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Osteoporosis Management: Clinical scenario

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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  1. Osteoporosis Management:Clinical scenario

  2. 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?

  3. 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?

  4. 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

  5. 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

  6. 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).

  7. 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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