237

SECTION 12
BONE AND JOINT DISORDERS

Menopause at age 39.

95 Right carotid endarterectomy 2 years ago.

쐽 FH
OSTEOPOROSIS Paternal history (+) for CAD; father died at age 60 of “heart
trouble.” Maternal history (+) for stroke and vascular disorders;
Bone Up on Osteoporosis . . . . . . . . . . . . . . . . Level II mother became menopausal at approximately age 40.
Emily C. Farthing-Papineau, PharmD, BCPS
쐽 SH
Julia M. Koehler, PharmD
Widowed; G2P3; 21/2 ppd smoker, quit after MI; non-drinker

쐽 ROS
Mild headaches and new onset back pain, treated with acetamino-
LEARNING OBJECTIVES phen; vaginal dryness; has noticed that her height has decreased by
2'' since she was 35 years old; denies shortness of breath or chest
After completing this case study, students should be able to: pain
• Identify the risk factors for the development of osteoporosis.
쐽 Meds
• Recommend appropriate nonpharmacologic measures for the
Ramipril 10 mg po BID × 2 years
prevention and treatment of osteoporosis.
Tiotropium 18 mcg inhaled once daily × 9 months
• Recommend the correct amount and form of calcium supplemen- Advair 250/50 1 puff BID × 9 months
tation required for the prevention and treatment of osteoporosis. Albuterol MDI 2 puffs Q 6 h PRN
• Design an appropriate pharmacologic treatment regimen for the Synthroid 100 mcg po once daily × 20 years
treatment of osteoporosis in postmenopausal women. Atenolol 50 mg po once daily × 10 years
Aspirin 81 mg po once daily × 12 years
• Provide appropriate patient education regarding osteoporosis Omeprazole 20 mg po once daily × 1 year
and its therapy. Lipitor 10 mg po once daily × 3 months
Os-Cal 500 po TID × 3 months
PATIENT PRESENTATION 쐽 All
NKDA
쐽 Chief Complaint
“My back has been hurting a lot since yesterday.” 쐽 Physical Examination

쐽 HPI Gen

Beverly Jones is a 75-year-old Caucasian woman with a history of WDWN Caucasian woman in NAD
HTN, hyperlipidemia, COPD, hypothyroidism, and osteoporosis. VS
She presents to the family medicine clinic for a follow-up visit for
her HTN and osteoporosis. She has been experiencing episodes of BP 150/94, P 64, RR 17, T 37°C; Wt 53.5 kg, Ht 5'3''
constipation and flatulence since she began taking Os-Cal 500 after
Skin
her last clinic visit.
Fair complexion, color good, no lesions
쐽 PMH
HEENT
HTN first diagnosed at age 50.
S/P MI 12 years ago. PERRLA; EOMI; eyes and throat clear; funduscopic exam reveals
Hyperlipidemia × 13 years; patient modified diet and took cholesty- mild arteriolar narrowing, with AV ratio 1:3; no hemorrhages,
ramine for several years. exudates, or papilledema
Hypothyroidism × 27 years, treated with levothyroxine.
Osteoporosis diagnosed by DXA scan 2 years ago. Neck/Lymph Nodes
COPD diagnosed several years ago. History of repeated exacerba- Supple, without obvious nodes; no JVD
tions requiring prednisone; last exacerbation 6 months ago.
Currently stable on multiple inhalers. Chest
Breast cancer with mastectomy of left breast and radiation therapy Decreased breath sounds bilaterally; air movement decreased; no
at age 40. rales or rhonchi

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 238
Breasts 3.b. What feasible pharmacotherapeutic alternatives are available
for treatment of the osteoporosis?
SECTION 12

Mastectomy scar left breast; right breast normal

CV Optimal Plan
RRR; no murmurs; normal S1 and S2, no S3 or S4 4.a. What drug, dosage form, dose, schedule, and duration of
therapy are best for treating this patient’s osteoporosis?
Abd
4.b. What alternatives would be appropriate if the initial therapy
Soft, NT/ND, (+) BS
fails or cannot be used?
Genit/Rect
Outcome Evaluation
Bone and Joint Disorders

Deferred
5. Which clinical and laboratory parameters are necessary to evalu-
MS/Ext ate the therapy for achievement of the desired therapeutic out-
Good pulses bilaterally come and to detect or prevent adverse effects?

