A 67 y/o Caucasian female presents to your clinic with new onset back pain. Her past medical history is significant for rheumatoid arthritis and hypothyroidism. She is a smoker (50 pack years). Her labs are within normal limits; she has no allergies, and has no history of trauma. Her meds include prednisone 5mg po every other day, etanercept 25mg SQ twice a week, and l-thyroxine 0.1mg po daily.

The medical student does an exam and thinks this patient’s problem is muscle strain and wants to send her home with some pain med and muscle relaxants.

Do you agree or not? Why or why not?

SELECT  here for discussion

In this particular patient, osteoporosis should be considered. She has multiple risk factors and the back pain could be from a vertebral fracture.

Risk factors include:

-    Elderly – women start to lose their bone mass almost from birth but this significantly accelerates after menopause. She is on no medication to prevent or slow bone resorption. She is not likely to be getting her 1,200 to 1,500 mg of calcium a day.

-    Female – women need to ensure they receive 1,200 to 1,5000 mg of elemental calcium per day through diet, supplements, or a combination. Weight bearing exercise is important as well.

-    Race – Caucasian or Asian women appears to have the highest risk

-    Other life style risk factors may include sedentary life style, lack of exercise (esp weight bearing exercise), small body frame, family history, late menarche, and early menopause (natural or surgical).

-    Medications – several medications can cause of worsen osteoporosis. Some of these medications include:

     o    Corticosteroids – both oral and inhaled steroids can cause osteoporosis. The greatest bone loss occurs during the first 6-12 months of therapy. The biphosphonates can prevent this steroid-induced osteoporosis in both women and men.

o    Thyroid replacement – excessive thyroid replacement can cause bone loss, esp in younger women.

o    Heparin – long-term heparin use (> 3 months) in doses of > 15,000 to 20,000 units a day can cause osteoporosis. Low molecular weight heparins appear to pose a lesser risk.

o    Tobacco use – cigarette and cigar smoking is directly harmful to bones. Encourage patients to quit for this and a multitude of other reasons.

o    Immunomodulatory drugs – chemotherapy drugs and immunosuppressants can cause osteoporosis. Obviously, cancer patients and transplant recipients receive these agents but so do severe asthmatics, rheumatoid arthritis patients, Crohn’s patients, multiple sclerosis, etc.

It is estimated 8 million women over age 50 have osteoporosis and 22 million have low bone mass. Both are risk factors for fractures, esp hip fractures, which are a significant source of morbidity and mortality in this patient population.

Ensure ALL your female patients, esp those over age 50 and/or post menopausal by whatever means are getting their required daily intake of calcium, the use of osteoporosis drugs are minimized (if possible), stop smoking, and are on some type of bone mass sparing medication (if appropriate) such as alendronate, calcitonin, calcium plus vitamin D, a SERM (selective estrogen receptor modifier) such as raloxifene, etc.

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.