1.

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?

2. A 52 year old Caucasian woman is referred to you by an orthopedic surgeon. She

has acute thoracic back pain associated with rolling over in bed the night before. An
x-ray taken in his office shows an acute thoracic 8 (T8) compression fracture.
Between ages 20 and 26 she had thyrotoxicosis; it was treated with radioiodine; she
has been maintained on l-thyroxine. Menopause occurred at age 49. Her mother and
maternal grandmother have osteoporosis. Her grandmother has had a myocardial
infarction and the patient has a high-risk lipid profile.

She is 68 inches tall (maximum was 70 inches), weighs 118 pounds, had a blood
pressure of 120/80 mm Hg and a regular pulse of 94 per minute. There was new
dorsal kyphosis and tenderness to palpation at T8. The thyroid was not palpable.

Review of the outside x-rays confirmed the fracture at T8 and generalized

demineralization of the thoracolumbar spine. The dual energy x-ray absorptiometry
bone mineral density of the lumbar spine had a T score of minus 3.2 (density is 3.2
standard deviations below the mean of a similar 20 year old woman suggesting bone
loss consistent with osteoporosis). Her TSH concentration was undetectable.

Her l-thyroxine maintenance dose was lowered. She was asked to mobilize as pain
allowed and to walk 1.5 miles three times per week. Non-steroidal anti-inflammatory
agents were recommended for pain. She was instructed on a 1500 mg elemental
calcium diet with calcium citrate supplements as needed. After starting this her
twenty-four hour urinary calcium excretion was low at 0.5 mg/kgm (1.5 to 4.5).
1,25(OH)2 Vitamin D3, 0.25 mcg per day, was started. This increased her urinary
calcium excretion to 1.6 mg/kgm. Because of associated myocardial risk, she was
asked to use conjugated equine estrogens, 0.625 mg and medroxyprogesterone
acetate, 2.5 mg daily.

She returned in two years. Bone mineral density remained the same. She had taken
the estrogen for one year, but stopped it because of fear that it might cause breast
carcinoma. Alendronate, 10 mg daily, was prescribed. Two years later her bone
mineral density had increased 6%. But during her office visit she mentioned
developing esophageal pain related to a bedridden episode of the flu.
 1. List some of the major risk factors for osteoporosis in this patient.  

2. What was the reason l-thyroxine was reduced in this patient?   

3. What was the significance of the low urinary calcium excretion and how does
therapy with 1,25(OH)2 vitamin D3 correct this problem?  

4. What are some reasons for use of hormone replacement therapy in this
woman? Is therapy with estrogen and progesterone sufficient?  

5. Is the patient’s concern regarding breast carcinoma valid?   

6. Discuss the benefits and side effects of alendronate used to treat osteoporosis
in this patient. If she had esophageal emptying problems, would you use it?   

3. Agnetha Perry is 36 years old and she has been taking Ovranette (ethinylestradiol
30μg and levonorgestrel 150μg; Pfizer) for six months. She has no personal or family
history of heart disease or venous thromboembolism (VTE). She stopped smoking
over a year ago, but has recently started to smoke again because of stress at work.
She now smokes 20 cigarettes a day. She has noticed some bad headaches;
sometimes she has to take time off work because of them. She is not sure what is
causing her headaches. She has just seen the practice nurse at her GP surgery to
get a repeat prescription. Her blood pressure at check-up was 120/67mmHg and her
body mass index (BMI) was 27. Should she continue on Ovranette?