NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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July 30, 2024
MKSAP 18 Endocrinology & Metabolism Question 53
Stem:
A 74-year-old woman is evaluated for back pain after a fall occurring 2 weeks ago. Medical history is significant for deep venous thrombosis 3 years ago following a 12-hour airplane flight. Medications are acetaminophen as needed for back pain and calcium carbonate with vitamin D.
On physical examination, vital signs are normal. She has minimal pain to percussion over T8. Her examination is otherwise normal.
Laboratory studies:
- Alkaline phosphatase: 82 U/L
- Calcium, serum: 9.9 mg/dL (2.5 mmol/L)
- Creatinine, serum: 1.1 mg/dL (97.2 µmol/L)
- 25-Hydroxyvitamin D: 40 ng/mL (99.8 nmol/L)
Lateral spine radiograph shows 30% compression of T8, not present on prior radiographs. Bone mineral density by DEXA shows a lumbar spine T-score of −3.0 and femur neck T-score of −2.8.
Which of the following is the most appropriate treatment?
A. Alendronate
B. Calcitonin
C. Denosumab
D. Raloxifene
E. Teriparatide
Responses Received from Members (Response numbers and distribution posted on Thursday):
The Correct Answer is: A. Alendronate
Educational Objective
Treat postmenopausal osteoporosis.
Critique
The most appropriate treatment for this patient is alendronate. The American College of Physicians (ACP) recommends that clinicians offer pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis.
Individual patient factors and cost help decide which agent is initially used. Bisphosphonates are the most commonly prescribed first-line therapy as they have been shown to reduce the risk of fractures in large, randomized, placebo-controlled trials, and are generally well tolerated with low risk for serious adverse effects.
Although calcitonin increases spine bone mineral density in clinical trials, its anti-fracture efficacy is inconsistent at the spine. The availability of intravenous bisphosphonates and denosumab negates the argument for calcitonin in patients who cannot tolerate oral osteoporosis medications.
Denosumab is effective for prevention of vertebral fracture in postmenopausal women, yet it is expensive and, once started, should be continued indefinitely. Even if followed by intravenous bisphosphonate therapy, discontinuation results in loss of bone mineral density and has been associated with an increased risk of vertebral fracture. Denosumab may be used safely in the setting of compromised kidney function (KDIGO stage G3b and G4). It may also be preferred in patients with poor adherence or tolerance of oral bisphosphonates.
Raloxifene is approved in postmenopausal women for the prevention and treatment of osteoporosis and the prevention of invasive breast cancer in those at high risk. However, raloxifene is contraindicated in those at increased risk of venous thromboembolism. ACP recommends against raloxifene for the treatment of osteoporosis in women.
Teriparatide and abaloparatide are anabolic therapies that reduce the risk of vertebral fracture in postmenopausal osteoporosis. Each increases bone mass and strength of the spine more than antiresorptive drugs and may be preferred if spine bone mineral density is severely low (T-score ≤ −3.5), in patients who fail bisphosphonate therapy, and in glucocorticoid-induced osteoporosis. Neither drug should be prescribed for patients who are at increased risk for osteosarcoma including those with a history of radiation therapy.
Key Points
Alendronate, risedronate, zoledronic acid, and denosumab have been shown to reduce the risk for spine, hip, and nonvertebral fractures, and are generally well tolerated with low risk for serious adverse effects.
Qaseem A, Forciea MA, McLean RM, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Treatment of low bone density or osteoporosis to prevent fractures in men and women: A Clinical Practice Guideline Update From the American College of Physicians. Ann Intern Med. 2017;166:818-
839. PMID: 28492856
Copyright 2018, American College of Physicians.
July 16, 2024
MKSAP 18 Gastroenterology & Hepatology Question 51
Stem:
A 21-year-old woman is evaluated for a 6-week history of frequent bowel movements (three times daily) with intermittent passage of small amounts of blood and mucus. She also reports suprapubic cramping pain that is relieved with passage of stool. She reports no fever, chills, nausea, vomiting, or weight loss. She is otherwise healthy and takes no medication.
On physical examination, vital signs are normal. The abdomen is scaphoid, with tenderness to palpation in the suprapubic area. Rectal examination is notable for a small amount of blood on the examining finger.
Laboratory studies show a normal complete blood count and C-reactive protein level. Stool testing for enteropathogens, including Clostridium difficile, is negative.
Results of colonoscopy show continuous, symmetric rectal and sigmoid inflammation characterized by erythema, edema, and friable mucosa. The remainder of the colonic mucosa and distal ileum is normal. Biopsy specimens from the rectum and sigmoid colon show evidence of mildly active chronic colitis.
Which of the following is the most appropriate treatment?
A. Mesalamine enema
B. Mesalamine suppository
C. Oral mesalamine
D. Oral mesalamine and mesalamine enema
Responses Received from Members (761 responses):
The Correct Answer is: D. Oral mesalamine and mesalamine enema
Educational Objective
Treat left-sided ulcerative colitis.
Critique
Oral mesalamine with mesalamine enema is the most appropriate treatment. Ulcerative colitis typically presents with bloody diarrhea and abdominal discomfort, the severity of which is related to the extent and severity of inflammation. The distribution of ulcerative colitis is generally divided into proctitis (involving the rectum only), left-sided colitis (inflammation does not extend beyond the splenic flexure), and pancolitis (inflammation extends above the splenic flexure). The choice of treatment depends on the extent and severity of inflammation. This patient's stool passage frequency (three per day), intermittent hematochezia, normal blood count and C-reactive protein level, and normal vital signs categorize her disease as mild. Results of colonoscopy with biopsy show moderate inflammation of the rectum and a sigmoid colon consistent with chronic idiopathic left-sided ulcerative colitis.
Mesalamine preparations are the mainstay of treatment in patients with mild to moderate disease. Mesalamine given orally or topically is effective in inducing and maintaining remission in ulcerative colitis. Evidence suggests that combined mesalamine therapy (oral and topical) is superior for induction of remission in mild to moderately active disease compared with oral or topical therapies alone; however, patient adherence to this dual treatment regimen can be difficult.
A mesalamine enema has topical effects up to the splenic flexure of the colon and would be a more effective topical agent when combined with oral mesalamine in this patient.
A mesalamine suppository is appropriate for treatment of ulcerative proctitis but is not effective for topical treatment of inflammation above the rectum.
Key Points
Combined mesalamine therapy (oral and topical) is superior for induction of remission in mild to moderately active ulcerative colitis compared with oral or topical therapies alone.
Bressler B, Marshall JK, Bernstein CN, Bitton A, Jones J, Leontiadis GI, et al; Toronto Ulcerative Colitis Consensus Group. Clinical practice guidelines for the medical management of nonhospitalized ulcerative colitis: the Toronto consensus. Gastroenterology. 2015;148:1035-1058.e3. PMID:
25747596 doi:10.1053/j.gastro.2015.03.001
Copyright 2018, American College of Physicians.