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Case contributed by Assoc. Prof. Dr. Terence Ong Ing Wei, Consultant Geriatrician, Universiti Malaya Medical Centre, Malaysia
Patient Information
Age: 65 years
Sex: Female
Ethnicity: Indian
Comorbidities:
- Hypertension
- Previous gallbladder surgery
- Hernia repair
- Moderate-to-severe aortic regurgitation
- Multinodular goitre
Underlying condition: Osteoporosis
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History
- Fell in January 2023 and sustained multiple fractures: vertebral, left proximal humerus, and right lateral malleolus.
- Slipped and fell due to a slippery floor.
- She also had a non-injurious fall 6 months prior.
- Imaging confirmed fractures involving L1, left proximal humerus, and right lateral malleolus. All were managed non-operatively.
- FRAX MOF: 14%, hip: 5.4%.
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Investigation
DXA scan
X-ray
Tests for secondary cause of osteoporosis
- Vitamin D: 48 ng/mL
- Intact parathyroid hormone (iPTH): 2.2 pmol/L
- Erythrocyte sedimentation rate (ESR): 10 mm/hr
- Thyroid-stimulating hormone (TSH): 0.9 mIU/L
- Free thyroxine (fT4): 12.4 pmol/L
- Free triiodothyronine (fT3): 6.0 pmol/L
- Serum protein electrophoresis: No paraprotein band detected
- Additional findings:
- Computed tomography (CT) done as part of her fracture imaging identified a multinodular goitre with calcification and retrosternal extension.
- Ultrasound (USS) done 15.3.2023 showed bilateral thyroid lobes increased in size with retrosternal extension and multiple thyroid nodules (three on the right, three on the left).
- Largest nodule on the right measured 2.2 x 2.3 x 2.1 cm and on the left 2.9 x 4.1 x 3.8 cm.
- Fine needle aspiration cytology – benign.
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Treatment
- Romosozumab 210 mg SC monthly initiated for 12 months.
- Following completion, transitioned to Denosumab 60 mg SC every 6 months.
- Calcium carbonate 500 mg twice daily.
- Cholecalciferol 50,000 IU every 4 weeks.
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Summary
- 65-year-old female with multiple fragility fractures (vertebral, humeral, malleolar) and discordantly low lumbar spine BMD.
- Despite her initial FRAX score, her true fracture risk was high after adjustment for her history of falls (increase MOF by +30%) and lumbar-hip spine discordance (increase by 10% for each rounded T-score difference between lumbar spine and femoral neck, +20%) (MOF ≈ 21.8%).
- Demonstrated improvement in BMD post 12 months with Romosozumab.
- Treated with Romosozumab for 12 months followed by Denosumab per guideline-based sequential therapy.
- The reported FRAX may appear relatively low. There is a discordantly low lumbar spine BMD compared to the femoral neck BMD, which is the site used for input into the FRAX model. Adjustments can be made according to NOGG 2021, where the MOF probability increases by approximately 10% for each rounded T-score difference between the lumbar spine and femoral neck. In this example, there is an almost 2-point T-score difference, which would increase the MOF risk by about 30%.
- However, even without this, the severity of the BMD and multiple fractures would point towards a very high fracture risk.
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Abbreviations
BMD, bone mineral density; CT, computed tomography; DXA, dual-energy X-ray absorptiometry; ESR, erythrocyte sedimentation rate; FN, femoral neck; FRAX, fracture risk assessment tool; fT3, free triiodothyronine; fT4, free thyroxine; iPTH, intact parathyroid hormone; L1-L4, first to fourth lumbar vertebrae in the lumbar spine. MOF, major osteoporotic fracture; NOGG, National Osteoporosis Guideline Group; SC, subcutaneous; TH, total hip; TSH, thyroid-stimulating hormone; USS, ultrasound scan
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Important Safety Information:Osteoporosis Case BinderThis curated collection of patient case studies aims to provide healthcare practitioners in the area of bone health, with a comprehensive understanding of risk-based treatment approach in the long-term management of patients living with osteoporosis.The patient cases were contributed by bone health experts from respective clinical setting, incorporating evidence-based discussions, guidelines and clinical considerations in the individualised treatment sequencing plans of different real-world scenarios..Please review full product information before prescribingFor Healthcare Professionals Only.Please refer to full prescribing information prior to administrationFor information on Amgen products or to report an adverse event involving an Amgen product, please contact Medical Information at 1800 818 227 or medinfo.JAPAC@amgen.comSC-MAL-CP-00139-Sep2025Endorsed By:
