Bone Abstracts

Background: Severe osteoporosis may present with atraumatic fractures, reflecting profound skeletal fragility. Patients at very high fracture risk benefit from early anabolic therapy, but intolerance to first-line agents can complicate management.

Case Presentation: A 62-year-old postmenopausal female was referred to the osteoporosis clinic due to concern regarding potential jaw osteoporosis with oral bisphosphonates, which was ruled out after dental review. She had recent two atraumatic vertebral fractures within the past year resulting in severe back pain requiring opiates, with limited mobility requiring walking aid. She was on long-term sodium valproate for migraine, inhaled corticosteroids for asthma, and has well-controlled hypothyroidism on levothyroxine. She had no other risk factors for osteoporosis, was a non-smoker with minimal alcohol intake, had no family history of osteoporosis, and went through menopause at age 50. BMI was 30.8 kg/m². Investigations showed severe osteoporosis on DXA (T-score -3.3). Routine osteoporosis blood screen was normal. Calcium and vitamin D were optimized, and weight-bearing exercise was encouraged, advising the patient to remain as mobile as possible. Given very high fracture risk and low cardiovascular risk, romosozumab was initiated, with bone turnover markers planned to monitor response. Injection-site reactions occurred: first dose-itchy, painful lump lasting 4-5 days; second dose-worsening reaction despite antihistamines. The supplier confirmed latex-free equipment due to the patients latex allergy. Therapy was switched to teriparatide due to intolerance to romosozumab. Serum calcium was normal. Mild injection reaction after the first dose lasted 2 days, likely related to shared excipients (glacial acetic acid and sodium hydroxide). A non-consecutive dosing strategy was initially used to allow reactions to subside and assess tolerability. To support confidence, the home healthcare team supported initial injections, and the patient subsequently self-administered daily injections independently without issues.

Discussion Conclusion: This case highlights:

The importance of early anabolic therapy in very high-risk osteoporosis. The need to adapt treatment when intolerance occurs rather than reverting to less effective. strategies Understanding the role of shared excipients, allergies, and supportive interventions in facilitating successful therapy. Patient-centered management including supportive interventions, mobility encouragement, and flexible dosing enabled successful long-term outcomes with sustained self-administration.