WBR0238

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Primary Care Office
Sub Category	SubCategory::Musculoskeletal/Rheumatology
Prompt	[[Prompt::A 43 year old female comes to the physician office with complaints of pain and morning stiffness in both hands for the past 6 months. She is on NSAID’s and steroids for the symptoms. She says the pain recurs when she stops taking her medications. She is an alcoholic, smokes 1 pack if cigarette/day. She hasn’t attained menopause and her menstrual periods are normal. After the examination, she was diagnosed with synovitis involving the metacarpophalangeal and the proximal interphalangeal joints. She is started on prednisone on a chronic basis with 7.5mg/day. What is the most appropriate action to prevent osteoporosis?]]
Answer A	AnswerA::Exercise, calcium and Vit D
Answer A Explanation	[[AnswerAExp::Incorrect : The recommended treatment is adequate calcium, vitamin D, and exercise in all premenopausal women with low bone mass. Elemental calcium (from diet and supplements) of 1000 mg and 600 int. units vitamin D daily is recommended.]]
Answer B	AnswerB::Calcium , Vit D, Bisphosphonates
Answer B Explanation	[[AnswerBExp::Correct : Bisphosphonates are an option for women with fragility fractures or accelerated bone loss (≥4 percent/year) while receiving glucocorticoids (7.5 mg prednisone equivalent for ≥3 months) who do not need estrogen replacement therapy because they have normal menstrual function. This patient having normal menstruation should be on Calcium, Vit D and bisphosphonates to prevent osteoporosis.]]
Answer C	AnswerC::Start her estrogen.
Answer C Explanation	[[AnswerCExp::Incorrect : For premenopausal women of childbearing potential taking or initiating glucocorticoids who have amenorrhea can take oral contraceptive or hormone replacement therapy (if not contraindicated)]]
Answer D	AnswerD::Bone densitometry every 6 months
Answer D Explanation	[[AnswerDExp::Incorrect : Patients treated with steroids for more than 3 months should have a baseline bone densitometry done and repeated every one year]]
Answer E	AnswerE::Calcitonin
Answer E Explanation	[[AnswerEExp::Incorrect : Calcitonin is used if bisphosphonates are contraindicated.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::Premenopausal women on chronic glucocorticoids for a variety of inflammatory or autoimmune conditions present a special therapeutic challenge as glucocorticoids reduce the production of sex steroids. As a result, it is logical to start an estrogen-progestin oral contraceptive pill (if not contraindicated) in premenopausal women with amenorrhea who are initiating or taking glucocorticoids. Calcium, vitamin D, and weight bearing exercise are recommended for most women with premenopausal osteoporosis. Pharmacologic therapies that have shown antifracture efficacy in postmenopausal women include bisphosphonates, SERM's, parathyroid hormone (PTH). Educational Objective: References: ]]
Approved	Approved::Yes
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