Learning objectives
- •
The integration of DXA scan results, FRAX algorithm score, NOF guidelines, and patient’s clinical condition to develop a management strategy tailored to the individual circumstances of the patient.
- •
Appreciate that, like osteoporosis, osteopenia is asymptomatic until a fracture is sustained.
The case study
Reason for seeking medical help
- •
ON is 72-year-old Caucasian woman. She is recovering well from pneumonia and is referred because a plain X-ray of her lungs showed evidence of moderate, wedge vertebral compression fractures of T7, T8, and T9. She denies any trauma to her back and has not experienced any falls, near-falls, or dizzy spells.
Past medical and surgical history
- •
Natural menopause at age 49 years, has been on hormonal replacement therapy (HRT) since then; still on HRT, good compliance, no adverse effects.
- •
Menarche at age 12 years, regular menstrual periods until age 49 years.
- •
Two children aged 59 and 55 years, both in good health.
Lifestyle
- •
Physically sedentary lifestyle. Works as a phone operator.
- •
Good appetite, no weight loss.
- •
Daily calcium intake about 600 mg daily.
- •
Smokes an average of 10 cigarettes daily. Has tried to stop but was not able.
- •
Alcohol intake: two to three glasses of wine with dinner, often more during the weekend.
- •
At least 6 cups of coffee a day and 6 cans of diet Coca-Cola or Pepsi-Cola.
- •
No recreational drugs.
Medication(s)
- •
Hormonal replacement therapy: estrogen and progesterone.
- •
Simvastatin 40 mg once a day.
- •
Multivitamin/mineral tablet supplements.
- •
Occasional (about once a week) over-the-counter hypnotic.
Family history
- •
Positive for osteoporosis: mother and maternal grandmother sustained fragility hip fractures.
- •
Older sister has been diagnosed with osteoporosis and is receiving treatment.
Clinical examination
- •
Weight 167 pounds, height 5′2″, says she lost about 2″ compared to her height when she was in her thirties. Mild postural kyphosis.
- •
Alert, cooperative, cognitively intact. Concerned about osteoporosis.
- •
BP 138/92 sitting; 131/96 standing, no clinical evidence of orthostasis.
- •
Pulse rate 84/min, regular.
- •
No difficulties standing up.
- •
Completes the Timed Up and Go (TUG) test in 8.1 s.
- •
Clinical examination does not reveal any significant clinical finding.
Laboratory results
About 3 weeks before referral she had a number of laboratory tests done. All results were within normal limits, including comprehensive blood count (CBC), comprehensive metabolic panel (CMP), serum vitamin D, parathyroid hormone (PTH), and thyroid stimulating hormone (THS). Serum cholesterol has been marginally elevated for about 2 years.
DXA and radiological(s)
- •
Lowest T-score −1.8 in lumbar vertebrae.
- •
Vertebral Fracture Assessment: evidence of three vertebral compression fractures: T7, T8, and T9. ON denies any trauma to her back or other parts of her body. She has led a mostly sedentary lifestyle.
- •
FRAX scores: 2.2% hip and 17% major fracture.
Diagnosis
- •
Osteoporosis as evidenced by the presence of “silent” vertebral compression fragility fractures.
- •
The presence of a fragility fracture overrides the densitometric diagnosis of osteopenia and the FRAX derived risks of sustaining a fracture.
Lowest T-score: −1.8 at L1 to L4
FRAX Scores (10-year probability of fracture):
Hip fracture risk: 2.2%
Other major fractures risk: 17%
National Osteoporosis Foundation threshold for initiating treatment: NOT reached .
Evidence of fragility/silent/morphometric vertebral compression fractures, therefore:
Opportunistic diagnosis of osteoporosis .
Multiple choice questions
- 1.
The following is/are true about ON’s vertebral compression fractures of T7, T8, and T9:
- A.
They are asymptomatic and part of the normal aging process.
- B.
They can be ignored.
- C.
Vertebral augmentation procedures should be considered.
- D.
A and B.
- E.
None of the above.
