Osteoporosis Case history: 68-year-old white womanPresents to accident and emergency department with right wrist pain, swelling, and displacement following a fall onto outstretched hand on the stairs at home

History Past medical history asthma since childhood (treated with corticosteroids aged 5055), gastric ulcer aged 45, menopause age 59, left wrist fracture aged 67Family history stroke in sister aged 65, hip fracture in mother aged 78. Mother diagnosed with osteoporosisSocial history lives alone, 2 children, retired, smokes 5 cigarettes per day, occasional alcohol, takes no exercise, fully mobile and able to complete all ADLs (activities of daily living)

Examination On examination wrist displaced, swollen, no open woundNo loss of sensation or vascular compromiseX-ray Colles fracture of distal radius present N.B. The most common osteoporotic fractures are vertebrae, wrists, and hips. Lifetime risk of fracture in white women is 20% for spine, 15% for wrist, and 18% for hip. There is an exponential increase in fracture over 50 years

Further issues for you to consider... How can further fractures be prevented? Bisphosphonates are the most commonly used treatment, but how useful are they? Are there any non-pharmacological treatments that would help? Which of these options are most appropriate for this particular person? How strong is the evidence for these options?

Bisphosphonates Clinical question Different bisphosphonates for which we have searched for systematic review or randomised control trial evidenceCategorisation of effectiveness for each bisphosphonate we cover Click on the drug of interest to see the evidence base for the benefits and harms

Individual medicine Thinking about this person: Past medical history previous fracture, postmenopausal, corticosteroid use, gastric ulcer We can see from the review that alendronate, (and other bisphosphonates) are associated with gastric ulcers and erosionsTherefore, we should consider other options, but remember as well that this is not a contraindication, but a caution about their use

Family history stroke (raloxifene may increase stroke risk) What would be better?

Using Clinical Evidence to help answer the patients questions Questions your patient has Several friends take HRT and have recommended this should she do the same? At present, she does not take any regular exercise, but wonders whether this is important. She has heard that exercise strengthens the bones, but is worried about having a fall and getting another fractureSince the diagnosis she has been taking calcium and vitamin D supplements as she hoped these would reduce her fracture risk are these a good use of money and are they harmful in any way?

Conclusions Risks of HRT outweigh the benefitsWe dont know if exercise is beneficialMonotherapy with calcium or vitamin D has not been shown to reduce fractures Bisphosphonates are effective but are associated with gastric ulcersRaloxifene increases stroke risk

Audrey is a 45-year-old female with heavy periods that are becoming increasingly irregular. She and her partner currently use condoms but she wonders if this is necessary (she thinks its unlikely that she could become pregnant at her age). She is healthy with no history of hypertension and she doesnt smoke. Some of her friends are using the birth control pill to regulate their periods (and sometimes to avoid their periods altogether!) but she wonders if this is safe. She had used the pill in the past with no problems but stopped taking it because she thought that she had to stop taking it when she turned 35.

Who can take the OC?Is menstrual suppression with the pill safe?Whats the risk of venous thromboembolism (VTE) among OC users? Should women be screened prior to starting the OC?Is the Pill associated with an increased risk of cancer?Role of anti retroviral agents in OC users!

an older gentlemen named Crandle and he comes to you with spiking back pain. On exam, he has loss in his arms and legs, loss of motor function. You suspect metastatic cancer of the prostate to the SPINE. What are the classes of drugs you will be asked to master for this MOST COMMONLY diagnosed cancer in the US

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