Atypical Femur Fracture on Denosumab and Prednisone with Multiple Vertebral Compression Fractures, Frailty and Diminishing Quality of Life

Case Description

Atypical Femur Fracture on Denosumab and Prednisone with Multiple Vertebral Compression Fractures, Frailty, and Diminishing Quality of Life CO is a 70yo female with end-stage O2 and steroid dependent COPD/asthma with multiple thoracic and lumbar compression fractures contributing/causing non-ambulatory status and impairment of ADL's. She was treated with denosumab(Prolia) 2011-2015 until atypical femur fracture (figure 1) and metatarsal fracture occurred. She was on risedronate(Actonel) prior to this, 2004-2007, until side effects of esophageal spasm/GI irritation occurred and therapy was discontinued. Teriparatide(Forteo) was offered after discontinuing denosumab however patient noted possibility of bone cancer and declined it.

Compression fracture bracing and walker to wheelchair transition occurred about 2 months prior to referral for treatment recommendations. PMH: osteoporosis, COPD, asthma, osteoarthritis, low back pain with scoliosis and kyphosis, hypertension, previous smoker-quit 2010 (+/-25 pack year hx), hypokalemia, ocular migraines PSH: femur repair, cataracts, tubal ligation Meds: lisinopril 40mg, prednisone 10mg alternating with 5mg qd, tiotropium inhaled, montelukast 10mg, symbicort 160/4.5 2 puffs bid, albuterol prn (uses daily), ipratropium/alb nebs bid prn, potassium chloride 20meq qd, fluticasone NS qHS, cetirizine 10mg bid, cyclobenzaprine 5mg prn, acetaminophen prn Supplements: multivitamin, glucosamine/chondroitin qd, Vit D 2000IU qd, Ca citrate/D 315-200 qd FamHX: mother: breast cancer & OP Social Hx: married, retired piano instructor, rare alcohol, attends pulmonary rehab 2x/week until recent compression fracture, now unable due to pain ROS: unintended weight loss, prednisone dependent x 10 years; unable to tolerate multiple attempts at prednisone taper, significant pain reported from new compression fracture with mobility impairment Imaging Studies XRays: Thoracic spine (2 months prior to eval)1. Scoliosis 2. Multilevel age- indeterminate compression fractures, T10-12. Estimated 50% vertebral body height loss, no change. Mild, anterior compression deformity L1, stable compared to 2018. 2 week follow-up X-ray to above:

1. New mild anterior compression deformity of L2 with approximately 15% vertebral height loss. 2. Unchanged T10-L1 compression fractures. 4mm anterolisthesis of L4 on L5 without change. DXA: recent; Hip T score, total -3.5, femoral neck -4.1, Spine (L1-4) T score -3.0 Comparison to study done 5 years prior: Hip: loss of 16.3%, spine: stable Labs: (Pertinent) Vitamin D 35, CBC: WBC 11.7, Hgb 14.2, platelets 324, CMP: n'l, Alk phos: n'l, Ca 9.9, TSH n'l PE: Height; original 4’ 8.5” current 4’ 5.5”, weight 88#, BMI 21, 02: 90% on 3 liters Alert, spry, cognition intact, in wheelchair, labored breathing, prominent thoracic kyphosis, back brace in place. Patient request to “heal vertebrae and have ability to walk without a walker and back brace.” A treatment dilemma given history of atypical femur fracture while on denosumab and prednisone and continued progression/worsening of compression fractures, frailty and diminishing quality of life.