Neuro
Patient Counseling
CN II–XII intact; DTRs 2+; sensory and motor levels intact
6. What information should be provided to the patient to enhance
쐽 Labs compliance, ensure successful therapy, and minimize adverse
effects?
Na 141 mEq/L TSH 3.492 mIU/L Current fasting lipid Three months ago:
K 4.2 mEq/L AST 32 IU/L profile: T. chol 250 mg/dL
Cl 104 mEq/L ALT 27 IU/L T. chol 177 mg/dL Trig 265 mg/dL ■ SELF-STUDY ASSIGNMENTS
CO2 25 mEq/L Trig 215 mg/dL HDL 30 mg/dL
BUN 17 mg/dL HDL 32 mg/dL LDL 167 mg/dL
1. Create a list of medications associated with an increased risk for
SCr 1.0 mg/dL LDL 102 mg/dL AST 20 IU/L developing osteoporosis.
Glu 98 mg/dL ALT 17 IU/L 2. Investigate the new drugs and drug classes under development
for the treatment of osteoporosis.
쐽 Other
3. Develop an exercise plan to prevent osteoporosis.
DXA scan of lumbar spine today reveals: L2–4 = 0.780 g/cm2 (T score:
–3.2 SD); right femoral neck = 0.615 g/cm2 (T score: –3.1 SD)
X-ray of the spine today shows a new compression fracture on L3 CLINICAL PEARL
쐽 Assessment In elderly patients or those on acid-suppressive therapy, recom-
1. Back pain secondary to a vertebral compression fracture mend calcium citrate instead of calcium carbonate, as this salt form
does not require an acidic gastric pH for dissolution.
2. Severe osteoporosis requiring further intervention
3. Hypertension not adequately controlled
4. Hyperlipidemia responding to therapy, but not at goal
REFERENCES
5. Stage IV COPD stable on present regimen 1. Yang YX, Lewis JD, Epstein S, et al. Long-term proton pump inhibitor
6. Hypothyroidism well controlled on present regimen therapy and risk of hip fracture. JAMA 2006;296:2947–2953.
2. National Institutes of Health. JNC 7 express; Seventh report of the
7. Constipation Joint National Committee on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure. Bethesda, Md: National Heart,
Lung, and Blood Institute. National Institutes of Health; 2003. NIH
Publication No. 03-5233.
QUESTIONS 3. Feskanich D, Willett WC, Stampfer MJ, et al. A prospective study of
thiazide use and fractures in women. Osteoporos Int 1997;7:79–84.
Problem Identification 4. National Cholesterol Education Program Expert Panel. Final report of
the third report of the National Cholesterol Education Program
1.a. Create a list of the patient’s drug therapy problems. (NCEP) expert panel on detection, evaluation, and treatment of high
1.b. What information (signs, symptoms, laboratory values) indi- blood cholesterol in adults (adult treatment panel III). Bethesda, MD:
cates the presence or severity of the patient’s osteoporosis? National Heart, Lung, and Blood Institute. National Institutes of
What are the patient’s risk factors for developing osteoporosis? Health; 2002. NIH Publication No. 02-5215.
5. Grundy SM, Cleeman JI, Merz CN, et al. for the Coordinating Commit-
1.c. What additional information would be useful in determining tee of the National Cholesterol Education Program. Implications of
the extent of the patient’s osteoporosis and the need for recent clinical trials for the National Cholesterol Education Program
aggressive therapy? Adult Treatment Panel III guidelines. Circulation 2004;110:227–239.
6. Global strategy for diagnosis, management, and prevention of chronic
obstructive lung disease executive summary. 2006. pgs. 1–31. Available
Desired Outcome at: www.goldcopd.org. Accessed May 24, 2007.
2. What are the goals of pharmacotherapy for osteoporosis in this 7. Management of osteoporosis in postmenopausal women: 2006 posi-
case? tion statement of The North American Menopause Society. Meno-
pause 2006;13:340–367.
8. American Association of Clinical Endocrinologists Osteoporosis Task
Therapeutic Alternatives Force. AACE medical guidelines for clinical practice for the prevention
3.a. What nondrug therapies might be useful for this patient’s and treatment of postmenopausal osteoporosis: 2001 edition, with
osteoporosis? selected updates for 2003. Endocr Pract 2003;9:544–564.