case study osteoporosis default

8/19/2019 Case Study Osteoporosis Default

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Osteoporosis

• Case history: 68-year-old whitewoman

•Presents to accident and emergencydepartment with right wrist pain,swelling, and displacement followinga fall onto outstretched hand on thestairs at home

Case study constructedfor purpose of ClinicalEvidence demonstration.Not based on a patientseen by the author, or onany particular individual


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History

• Past medical history asthma sincechildhood !treated with corticosteroids aged"# ""$, gastric ulcer aged %", menopauseage "&, left wrist fracture aged 6'

• (amily history stro)e in sister aged 6", hipfracture in mother aged '8. *otherdiagnosed with osteoporosis

• +ocial history lives alone, children,

retired, smo)es " cigarettes per day,occasional alcohol, ta)es no e ercise, fullymobile and able to complete all /0s!activities of daily living$


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Examination

• 1n e amination wrist displaced, swollen,no open wound

• No loss of sensation or vascular compromise

• 2-ray Colles3 fracture of distal radiuspresent N.4. 5he most common osteoporotic fractures

are vertebrae, wrists, and hips. 0ifetime ris)

of fracture in white women is # for spine,7" for wrist, and 78 for hip. 5here is ane ponential increase in fracture over "#years


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Investigations and treatment for presentingproblem

• Colles3 fracture treated conservativelywith cast and analgesia

• / 2 scan arranged aspostmenopausal woman with historyof previous fracture, corticosteroiduse, and family history ofosteoporosis osteoporosisdiagnosed in this patient


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urther issues for you to consider!!!

• 9ow can further fractures be prevented• 4isphosphonates are the most commonly

used treatment, but how useful are they• re there any non-pharmacological

treatments that would help• ;hich of these options are most

appropriate for this particular person• 9ow strong is the evidence for these

options


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"isphosphonates

Clinicalts and harms?


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# %&A'E table

5hese Btable rowsfocus onalendronate

5hiscolumnshows thenumber ofstudiesandparticipants that the@A /statementis basedon

9ere, theevidencewas AC5s or+As,gaining a

ma imumof % points.

5he @A /depends on the>nal score oncethe numbers inthe table roware addedtogether. score of %means high-


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Other pharmacological treatments

Fust as withbisphosphonates,clic) on thets and

harms


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(on)pharmacological treatments

? and thesame for non-

pharmacologicaltreatmentsG

Clic) on theseicons to readabout our

categorisationof interventions:they are basedon a systemderived by theCochraneCollaborationPregnancy andChildbirth group


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Individual medicine

• 5hin)ing about this person:• Past medical history previous fracture,

postmenopausal, corticosteroid use, gastriculcer

• ;e can see from the review that alendronate,!and other bisphosphonates$ are associatedwith gastric ulcers and erosions

• 5herefore, we should consider other options,but remember as well that this is not acontraindication, but a caution about their use


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/sing Clinical Evidence to help answer thepatient0s 1uestions#

• Huestions your patient has?• +everal friends ta)e 9A5 and have recommended

this should she do the same• t present, she does not ta)e any regular

e ercise, but wonders whether this is important.+he has heard that e ercise Estrengthens thebones3, but is worried about having a fall andgetting another fracture

• +ince the diagnosis she has been ta)ing calciumand vitamin / supplements as she hoped thesewould reduce her fracture ris) are these a gooduse of money and are they harmful in any way


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H&2 (rom the EIeyPoints3 section, wesee that although9A5 may reducefractures, the ris)sof adverse e=ectsare thought tooutweigh thebene>ts. (rom this,you can advise thepatient of this, andsuggest that thereare other optionsthat are ase=ective but safer

5his may help answer the patient3s cial e=ects, the evidence here showsthat, contrary to media reports, there is notenough high-


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5he patient was )een to>nd out more aboutcalcium versus vitamin /.+he also wanted to )nowwhether there was anyharm in continuing tota)e calciumsupplements in theabsence of goodevidence for their use


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Conclusions

• Ais)s of 9A5 outweigh the bene>ts• ;e don3t )now if e ercise is bene>cial

• *onotherapy with calcium or vitamin/ has not been shown to reducefractures

• 4isphosphonates are e=ective but areassociated with gastric ulcers

• Aalo ifene increases stro)e ris)

case study osteoporosis default

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