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Question 5#

An orthopedic surgeon asks you to help him manage an 82-year-old woman who just received a hip replacement as a result of a hip fracture. The patient was watering her flowers when she tripped on the water hose and heard her hip crack as she fell to the ground. She has a history of hypothyroidism, mild CVA, and hypertension. Her mother had lost about 5 inches of height in her older years. She believes that she has lost “a few inches” in comparison to her husband. On review of systems, she admits to chronic diarrhea. Her only home medication is metoprolol. On physical examination, her blood pressure is 158/90; pulse 88 and regular; the hip is tender to palpation. Labs show normal calcium, renal function, and alkaline phosphatase. TSH, celiac panel, and 25-OH vitamin D level are also normal.

Which of the following medications would be most effective in preventing another fracture? 

a. Raloxifene
b. Calcitonin-salmon nasal spray
c. Estradiol
d. Hydrochlorothiazide
e. A bisphosphonate

Correct Answer is E


This patient has a diagnosis of osteoporosis based on the occurrence of the hip fracture, regardless of her T-score. Bisphosphonate therapy is proven to reduce the high risk of subsequent hip and vertebral fractures. Raloxifene is less appropriate for this patient with her history of a CVA, as it has been associated with increased incidence of thromboembolic events and stroke. The effect of nasal calcitonin on fracture risk is unknown. Estrogen therapy is approved by the FDA for the prevention of osteoporosis, but not for treatment. Estrogens and raloxifene are equally thrombogenic. Hydrochlorothiazide decreases urine calcium loss and helps maintain bone density. Epidemiologic data suggest decreased first fracture risk with long-term use, but it is not proven to decrease risk of subsequent fractures.