Correct answer: E
Comment:
Clinically silent vertebral compression fractures are fragility fractures. They are diagnostic of osteoporosis, and therefore cannot be ignored. They should be considered as “warning signs” because once a patient develops a fragility fracture, she/he is likely to sustain further fractures. It is therefore appropriate to investigate these patients for causes of secondary osteoporosis and develop a management strategy tailored to the patient’s condition and needs. Often the underlying cause is readily identified, such as orthostatic hypotension; cardiac arrhythmias; sensitive carotid sinus; low calcium intake; sedentary lifestyle; cigarette smoking; excessive alcohol, coffee, and sodium intake.
It is also important to conduct a full clinical examination to identify a number of conditions that may increase the risk of falls and fractures. In ON’s case the vertebral compression fractures are silent, i.e., asymptomatic, and therefore there is no need to consider vertebral augmentation procedures.
- A.
- 2.
The following is/are true about ON’s final diagnosis:
- A.
Osteopenia.
- B.
Osteoporosis.
- C.
Increased fracture risk.
- D.
A and C.
- E.
B and C.
Correct answer: E
Comments:
ON has densitometric evidence of osteopenia. However, the presence of the morphometric vertebral compression fractures overrides the densitometric findings as it indicates that her bones are fragile and susceptible to sustaining fractures. This patient therefore needs medication to increase the bone density and reduce the risk of fractures. The National Bone Health Alliance working group recommends that postmenopausal women and men aged 50 years be considered for pharmacological treatment to increase bone mass and therefore reduce the fracture risk. In the USA, the threshold is 3% and 20% for the 10-year risk of sustaining a hip or major fracture, respectively.
- A.
- 3.
In ON’s case, factors increasing the risk of osteoporosis include:
- A.
Age 72 years.
- B.
Status postmenopause.
- C.
Positive family history for osteoporosis.
- D.
Alcohol intake.
- E.
A, B, and C.
Correct answer: E
Comment:
Menopause is a risk factor for osteoporosis unless the patient is on hormonal replacement therapy. A positive family history, especially hip fracture, increases the risk of osteoporosis. Alcohol intake exceeding the threshold of two drinks a day for women and three drinks a day for men increases the risk of osteoporosis. Alcohol intake less than that threshold may have a bone mass protective effect. It is, however, not clear whether this benefit is the result of the alcohol intake per se or whether it is due to the patient’s lifestyle.
Patients who consume alcoholic drinks also are at risk of falling: alcoholic drinks may interfere with postural stability and the efficiency of postural reflexes, thus increasing the risk of falls and hence fractures. It also may blunt cognitive functions.
The use of over-the-counter hypnotics is particularly problematic in older patients for a number of reasons, including the often long half-life of these compounds and the potential interactions with other medications or alcohol the patient may be consuming. Excessive caffeine and sodium intake may lead to polyurea and an increased need to get to a toilet frequently and in a relatively short period of time, thus increasing the likelihood of falling and therefore fractures.
- A.
- 4.
The following laboratory tests are indicated:
- A.
24-h urinary calcium.
- B.
24-h urinary magnesium.
- C.
24-h urinary sodium.
- D.
All of the above.
- E.
None of the above.
Correct answer: E
Comment:
At this stage there is no need for any of these laboratory tests.
- A.
- 5.
The following laboratory tests are recommended:
- A.
Comprehensive metabolic panel.
- B.
25-hydroxy-vitamin D.
- C.
1,25-Di-hydroxy-vitamin D.
- D.
All of the above.
- E.
None of the above.
Correct answer: E
Comments:
At this stage there is no need for any of these laboratory tests. These tests have been done about 2 weeks prior to her visit.
- A.
- 6.
In ON’s case:
- A.
The FRAX scores reach the threshold recommended by the NOF to initiate pharmacologic treatment.
- B.
She should be offered pharmacologic treatment for osteoporosis.
- C.
She should be counseled about her dietary intake of calcium or prescribed calcium supplements.
- D.
B and C.
- E.
