Monitoring the patient with the use of alendronate 70 mg weekly

      Monitoring should include:

• DEXA scan annually.
• An endoscope to check for stricture formation if difficulty in swallowing.
• U and E: especially plasma calcium and creatinine.

Case Study- Osteoporosis Treatment Options

• Bisphosphonates: available as daily, weekly or monthly preparations, taken on an empty stomach to avoid chelation with the metal ions in the food. It improves bone mineral density by 3 % per year when taken with calcium supplements.
• Calcitonin: available as nasal spray, but requires dietary calcium intake.
• Calcitriol: oral, but need to monitor plasma calcium and creatinine.
• Hormone Replacement Therapy: reverses the urogenitory symptoms but increases the chances of breast cancer.
• Strontium ranelate: must be taken on an empty stomach to avoid chelation with the metal ions in the food.
• Teriparatide: only by injection.
• Raloxifene: does not alter menopausal vasomotor symptoms.

Case Study- Goals of Therapy

The goals of the therapy are to increase the bone mineral density and reduce the likelihood of fracture.

Case Study-Osteoporosis Tests

Bone Mineral Density (BMD) using dual energy X-ray absorptiometry (DEXA) of the head of the femur (on the hip) is performed. The World Health Organization defines osteoporosis if the BMD is 2.5 or more below the adult female mean value. The difference of which is T-score. The T-score of -1 and -2.5 is considered as osteopenia. Other test for detecting osteoporosis is ultrasonography of the heel is performed.

Case Study- Osteoporosis Risk Factors

Mrs. Patel has a low body mass index (<21) and she is on long term steroids.

Other risk factors include poor dietary intake of calcium, lack of weight bearing exercises, excessive alcohol intake, premature menopause (before the age of 45), poor absorption of food consumed, occasional fractures, 3 or more episodes of amenorrhea before menopause, hyperparathyroidism, family history (maternal side).

Case Study-Osteoporosis

Osteoporosis is characterized by micro architectural deterioration of bone tissue and decreased bone mass, with increased bone fragility and risk of bone fracture.

Additional Information with the use of HRT

• To use barrier methods of contraception, as she can still conceive for upto 2 years after her menstruation stops.
• The risk of osteoporosis is decreased while using HRT.
• The risk of thromboembolism, endometrial and breast cancer is increased while using HRT.

Non hormonal treatments-menopause

       Non hormonal treatments include:

• Clonidine: for hot flushes.
• Selective serotonin reuptake inhibitors (SSRIs): for hot flushes.
• Gabapentin: for hot flushes, paraesthesia, aches and pains.

Hormonal treatments for menopause

Due to the presence of estrogen there is increased risk of breast, endometrial and ovarian cancer, venous thromboembolism and stroke, but there are decreased chances of vaginal atrophy, vasomotor instability and osteoporosis.

The use of transdermal formulations is preferred because of decreased systemic side effects as the drug may not undergo the first pass effect in liver, but patient’s preference is important.

• For localized (urogenital) effect: vaginal preparations are preferred having less systemic side effects.
• Without uterus: oral or non-oral estrogens without progesterone are used to avoid endometrial cancer.
• With uterus and perimenopausal: sequential HRT is used to allow a bleed.
• With uterus and postmenopausal: continuous combined HRT is used.
• High dose progestogen (medroxyprogesterone) is useful for vasomotor instability without any cardiovascular conditions.

Case Study- Menopause Cause

Reduction in the circulating estrogen levels. Serum Follicle Stimulating hormone (FSH) will be greater than 30IU/L.