Pharmacology
Osteoporosis
Case Study
Patient Profile
Name: Jody Kutnetsov
Age: 65 years old
Gender: female
Current Medications
None
History of Present Illness
J.K. is a 65-year-old woman presenting to your office for a routine annual visit. She had not been keeping up with her preventive health care. She agreed to start engaging in recommended preventive care after she fell and broke her arm last month. She is a one pack per day smoker for 45 years. She states she knows she should quit smoking but does not want to talk about that today.
Relevant Assessment
Afebrile, hemodynamically stable, well oxygenated on room air.
Constitutional: Thin, frail appearing women. No acute distress.
Musculoskeletal: Cast left forearm.
Mammogram: BIRADS score of 0; no evidence of malignancy, benign.
DEXA scan results support a diagnosis of osteoporosis with a forearm score of -2.5= osteoporosis. (The other measurements are omitted here as once one area meets this criterion the diagnosis is established.)
Serum calcium results within normal limits; vitamin 25 (OH) D low-15 ng/mL; estimated glomerular filtration rate greater than 60 mL/min/1.73 m2.
No other expanded review of system (subjective data) or examination (objective data) has an impact on the diagnosis reviewed in this case.
Differentials
Osteoporosis, osteopenia, osteomalacia, hyperparathyroidism, Paget’s disease, bone metastasis from malignancy
Diagnosis
Osteoporosis
Diagnostic Testing
No further testing for osteoporosis at this time
Referrals
None at this time
Patient/Provider Collaborative Goals
The patient will have no further fractures and bone density loss will slow or halt by time of planned follow-up.
Therapeutic Interventions
- Describe a first-line pharmacologic treatment: Include drug name, dose and formulation, frequency, and length of treatment at this dose.
Answer:
One option is alendronate (Fosamax) 70 mg tablet by mouth once weekly.
- Drug Mechanism of Action:
Answer:
Alendronate (Foxamax) is a bisphosphonate. This class of drugs inhibits bone resorption via actions on osteoclast precursors or osteoclasts. Alendronate (Fosamax) slows the rate of bone resorption, increasing bone mineral density.
- Contraindications if applicable:
Answer:
Hypersensitivity to alendronate (Fosamax) or any of the components in the formulation. Additionally, low serum calcium, esophageal stricture or achalasia, inability to maintain upright posture for 30 consecutive minutes, or high aspiration risk.
- Drug Mechanism of Action:
- Therapeutic advisement and monitoring: (include any specific instructions that apply, such as when to take the medication, if there are foods to avoid, storage issues, etc; include what laboratory/other (i.e., EKG) test monitoring to expect and how often and monitoring for adverse effects both common and serious)
Answer:
Specific Instructions: Instruct patients to sit upright for a minimum of 30 consecutive minutes after ingesting alendronate (Fosamax). Counsel the patient that if they miss a dose, they should take the dose on the day they realize, then resume taking the weekly dose on the day that had been previously scheduled. However, patients should be advised not to take two doses in one day.
Inform patients to make sure to take this medication on an empty stomach with a full glass of water without anything else. Any type of food or drink can make this medication ineffective. Advise the patient to please wait at least 30 minutes before eating or drinking and two hours before taking any type of calcium supplement or antacid.
Ask the patient if she knows how smoking relates to bone health. Counsel the patient that smoking cessation will not just help keep lungs healthy; it will also help increase bone density or at least help prevent further bone loss. If the patient is willing to consider smoking cessation, offer and provide support including nicotine replacement, other medications, or cognitive behavioral therapy.
Educate the patient that nutrition is very important to bone health. Instruct the patient to add calcium-containing foods to their diet such as cheese, milk, yogurt, broccoli, and spinach. The goal is a minimum of 1,200 mg daily.
Patients should also be advised to report any serious adverse effects listed below.
