Osteoporosis in HIV and Aging

Aroonsiri Sangarlangkarn, MD, MPH, Jonathan S. Appelbaum, MD, FACP

By the end of the session, learners will be able to:

  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.

Suggested reading:

  1. McComsey GA, Tebas P, Shane E, et al. Bone disease in HIV infection: a practical review and recommendations for HIV care providers. Clinical Infect Dis 51.8 (2010):937-46.
  2. American Academy of HIV Medicine (online). Osteoporosis in HIV and Aging. Available at: http://hiv-age.org/wp-content/uploads/2014/02/18.-Osteoporosis-in-HIV-and-Aging.pdf. Accessed July 25, 2014.

This case is part of a case-study series on common diseases in aging HIV-infected patients. New cases will be posted monthly on our website. Users should first download the learner portion or read on below, review the suggested reading, and answer the case questions. When you’re ready to check answers, download the answer key to do so. Please contact Ken South at ken@aahivm.org if you’d like more information on the series.

You are free to share, copy, or adapt the series for any purpose, even commercially, as long as you give appropriate credit and indicate if changes were made. Please see our license for more information.

CASE ONE:

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 10mg daily, methadone 100mg 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:

  1. What is osteoporosis? How does it differ from osteopenia?

  2. How does the prevalence rate among HIV-infected patients differ than that in the general population?

  3. Why does the prevalence for osteoporosis differ in HIV-infected patients compared to the general population? What are the effects of HIV on bone metabolism?

  4. What are risk factors for bone loss? Your answer should address traditional risk factors and HIV-associated risk factors.

  5. What questions would you ask Ms. Fracture to determine her risk factors? Would you order any lab tests?

CASE ONE CONTINUED:

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 20mg every other day for blood pressure and esomeprazole 40mg 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.

  1. What are Ms. Fracture’s risk factors for osteoporosis? Which ones can you potentially modify and how would you optimize them?

CASE ONE CONTINUED:

Ms. Fracture is eager to make the changes you suggest, but she also wants to know if she has osteoporosis.

  1. Would you screen Ms. Fracture for osteoporosis and why? What test would you order if you decide to screen her?

CASE ONE CONTINUED:

DXA results show the following T-scores: Hip total -2.8, femoral neck -2.4, L4 -2.5

  1. Does Ms. Fracture have osteoporosis? What other tests would you order?

  2. How would you treat Ms. Fracture?

  3. Would you switch Ms. Fracture’s ART regimen?

  4. How would you monitor treatment?

Additional reference:

  1. Brown TT, Qaqish RB. Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. AIDS 20.17 (2006):2165.
  2. Bonjoch A, Figueras M, Estany C, Osteoporosis Study Group. High prevalence of and progression to low bone mineral density in HIV-infected patients: a longitudinal cohort study. AIDS 24.18 (2010):2827.
  3. Triant VA, Brown TT, Lee H, et al. Fracture prevalence among human immunodeficiency virus (HIV)-infected versus non-HIV-infected patients in a large U.S. healthcare system. J Clin Endocrinol Metab 93.9 (2008):3499.
  4. Aukrust P, Haug CJ, Ueland T, et al. Decreased bone formative and enhanced resorptive markers in human immunodeficiency virus infection: indication of normalization of the bone-remodeling process during highly active antiretroviral therapy. J Clin Endocrinol Metab 84.1 (1999):145.
  5. Hellman P, Albert J, Gidlund M, et al. Impaired parathyroid hormone release in human immunodeficiency virus infection. AIDS Res Hum Retroviruses 10.4 (1994):391.
  6. Jaeger P, Otto S, Speck RF, et al. Altered parathyroid gland function in severely immunocompromised patients infected with human immunodeficiency virus. J Clin Endocrinol Metab 79.6 (1994):1701.
  7. Yin MT, Shi Q, Hoover DR, et al. Fracture incidence in HIV-infected women: results from the Women’s Interagency HIV Study. AIDS 24.17 (2010):2679
  8. Young B, Dao CN, Buchacz K, HIV Outpatient Study (HOPS) Investigators. Increased rates of bone fracture among HIV-infected persons in the HIV Outpatient Study (HOPS) compared with the US general population, 2000-2006. Clin Infect Dis 52.8 (2011):1061-8.
  9. Manolagas SC, Jilka RL. Bone marrow, cytokines, and bone remodeling. Emerging insights into the pathophysiology of osteoporosis. N Engl J Med 332.5 (1995):305
  10. Gibellini D, De Crignis E, Ponti C, et al. HIV-1 triggers apoptosis in primary osteoblasts and HOBIT cells through TNF-alpha activation. J Med Virol 80.9 (2008):1507.
  11. Gallant JE, Staszewski S, Pozniak AL, 903 Study Group. Efficacy and safety of tenofovir DF vs stavudine in combination therapy in antiretroviral-naive patients: a 3-year randomized trial. JAMA 292.2 (2004):191.
  12. Aberg JA, Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 58.1 (2014):1.
  13. Brown TT, McComsey GA. Osteopenia and osteoporosis in patients with HIV: a review of current concepts. Curr Infect Dis Rep 8.2 (2006):162.
  14. Tannenbaum C, Clark J, Schwartzman K, et al. Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women. J Clin Endocrinol Metab 87 (2002):4431–4437
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