Difficult Problems with Osteopenia


Question

S-I practice (general endocrinology) in Tupelo, MS (the birthplace of elvis presley). I was wondering if you could share your thoughts regarding these 2 cases.

Patient #1:

Patient #1: are you comfortable in giving forteo on this pt?

Ms. Owen is a 48 year old white female with a diagnosis of clinical osteoporosis, osteomalacia with multiple fractures. tolerated pamidronate IV infusion (although with some nausea) in 10-05. also had zometa injection 4 mg 02-20-06 and 05-07. has missed dose of zometa this year. had allergic reaction of boniva IV. continues to have leg cramps and bone pains. +pain hips r>left, radicular pain to right leg. stopped smoking in 2007 after taking chantix (took for 5 months). h/o Mild to moderate mitral regurgitation in 05-07 - requires prophylaxis for endocarditis.

Interval history:

h/o osteogenesis imperfecta. sees hematology for hypercoagulopathy due to factor XIII deficiency, h/o pulmonary emobolism, h/o hyperhomocystinemia, osteoporosis. h/o multiple fractures even with trivial trauma. pt is shortest in the family. +decreased hearing left, teeth loss. no kidney stones. did not tolerate fosamax, actonel, miacalcin spray. h/o hypercoagulopathy. h/o pulmonary emboli s/p filter placement. MRI 06-15-06: mild canal stenosis C5-6 due to endplate osteophyte. complains of neck and upper back pain and also lower back pain. decreased hearing left ear

PTH PG/ML 63.8 PG/ML SODIUM 142 MEQ/L (136-145) POTASSIUM 4.5 MEQ/L (3.6-5.0)

CHLORIDE [H] 111 MEQ/L (98-107) CO2 25.0 MEQ/L (22-30) GLUCOSE SERUM 82 MG/DL (70-110)

BLOOD UREA NITROGEN 8 MG/DL (6-20) CREATININE SERUM 0.8 MG/DL (0.6-1.0)

ALBUMIN 4.0 GM/DL (3.2-5.0) TOTAL PROTEIN 6.5 G/DL (6.3-8.2) CALCIUM 9.6 MG/DL (8.7-10.4)

BILIRUBIN TOTAL 0.3 MG/DL (0.2-1.3) ALKALINE PHOSPHATASE 94 IU/L (38-126)

SGOT 20 U/L (15-46) SGPT 18 U/L (9-52)

Bone mineral density (BMD) of the femoral neck is 0.632 g/cm2. The value is 2.0 standard deviations below the mean for young normal control subjects (T-score) and 1.2 standard deviations below for age and sex-matched control subjects (Z-score). The relative risk for future hip fracture is 7.

Bone mineral density (BMD) of the distal ulna and radius is 0.426g/cm2. This value is 2.7 standard deviations below the mean for young normal control subjects (T-score)and 1.9 standard deviations below the mean for age and sex- matched control subjects (Z-score).The relative risk for future fracture is 10.

Based on a minimal detectable change of 0.01 g/cm2 in this bone densitometry unit, there is a statistically significant change -3.2% in the BMD of the femoral/neck compared to 10-06-05.

Impressions: Osteopenia of the hip.

Osteoporosis of the distal ulna/radius.

Unable to adequately interpret lumbar spine view.

Decreased Bone mineral density of the left hip compared to 10-06-05

Patient #2:

Patient #2: What do you think about this case? Only mild osteopenia of forearm. Does she need bone biopsy to confirm osteoporosis or go ahead tx with forteo?

55 y/o white lady with h/o stress fracture 1994 of both hips s/p percutaneous screw fixation. a right hip recurrent stress fracture - s/p surgery 05-05-08. G1P1. hysterectomy 09-2007 due to DUB (ovaries intact) - been on estradiol since then. h/o ruptured disc in 2006 - no surgery. mother has osteoporosis 92 y/o with kyphosis. no loss of height. no kidneys stones. BMD 7 years ago - normal as per pt. does not smoke or drink ETOH. no intake of anti-seizure meds. hearing ok.

XR note from orthopdeic surgery dated 04-08: no sign of avascular necrosis. There is some DJD of right hip. right hip sill has suggestion of an incomplete femoral neck fracture on inferior aspect of the neck. normal appearance of left hip with percutaneous screws.

Bone mineral density (BMD) of the distal ulna and radius is 0.511g/cm2. This value is 1.0 standard deviations below the mean for young normal control subjects (T-score)and 0 standard deviations above the mean for age and sex- matched control subjects (Z-score).The relative risk for future fracture is 2.

HIP BMD unable to be performed due to bilateral hip surgery.

Impressions:

Osteopenia of the distal ulna/radius.

Unable to adequately interpret lumbar spine view.

CALCIUM URINE 159.6 MG/24HR ! 25-HYDROXY D TOTAL 35 PTH PG/ML 24.6 PG/ML

SODIUM 139 MEQ/L (136-145) POTASSIUM 4.7 MEQ/L (3.6-5.0) CHLORIDE 104 MEQ/L (98-107)

CO2 26.0 MEQ/L (22-30) GLUCOSE SERUM 88 MG/DL (70-110) BLOOD UREA NITROGEN 15 MG/DL (6-20)

CREATININE SERUM 0.8 MG/DL (0.6-1.0) ALBUMIN 4.3 GM/DL (3.2-5.0) TOTAL PROTEIN 7.3 G/DL (6.3-8.2)

CALCIUM 9.5 MG/DL (8.7-10.4) BILIRUBIN TOTAL 0.2 MG/DL (0.2-1.3) ALKALINE PHOSPHATASE 96 IU/L (38-126)

SGOT 23 U/L (15-46) SGPT 13 U/L (9-52) GFR NON AFRICIAN AMERICAN 74

ML/MIN PER 1.73 SQUARE METERS GFR AFRICIAN AMERICAN 90

ML/MIN PER 1.73 SQUARE METERS

PERFORMED AT NORTH MS MEDICAL CENTER, 830SOUTH GLOSTER STREET, TUPELO, MS 38801

TSH 2.100 UIU/ML (0.49-4.67) NTX, TELOPEPTIDE, UR 36 SIEP and UIEP normal.

thank you. Gan Lim Leonil

Response

Patient #1:

Patient #1: There is very little data regarding the use of Forteo in patients with OGI. Also, I generally do not use Forteo in the setting of osteomalacia. If you are comfortable that the osteomalacia has been adequately treated (not sure what the underlying cause for that was), I think it would be ok to treat with Forteo for 2 years followed by IV zolendronate, if she can tolerate that. Sundeep Khosla, MD

Patient #2:

Patient #2: Puzzling situation, and the cause of her fractures is somewhat unclear to me. I would prefer in a relatively young patient such as this to obtain a tetracycline labelled bone biopsy (to evaulate bone volume, exclude osteomalacia, or other marrow dyscarasia) before initiating treatment. If the biopsy is unrevealing, then at least you have done what you can to uncover an explanation. Sundeep Khosla, MD