- Therapeutic Monitoring: The nurse practitioner (NP) should order a DEXA scan at baseline and then every one to three years during alendronate (Fosamax) therapy. NPs should monitor renal function tests, including Creatinine, blood urea nitrogen, (BUN), and estimated glomerular filtration rate (eGFR) at baseline and quarterly or semiannually thereafter depending upon the patient’s risk of renal impairment. Additionally, vitamin D, calcium, and phosphorus levels should be assessed at baseline and then quarterly or semiannually thereafter, once the patient’s levels have been stable for a year. The NP should consider ordering supplementation to achieve therapeutic levels if necessary.
- Serious Adverse Effects:
- Hypocalcemia: This is the most common adverse effect. Monitor and supplement as noted above in question two.
- Atypical Femur Fracture: Patients should be educated to call the office for evaluation if they develop groin, hip, or thigh pain.
- Gastrointestinal Mucosa Irritation: Esophagitis, dysphagia, esophageal ulcer, erosive esophagitis, esophageal stenosis, and esophageal perforation are potential but rare adverse effects.
- Musculoskeletal Pain: Rarely, some patients experience this type of pain, making alendronate therapy intolerable. The benefits and risks of continuing alendronate (Fosamax) should be discussed, and shared decision-making outcomes should be documented.
- Osteonecrosis of the Jaw: If patients experience jaw swelling or pain, they should seek medical attention. This drug may cause jawbone problems. This risk may be higher with longer use, cancer, dental problems, ill-fitting dentures, anemia, blood clotting problems, or infection. It may also be higher if the patient has dental work, chemotherapy, radiation, or takes other drugs that may cause jawbone problems.
- Skin Problems: Erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN) can occur. Monitor patients for any skin rashes including blisters or peeling skin. If present, the patient should be evaluated immediately, especially if the patient has a fever. These may occur without a fever as well.
- Ocular Emergencies: If the patient experiences dry, painful, red eyes, or any visual disturbances, these are signs and symptoms of ocular inflammation. Ocular inflammation can be associated with rare but serious eye problems called scleritis, episcleritis, and uveitis. Should this occur, the patient needs prompt attention from an eye specialist.
- Planned follow-up should consider adverse effect monitoring, dose adjustment considerations, and decisions about continuing versus discontinuing. In this case, planned follow-up would be:
Answer:
Follow-up in one year with DEXA scan completed prior to the office visit. Call for an appointment sooner if there is concern about adverse effects.
Review Questions
Click the arrow to expand the section and view the correct answers.
- What medication represents the bisphosphonate class used to treat osteoporosis in post-menopausal women?
- Denesumab (Prolia)
- Alendronate (Fosamax)
- Romosozumab (Evenity)
- None of these
Answer:
B. Alendronate (Fosamax)
Feedback: Bisphosphonates are the most commonly used drug class to treat post-menopausal osteoporosis. The most common of those is alendronate (Fosamax). Others include risedronate (Actonel) and ibandronate (Boniva). Additionally, there is an intravenous bisphosphonate, zoledronic acid (Reclast).
- Considering comprehensive care for osteoporosis, what interventions in addition to bisphosphonate therapy are appropriate? (Select all that apply)
- Vitamin D replacement for serum vitamin 25 (OH) D of 38 ng/mL
- Vitamin D replacement for serum vitamin 25 (OH) D of 15 ng/mL
- Smoking cessation
- Minimize physical activity to avoid fractures
- Encourage weight bearing exercise to promote increased bone density
- Encourage foods rich in calcium
- Avoid excessive calcium intake
Answer:
B. Vitamin D replacement for serum vitamin 25 (OH) D of 15 ng/mL; C. Smoking cessation; E. Encourage weight bearing exercise to promote increased bone density; F. Encourage foods rich in calcium
Feedback: Comprehensive care for your patient with post-menopausal osteoarthritis includes correcting deficiencies in vitamin D and calcium. In addition, comprehensive care includes smoking cessation for smokers. Promote weight bearing exercise to stimulate osteoclast production, increase bone density, and improve balance and strength to prevent falls. Falls prevention is also important; advise your patient to have good lighting and to avoid throw rugs and electrical cords.
- Oral bisphosphonates are contraindicated in which patient?
