Aroonsiri Sangarlangkarn, MD, MPH, Jonathan S. Appelbaum, MD, FACP
1. Describe two features that distinguish osteoporosis in HIV-infected patients from that in the general population.
2. Outline a factor for osteoporosis in HIV-infected patients and the strategy to minimize its effects on bone health.
3. Apply an evidence-based approach to the evaluation and management of osteoporosis in HIV-infected patients.
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Ms. Fracture is a 50-year-old woman with past intravenous drug abuse, chronic obstructive pulmonary disease (COPD) from tobacco abuse, HIV well-controlled on ART who presents to your clinic to establish care. Her current medications include prednisone 10 mg daily, methadone 100 mg daily, ritonavir, atazanavir, tenofovir and emtricitabine daily. Her last CD4 count is 200 cells/mm3, and her viral load is undetectable.
As part of the initial intake, you ask whether she has had a bone density scan in the past to screen for osteoporosis, to which Ms. Fracture replies, “Doctor, what is osteoporosis?”
Questions:
After explaining to Ms. Fracture what osteoporosis is, you proceed to collect more information regarding her medical history.
Ms. Fracture was diagnosed with HIV 20 years ago during a period of heavy drinking and injection drug use, when she was found to have Pneumocystis jiroveci pneumonia (PCP) because her CD4 was “nonexistent.” Ms. Fracture underwent menopause when she was 46 years old. Although she has never broken any bones because she is sedentary, her mother broke her hip and wrist due to falls before she passed away.
When you review the medication bottles, you learn that she is also taking furosemide 20 mg every other day for blood pressure and esomeprazole 40 mg daily, which was started during a hospitalization many years ago. She is unsure what the esomeprazole is for.
On physical exam, her weight is 120 lbs, BMI 17.15. She is afebrile, BP 110/60, pulse 65, oxygen saturation 100% on room air. She is thin, but otherwise her exam is unremarkable.
Ms. Fracture is eager to make the changes you suggest, but she also wants to know if she has osteoporosis.
DXA results show the following T-scores: Hip total -2.8, femoral neck -2.4, L4 -2.5
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