (× 2 years). Which statement represents the best course ...

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