82-year-old female with severe osteoporosis manifests with vertebral fractures. During treatment with Risedronate, she suffered another fracture. In the expert's opinion, taking into account the patient's age, the presence of fractures and low BMD, the patient is at a very high risk to develop a recurrent fracture so treatment must be given. The expert recommends to rule out secondary causes for osteoporosis such as vitamin D deficiency, to keep a healthy as possible way of life, and change the treatment with Risedronate to Forteo (Teriparatide).
1) Reasons for the occurrence of a fracture during treatment for osteoporosis.
2) treatment options
The patient is an 82 years old woman with severe osteoporosis and multiple vertebral fractures. Diagnosis is based on imaging tests: CT, MRI and BMD. She was treated with Risedronate for more than one year due to previous vertebral fractures.
A CT scan from Feb 2009 shows fractures in vertebrae L2 and L1. The fracture in L1 was not seen in a previous scan and might be considered as a new one.
An MRI done in Mar 2009 show kyphotic deformity of the spine, with fractures in L1 and L2. Both fractures are not interpreted as new ones. There is no evidence of spinal stenosis.
A BMD examination was done at March 2009. The BMD of the spine shows the fractures in L1 and L2. In L3-L4, the Tscore is (-2.45). The interpretation shown in the scan is flowed: the T score in L1 and L2 is elevated due to the fractures and the interpretation should only take into account L3 and L4. Due to this fact, the elevation in the interpretation is not a real improvement in BMD but results from the fractures and should be ignored.
The Tscore in the total hip is (-2.6) and in the femoral neck (-3.1) and decreased by 6-7% according to the scan.
Hemochemical examination is normal. There is no test for: 25 hydroxy vitamin D, anti-gliadin antibodies, protein electrophoresis.
To summarize – the patient is an elderly patient with severe osteoporosis manifests with vertebral fractures. During antiresorptive treatment with Risedronate, she suffered another fracture (according to the CT scan).
Minimal details are provided to me in the attached material concerning the clinical state of the patient. There is no data concerning her physical examination, medical history – diseases or drugs that she is currently having. In addition, no data is provided concerning the fractures themselves and the occurrence of back pain.
The occurrence of a fracture during treatment for osteoporosis might result from several reasons:
- Patient did not take the drug or having problems in absorption
- Patient has secondary cases for osteoporosis
- Fracture was due to trauma
- Disease is too severe.
My recommendations for the patient are as follows:
1. Rule out secondary causes for osteoporosis especially treatable ones. It is most important to rule out vitamin D deficiency, which is very common especially in elderly population. Also – it would be advisable to rule out the presence of celiac disease and multiple myeloma.
2. Keep a healthy as possible way of life:
- Physical activity – is very important to improve coordination and prevent falls and fractures.
- Avoid smoking
- Avoid as much as possible drugs that might exacerbate loss of BMD (such as glucocorticoids)
- Dietary calcium – should be 1200 mg per day. Calcium tablets should be added if her dietary calcium alone does not reach that goal.
- Vitamin D – if normal in the plasma (25-OH-D measured above 30ng/dl), vitamin D treatment should be in a maintenance dose of 800 units per day. If the 25-OH-D measures are lower than 30 ng/dl, vitamin D should be corrected using higher levels of vitamin D.
3. Reconsider treatment with Risedronate. This is a patient with a very elevated risk for recurrent fractures. A new fracture had already happened during treatment with Risedronate. Even if all reasons for the occurrence of a new fracture during treatment are ruled out, still, the best step at this point would be to change treatment to a drug which acts in a different way than Risedronate.
I believe, the best treatment for her would be with Forteo (Teriparatide) by subcutaneous injections of 20 mcg per day, as was advised by the specialist that examined her.
Prognosis - taking into account the patient's age, the presence of fractures and low BMD, the patient is at a very high risk to develop a recurrent fracture so treatment must be given to decrease that risk and improve her prognosis.