2 min read - Osteoporosis
A 63 years old retired teacher came to a GP to check her blood pressure as she had on and off headache for about 2 months. He denied vomiting, blurring of vision, angina or SOB. There was no significant past history except for a fall in the washroom causing a colles fracture to which had taken ayurvedic treatment.
On examination her blood pressure was 180/100 in both arms and there was no other significant positive finding.
GP adjusted the antihypertensives and within a several months, her BP was well controlled.
However, about a year later she came to GP in a wheelchair! She had again fallen in the bathroom, and this time had fractured her hip.
Oops!!!
Yeah, that's so unfortunate isn't it. There was a chance to prevent this fracture.
So what should have been done?
Any patient with a fragility fracture needs to be investigated for osteoporosis and treated.
What is osteoporosis?
In the simplest terms, there is reduced density and alteration of microarchitecture of the bone, making them vulnerable to fractures.
Any causes?
Most of the time we see osteoporosis in postmenopausal women. Low BMI, physical inactivity, smoking, alcohol, drugs like steroids, endocrine diseases and some malignancies can increase the risk of osteoporosis and fractures.
How do you know if one has osteoporosis?
Certainly if one has a fragility fracture you have to think of osteoporosis. Truly speaking all postmenopausal women aged more than 50 need to be evaluated for osteoporosis.
The standard test to be performed is dual-energy X-ray absorptiometry (DXA) which will give you bone mineral density (BMD).
How do you interpret the report?
Well, there are T scores and Z scores and many stuff, which you need to read. But for post menopausal women like this patient a T score of less than -2.5 indicates osteoporosis.
Is it available in government hospitals?
In some yes, but it is not very expensive to get it done from private sector as well.
What if it's low, but not lower than -2.5?
In such patients a risk assessment with a standard tool like FRAX is important. It gives the probability to have a fracture in the future.
Importantly, FRAX is standardized to Sri Lanka! You can check it up online.
Say, BMD T score is less than -2.5. What should be done now?
You have to look for treatable causes such as thyrotoxicosis. Also do not forget that malignancies like myeloma can cause osteoporosis. Sometimes, pathological fractures can be due to malignant deposits. Measurement of Calcium level and vitamin D level and correction is also important. Even if the levels are normal, it's better to treat with a calcium dose of 1g per day in divided doses with vitamin D 1000IU.
Life style modifications including smoking and alcohol cessation is also important.
However, the most important aspect is the prevention of falls!
Treatment wise, freely available drug of choice is oral bisphosphonate, Alendronate. Usual dosage is 70mg once a week.
What are the side effects?
Major problem is esophagitis and gastritis. You should advice the patient to take the pill empty stomach in the morning with a full glass of water, and stay erect for minimum of half an hour!
Patients can develop allergic reactions. Other MCQ type complications like osteonecrosis of jaw and atypical femoral fractures are seen usually with IV bisphosphonates. But, have a look at the mouth and if the teeth look terrible, refer to a dentist before starting treatment.
How do you know if the treatment is working?
Correction - In patients who are on alendronate it is sufficient to repeat DXA after 5 years, unless the patient suffers a fracture while on treatment. (Dr. Aruna Caldera - Senior Registrar in Rheumatology)
How long should you give?
To make it simple I'd say, give for 5 years and stop it!
Take home?
Never forget to look for osteoporosis in patients with high risk, particularly elderly women. Prevent falls at all costs!
Add another antihypertensive such as thiazides
ReplyDeleteVery useful as usual.. Keep it up Malli... Thanks
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