1. Osteoporosis Management: Clinical scenario

2. Case 1 Status Medical History Medical History Women, 49 y
Asymptomatic
- BMD T-scores: -2.7
Status
Menopause: 45y
Mother : hip fracture
at age of 79 y
Medical History
Medical History
Yes
Differentiation: Secondary osteoporosis
(Hypogonadism, thyroidism…)
Further examination?
Yes
Maybe asymptomatic vertebral fracture
(deformity)
Spinal X-ray?
Vertebral fx
Normal No
Because the risk for the patient sustaining
a fracture in the next 10 y is low
Rx?
Yes
Because the risk for a subsequent fx
is high
Rx?
Anti-resorption
(alendronate, risedronate or raloxifene)

3. Case 2 Status Medical History Medical History Women, 55 y Normal
Asymptomatic
- BMD T-scores: -1.5
Status
Normal
Medical History
Medical History NO
Further examination?
Considerable when having more
clinical evidence
Spinal X-ray?
Rx?
Vertebral fx
Normal No
Because the risk for the patient sustaining
a fracture in the next 10 y is low
Adequate calcium dietary, vitamin D
Icrease weight-bearing exercise
Prevent falls
Very low or ultra-low HRT or oral bisphosphonates can be considered
Rx?
Yes
Because the risk for a subsequent fx
is high
Rx?
Anti-resorption
(alendronate, risedronate or raloxifene)

4. Case 3 Status Medical History Women, 65 y Menaupause: 50y
Frequent back pain
- HRT: undesired
Menaupause: 50y
Lose ht: 8cm
Prior fx (distal radius)
Yes
Measure BMD
Further examination?
Yes
Maybe vertebral fracture (back pain)
Spinal X-ray?
Depend
Osteoporosis: YES
Non-osteoporosis: NO
Normal
Rx?
Rx?
Anti-resorption
(alendronate, risedronate or raloxifene)
Vertebral fx
Yes

5. Case 4 Status Medical History Men, 80 y
Arrival with hip fracture
(fall from standing height)
Difficult to keep balance when standing
Susceptible to fall NO
Further examination? NO
Apparently Clinical features
Spinal X-ray?
Normal
Rx?
Rx?
Anti-resorption
(alendronate, risedronate or raloxifene)
Vertebral fx

6. Case 5 Status Medical History Women, 45 y, teacher No height loss.
Body weight at average of age group.
Expiratory wheeze noted.
BP: 140/82
BMD T-scores: -2.6
Lab test results:
sCa: 8.9 (normal: )
normal CBC
normal cholesterol
24-hour urine calcium: 50 mg
25 OH vitaminD:8ng/mL (normal: > 20).
Never use HRT
Had asthma since childhood, current medications: b.i.d. steroid inhale+ glucocorticosteroid 5-6 times/y for 2-6 wk for exacerbations.
Diagnosed with a seizure disorder at aged 20y, currently well controlled with Phenytoin 300mg/d.
Currently use multivitamin daily
No history of osteoporotic fracture.
Surgical menopause five years previously

7. Case 5 Comments Summary BMD much lower than expected level for her age
Several risk factors for secondary osteoporosis:
early surgical menopause
chronic exposure to anticonvulsants
corticosteroids use
Vitamin D defficiency + seizure  high risk of fall
Summary
This case is a timely reminder that not all low bone density is simple osteoporosis. Several potential causes of secondary osteoporosis needed to be addressed before she could be treated successfully for
Further examination?
HRT is suitable
Bisphosphonates
Rx? NO