What is the next step in managing a vertebral fracture with suspected osteoporosis in a 68-year-old woman?

From the Guidelines

The most appropriate next step in management for this 68-year-old woman with a vertebral fracture after a minor fall is to schedule a dual-energy X-ray absorptiometry (DEXA) scan before starting any treatment. While the patient's age, fracture after minimal trauma, and family history strongly suggest osteoporosis, a DEXA scan is essential to confirm the diagnosis, determine the severity of bone loss, and guide appropriate treatment decisions 1. The scan provides T-scores that quantify bone mineral density and help classify the patient as having normal bone density, osteopenia, or osteoporosis. This information is crucial for determining the appropriate medication regimen and monitoring treatment effectiveness over time.

According to the American College of Physicians guideline update, pharmacologic treatment with bisphosphonates, such as alendronate or risedronate, is recommended to reduce the risk of hip and vertebral fractures in women with known osteoporosis 1. Additionally, the EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture emphasize the importance of preventing subsequent fractures through a comprehensive treatment plan that includes pharmacologic therapy, calcium, and vitamin D supplementation 1.

After obtaining the DEXA results, treatment would likely include a bisphosphonate (such as alendronate 70mg weekly or risedronate 35mg weekly), calcium supplementation (1000-1200mg daily), and vitamin D (800-1000 IU daily) 1. Pain management and physical therapy would also be important components of the treatment plan, but obtaining objective bone density measurements through DEXA scanning is the necessary first step to establish a baseline and guide evidence-based treatment decisions.

Some key points to consider in the management of this patient include:

• The patient's risk factors for osteoporotic fracture, including increasing age, female sex, and family history of osteoporosis 1
• The importance of confirming the diagnosis of osteoporosis through DEXA scanning before starting treatment 1
• The recommended pharmacologic treatments for osteoporosis, including bisphosphonates, denosumab, and teriparatide 1
• The need for a comprehensive treatment plan that includes calcium and vitamin D supplementation, as well as pain management and physical therapy 1

From the FDA Drug Label

The diagnosis can be confirmed by the finding of low bone mass, evidence of fracture on x-ray, a history of osteoporotic fracture, or height loss or kyphosis, indicative of vertebral (spinal) fracture The most appropriate next step in management is to Schedule a dual-energy X-ray absorptiometry (DEXA) scan before starting any treatment, as the patient has never undergone bone density testing and has a family history of osteoporosis, as well as a recent vertebral fracture 2.

From the Research

Next Steps in Management

The patient presents with a vertebral fracture and a family history of osteoporosis. Considering the evidence, the most appropriate next step in management would be to:

• Schedule a dual-energy X-ray absorptiometry (DEXA) scan before starting any treatment, as it is a crucial diagnostic tool for assessing bone mineral density and diagnosing osteoporosis 3, 4
• The DEXA scan will help determine the patient's bone mineral density and T-score, which are essential for guiding treatment decisions 3, 4
• While bisphosphonate therapy may be considered in the future, it is not recommended to initiate it immediately without first assessing the patient's bone mineral density 5, 6
• Calcium and vitamin D supplementation may be considered, but it is not the most appropriate next step without first assessing the patient's bone mineral density 5, 7
• Referral to an orthopaedic surgeon for surgical intervention may not be necessary at this stage, as the patient's condition can likely be managed conservatively with medication and lifestyle modifications 5, 6

Considerations for Treatment

When considering treatment options, it is essential to:

• Assess the patient's bone mineral density and T-score using a DEXA scan 3, 4
• Consider the patient's medical history, including their family history of osteoporosis 5, 7
• Evaluate the potential benefits and risks of bisphosphonate therapy, including its effects on bone mineral density and fracture risk 5, 6
• Discuss treatment options with the patient, including lifestyle modifications, medication, and potential surgical interventions 5, 6