- Someone with a history of recent fractures
- Someone with a history of dental caries
- Someone with a history of presbyopia
- Someone with a history of gastroesophageal reflux disease with esophagitis
Answer:
D. Someone with a history of gastroesophageal reflux disease with esophagitis
Feedback: Oral bisphosphonate therapy may cause esophagitis and even esophageal ulceration, though this is rare.
- You have a 68-year-old woman presenting for a same-day visit with concern for “pink eye” who wants antibiotics. She has a history of post-menopausal osteoporosis and is on bisphosphonate therapy. Which of the following statements is true?
- Patients with concern for pink eye need antibiotic eye drops.
- Patients with a history of post-menopausal osteoporosis on oral bisphosphonate therapy may experience release of inflammatory cytokines impacting the eyes.
- Patients with concern for blurry vision are likely having a stroke and should stop bisphosphonate therapy.
- None of these are accurate.
Answer:
B. Patients with a history of post-menopausal osteoporosis on oral bisphosphonate therapy may experience release of inflammatory cytokines impacting the eyes.
Feedback: Patients with a history of post-menopausal osteoporosis on oral bisphosphonate therapy may experience release of inflammatory cytokines impacting the eyes. Inflammatory cytokines may lead to conjunctivitis, scleritis, blurred vision, and eye discomfort.
- Patient education for bisphosphonate therapy includes lying flat for at least 30 to 60 minutes after ingestion of the medication, depending upon which agent is used. (True or False)
- True
- False
Answer:
B. False
Feedback: Patient education for bisphosphonate therapy includes remaining seated or standing upright for at least 30 to 60 minutes after ingestion of the medication, depending upon the agent used. Alendronate (Fosamax) and risedronate (Actonel) require a minimum of 30 minutes upright while ibandronate (Boniva) requires a minimum of 90 minutes upright to prevent esophagitis.
- Which instruction is correct when teaching patients about alendronate (Fosamax)?
- Dairy products are ok to ingest with alendronate.
- As long as the food contains vitamin D and calcium it is ok to take with alendronate.
- Alendronate should be taken in the morning before any food or fluid, except water to take the medication.
- After taking the medication, it is ok to eat and drink at any time.
Answer:
C. Alendronate should be taken in the morning before any food or fluid, except water to take the medication.
Feedback: With the exception of delayed release risedronate, bisphosphonates should be taken before any food or fluids. Additionally, there should be no food or fluid consumed for 30 minutes after taking the medication. Regarding ibandronate, food or fluid ingestion should be delayed for 60 minutes post ingestion.
- Raloxifene is used to treat osteoporosis by preserving bone mineral density and reducing serum cholesterol levels. Which class of medication is raloxifene?
- Selective estrogen receptor modulators
- Bisphosphonates
- Monoclonal antibodies
- Vitamin supplement
Answer:
A. Selective estrogen receptor modulators
Feedback: Raloxifene (Evista) is a selective estrogen receptor modulator used to preserve bone mineral density. It has an additional benefit of reducing serum cholesterol levels.
- Raloxifene is contraindicated for post-menopausal women with a history of stroke or risk factors for coronary heart disease. (True or False)
- True
- False
Answer:
A. True
Feedback: Raloxifene is contraindicated for post-menopausal women with a history of stroke or risk factors for coronary heart disease. This medication has a boxed warning related to increased risk of venous thromboembolic events and increased risk of stroke when used for post-menopausal women with history of or risk factors for coronary heart disease.
References
Condina Leik, M. T. (2025). Common disorders in geriatrics. In FNP Certification Intensive Review (pp. 493–512). Springer Publishing.
Rosen, H. N. (2025). Bisphosphonate therapy for the treatment of osteoporosis. UpToDate®. Retrieved June 11, 2025 from https://www.uptodate.com/contents/bisphosphonate-therapy-for-the-treatment-of-osteoporosis
Rosenthal, L. D., & Burchum, J. R. (2026). Drugs affecting calcium levels and bone mineralization. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 540–556). Elsevier.
impaired contraction of the esophageal preventing food from passing into the stomach