All of the above.
Correct answer: D
Comment:
The FRAX scores of 2.2% and 17% (for the probability of sustaining a hip or major fracture, respectively, within 10 years) do not reach the threshold recommended by the National Osteoporosis Foundation (3% or 20% for the 10-year probability of sustaining a hip or major fracture, respectively) to initiate pharmacologic treatment. ON, however, has radiographic evidence of two morphometric vertebral compression fractures that she was not aware of. This is diagnostic of increased bone fragility and overrides the DXA scan results. Pharmacologic management should therefore be considered, as if the patient had densitometric evidence of osteoporosis.
As her serum vitamin D level was within the normal range there is no need to prescribe vitamin D supplements. She should, however, be counseled regarding the dietary calcium intake. Supplements should be prescribed if she cannot increase her dietary calcium intake.
- A.
- 7.
Pharmacologic management recommendations include:
- A.
A Selective Estrogen Receptor Modulator (SERM): raloxifene.
- B.
An antiresorptive medication: bisphosphonates or denosumab.
- C.
An osteoanabolic medication: teriparatide or abaloparatide.
- D.
A and B.
- E.
None of the above.
Correct answer: D
Comments:
ON needs medication that can increase the bone mass and reduce her fracture risk. Traditionally, pharmacological treatment is initiated with an antiresorptive medication because most patients in the early menopause have an increased rate of bone resorption. Furthermore, the ease of administration, the relative paucity of adverse effects, and the cost of the medication are attractive. These medications will be discussed in other case studies.
- A.
- 8.
Nonpharmacologic management includes:
- A.
Engage in resistive and aerobic exercises.
- B.
Ensure a well-balanced diet particularly concerning calcium, vitamin D, and protein intake.
- C.
Limit or avoid alcohol intake.
- D.
All of the above.
- E.
None of the above.
Correct answer: D
Comment:
These issues are discussed in another case study.
- A.
- 9.
ON would benefit from counseling in the following areas:
- A.
Adequate dietary calcium and vitamin D intake.
- B.
Cigarette smoking cessation.
- C.
Increased physical exercise regularly undertaken.
- D.
Limit excessive caffeine and soda drinks.
- E.
All of the above.
Correct answer: E
Comment:
All these issues need to be addressed in an unhurried environment. It is important to get the patient’s collaboration to achieve this goal.
- A.
- 10.
The following follow-up is recommended:
- A.
Repeat DXA scan in 1 year.
- B.
Repeat DXA scan in 2 years.
- C.
Repeat DXA scan in 5 years.
- D.
Repeat the FRAX score in 6 months.
- E.
None of the above.
Correct answer: B
Comment:
These issues are discussed in other case studies.
- A.
Case summary
Analysis of data
Factors predisposing to bone demineralization/osteoporosis
- •
Status postmenopause.
- •
Positive family history for osteoporosis.
- •
Sedentary lifestyle.
- •
Cigarette smoking.
- •
Low daily calcium intake.
- •
Alcohol intake.
Factors reducing risk of bone demineralization/osteoporosis
- •
Hormonal replacement therapy since beginning of menopause.
- •
No excessive caffeine or sodium intake, or limit their intake.
Factors increasing risk of falls/fractures
- •
Intake of over-the-counter hypnotic tablets.
Factors reducing risk of falls/fractures
- •
None.
Diagnosis
- •
Osteoporosis.
- •
The presence of fragility fractures (T7, T8, and T9) is diagnostic of osteoporosis: “morphometric or opportunistic diagnosis.” Pharmacologic treatment is therefore recommended at this stage because the risk of subsequent fractures is increased.
Management recommendations
Treatment(s)
- •
Antiresorptive medication.
Diagnostic test(s)
- •
None at this stage.
Lifestyle
- •
Reduce alcohol intake.
Rehabilitation
- •
If possible, enroll in a physical exercise program.
DXA and radiological
- •
DXA scan in 2 years’ time, preferably at the same center where the present DXA scan was done to allow for a more accurate comparison of the scans.
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