Reduction of Risk Potential, Physiological Integrity, NCLEX-RN - Full Vignette with Extended Explana

A 77-year-old man on high-dose glucocorticoids for minimal change disease develops new diffuse bone aching and notable height loss over a year, with prior evidence of osteopenia and low vitamin D levels. What clinical considerations and patient factors should guide decisions to reduce his risk for fractures during ongoing steroid therapy? How do his symptoms and history influence immediate management strategies for bone health?

VIDEO INFO
Category: Reduction of Risk Potential, Physiological Integrity, NCLEX-RN
Difficulty: Moderate - Intermediate level - Requires solid foundational knowledge
Question Type: Complications
Case Type: Routine Visit - Standard clinical encounter in outpatient setting

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QUESTION
A 77-year-old man presents to his primary care clinic for a routine follow-up after starting high-dose glucocorticoids for a relapse of biopsy-proven minimal change disease 12 weeks ago....

OPTIONS
A. Begin oral alendronate 70 mg once weekly with fasting administration instructions, add elemental calcium to a total of approximately 1,200 mg/day and vitamin D3 800-1,000 IU/day, and arrange baseline and follow-up bone mineral density monitoring while tapering glucocorticoids to the lowest effect...
B. Administer zoledronic acid 5 mg IV once now as preferred first-line therapy in most patients initiating high-dose glucocorticoids, with calcium and vitamin D supplementation and routine BMD follow-up.
C. Start calcium (~1,200 mg/day) and vitamin D3 (800-1,000 IU/day) alone now and defer any antiresorptive therapy until the next DEXA result or a fragility fracture occurs.
D. No pharmacologic prophylaxis is indicated because he is male with normal serum calcium; reassess in 6-12 months after steroids are tapered off.

CORRECT ANSWER
A. Begin oral alendronate 70 mg once weekly with fasting administration instructions, add elemental calcium to a total of approximately 1,200 mg/day and vitamin D3 800-1,000 IU/day, and arrange baseline and follow-up bone mineral density monitoring while tapering glucocorticoids to the lowest effective dose.

EXPLANATION
Older adults beginning or continuing moderate-to-high dose glucocorticoids for at least three months face a rapid rise in vertebral fracture risk. The best immediate risk-reduction step in an ambulatory, oral-tolerant patient with preserved kidney function is to start an oral bisphosphonate plus foundational calcium and vitamin D. Alendronate 70 mg once weekly is first-line, provided the patient can follow fasting administration and upright precautions. Concurrent calcium to a total of roughly 1,200 mg/day and vitamin D3 800-1,000 IU/day support mineralization; bone mineral density monitoring and steroid tapering to the lowest effective dose complete the near-term plan.

Alternatives are either second line in this scenario or insufficient. Zoledronic acid 5 mg IV is effective and preferred when adherence to oral therapy is doubtful, oral intolerance exists, or malabsorption is suspected, but those issues are not present here. Calcium and vitamin D alone do not adequately blunt early glucocorticoid-induced bone loss and should not delay antiresorptive therapy in a 77-year-old on 40 mg prednisone daily for three months with documented osteopenia and vitamin D deficiency....


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