Ms. B, a 72-year-old woman, presents with new-onset low back pain. A comprehensive workup is performed, and a radiograph reveals compression fractures of the L1 and L2 vertebral bodies. The patient recalls no trauma to account for her fractures. Dual-energy x-ray absorptiometry (DXA) is ordered; the results show evidence of osteoporosis. Ms. B asks about initiating longterm treatment.
Osteoporosis is a disease of significant public health concern.1 According to the NIH Osteoporosis and Related Bone Diseases National Resource Center, more than 53 million people in the United States either have osteoporosis or are at high risk for it.2 The total cost of osteoporosis-related fractures is expected to reach $25.3 billion by 2025.3 It is estimated that one in three women (and one in five men) older than 50 will sustain osteoporotic fractures.4 The morbidity and mortality associated with these fractures must be recognized by health care providers in all medical specialties. Appropriate preventive and treatment modalities should be employed when providing care to persons with or at risk for osteoporosis. Advances in medical science have yielded multiple options for the prevention and treatment of osteoporosis.
CASE CONTINUED Ms. B’s medical history includes hypertension and GERD, for which she uses twice-daily dosing of a proton pump inhibitor (PPI). At age 53, she was diagnosed with left breast cancer, which required surgical excision and radiation therapy. She took tamoxifen for a total of five years, and the cancer did not recur. She takes no OTC products, including vitamins. She has no history of systemic inflammatory conditions, kidney stones, or extended treatment with corticosteroids. No history of gastrointestinal surgeries is reported. Ms. B has never smoked cigarettes and has never consumed two or more alcoholic beverages a day. She has no family history of osteoporosis in first-degree relatives. She is otherwise healthy but is physically inactive, with no regular weight-bearing exercise routine. It is also notable that she experienced an uneventful early menopause at age 41 and did not take estrogen replacement therapy.
Regular weight-bearing exercise, adequate calcium and vitamin D intake, smoking cessation, avoidance of heavy alcohol use, and education in fall prevention are vital. Recommended calcium intake varies by age, ranging from 1,000 mg/d to 1,200 mg/d in divided doses.2 Vitamin D intake is recommended at 600 IU/d until age 70; 800 IU/d after age 70;and additional units if deficiency is noted.2 Avoidance of medications that contribute to bone loss (eg, corticosteroids) is also encouraged, if possible. Patient education should include balance training and a home safety assessment.
CASE POINT Nonpharmacologic strategies should be encouraged for every patient to promote optimal bone health and to prevent or treat osteoporosis.
Oral bisphosphonates are considered firstline treatment for osteoporosis; currently available options include alendronate, risedronate, and ibandronate. Bisphosphonates work by inhibiting osteoclast function, thereby reducing bone resorption.5
Oral bisphosphonates have been clinically available since the 1990s and have demonstrated their efficacy, safety, and cost-effectiveness.6-8 However, a thoughtful approach should be taken to their use in specific patient populations: those with esophageal disorders, chronic kidney disease, and/or a history of bariatric gastrointestinal procedures. Bisphosphonates of any form should be avoided in a patient with chronic kidney disease with a glomerular filtration rate ≤ 30 mL/min or ≤ 35 mL/min (based on the package insert for the specific product).7 Patients with a recent or upcoming tooth extraction should also avoid using bisphosphonates until they have healed, due to concerns for osteonecrosis of the jaw.
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