Case Studies (October 2017)

CASE 1

BM is a 66-year-old white woman who was brought to the Emergency Department by her daughter after BM slipped in the shower. She had an x-ray of her right hip and leg. No fractures were noted, but the radiologist reported signs of osteoporosis in BM’s hip. BM’s bone mineral density T-score is −2.6 at the hip and −2.0 at the spine. Her Fracture Risk Assessment Tool (FRAX) score indicates that she has a 10-year probability of a major osteoporotic fracture of 45% and hip fracture of 19%. BM has a medical history of hypertension and rheumatoid arthritis, for which she takes hydrochlorothiazide 25 mg orally daily and methotrexate 20 mg orally weekly. She also reports taking naproxen 500 mg orally twice daily but no other OTC medications.

What recommendations regarding pharmacologic treatment would you provide to BM to manage her osteoporosis?

CASE 2

AP is a 77-year-old postmenopausal white woman presenting to her primary care physician for her yearly routine checkup. She has comorbid type 2 diabetes, gastroesophageal reflux disease (GERD), and hypertension. AP also has a history of severe chronic lower-back pain, which makes it difficult for her to stand or sit upright for extended periods. She takes sitagliptin 50 mg daily, pantoprazole 40 mg twice daily, lisinopril 10 mg daily, celecoxib 100 mg twice daily, and pregabalin 150 mg twice daily. AP has normal renal and liver functions. She has just received a diagnosis of osteoporosis by dual x-ray absorptiometry and has a T-score of —2.69 at the spine and –2.0 at the femoral neck. AP has a FRAX score indicating a 10-year probability of major osteoporotic fracture of 11% and hip fracture of 3.4%. Her primary care physician wants to start her on therapy to reduce her fracture risk.

What recommendations would you provide to AP to manage her osteoporosis and reduce the risk of fractures?

SEE THE ANSWERS BELOW

ANSWERS

CASE 1: According to guidelines on the treatment of osteoporosis to prevent fractures in men and women, the American College of Physicians (ACP) recommends that clinicians offer pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk of hip and vertebral fractures in women who have known osteoporosis (T-score ≤—2.3 or those who have experienced fragility fractures). Oral bisphosphonates are typically preferred as initial agents because of their efficacy, safety, and affordability. Zoledronic acid is associated with arthritis and arthralgias, making it a less-attractive choice to initiate in BM, who suffers from rheumatoid arthritis. Additionally, she takes the immunosuppressive agent methotrexate. Because denosumab is associated with an increased risk of infection, it would not be the optimal choice for her. Alendronate and risedronate are both supported by high-quality efficacy and safety data, but alendronate is considerably less expensive. ACP guidelines suggest that clinicians select generic drugs to treat patients with osteoporosis when possible. Taking BM’s chronic conditions, concurrent medications, and the cost of osteoporosis treatments into consideration, the pharmacist could recommend alendronate 70 mg orally once weekly as first-line therapy. Calcium and vitamin D supplementation is also recommended if dietary intake is inadequate.

CASE 2: Oral bisphosphonates are frequently used, cost-effective therapies for treating osteoporosis. However, for AP, oral bisphosphonates may not be the best choice because of her inability to sit upright or stand for extended periods and her comorbid GERD. Oral bisphosphonates are associated with esophageal adverse effects, including esophagitis, esophageal erosions, and perforation resulting from their direct irritation of the upper gastrointestinal mucosa. Patients are counseled to stay upright for at least 30 minutes following oral bisphosphonate administration to reduce exposure of the upper gastrointestinal tract and prevent esophageal adverse effects. According to ACP guidelines, zoledronic acid and denosumab are reasonable alternatives when oral bisphosphonates cannot be used. Either agent would be a reasonable choice to initiate in AP, with the decision being governed by both patient and provider preference. Zoledronic acid, an intravenous bisphosphonate, is dosed at 5 mg infused intravenously over at least 15 minutes and administered once a year. Denosumab, a receptor activator of nuclear factor— kappa B ligand inhibitor, is dosed at 60 mg subcutaneously every 6 months. Perhaps the most important intervention to manage AP’s osteoporosis would be to discontinue her proton pump inhibitor (PPI), pantoprazole, and start an H2 antagonist in its place. PPIs have been associated with increased fracture risk because they presumably reduce the intestinal absorption of calcium. H2 antagonists do not appear to pose this same risk and may be a better option to help manage AP’s GERD.