原创： Alpha Jun 阿尔法医学英语 3天前
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每周六，一个病例，一道题，一个知识点，掌握专业医学英语
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Medical Case
A 70-year-old woman presents with back pain. She was recently diagnosed with a T8 vertebral fracture and immunoglobulin G kappa multiple myeloma that is complicated by diffuse skeletal lesions.
She has a creatinine level of 1.9 mg/dL (reference range, 0.6–1.1) and a calculated glomerular filtration rate of 28 mL/min/1.73m2 (≥60). Her serum calcium and vitamin D levels are within normal limits.
Question
Which one of the following additional medications is most appropriate for this patient?
A. Denosumab
B. Pamidronate
C. Calcium supplement with vitamin D
D. Cinacalcet
E. Calcitonin
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Answer & Critique
Answer: A
Key Learning Point View Case Presentation:
A patient with multiple myeloma and lytic bone lesions should be treated with an osteoclast inhibitor, such as an intravenous bisphosphonate or denosumab.
Key Point
Patients receiving primary therapy for multiple myeloma with skeletal lesions should be considered candidates for at least 2 years of treatment with an osteoclast inhibitor, such as an intravenous bisphosphonate (e.g., zoledronic acid orpamidronate) or denosumab, to help reduce the risk for pathologic fractures.
In this particular case, bisphosphonates are contraindicated because the patient has stage 4 chronic kidney disease (CKD); pamidronate can be used (with dose adjustment) in CKD up to stage 3 but is not recommended once CKD reaches stage 4.
Therefore, denosumab, a monoclonal antibody targeting the receptor activator of nuclear factor kappa-B ligand (RANKL), is the best option in this case. Denosumab has been shown to have skeletal benefits similar to those of bisphosphonates and can be used in patients with CKD who are not on dialysis, although it is more expensive than a bisphosphonate and is associated with higher rates of hypocalcemia.
Calcium and vitamin D supplements are not sufficient to reduce skeletal events and may worsen hypercalcemia.
Calcitonin is used to treat acute hypercalcemia but not skeletal lesions in patients with multiple myeloma.
Cinacalcet is a calcium-receptor agonist that is not indicated to prevent fractures in patients with myeloma. It is indicated for patients with hypercalcemia associated with parathyroid carcinoma and for severe hypercalcemia in patients with primary hyperparathyroidism who are unable to undergo parathyroid surgery.
Citations
PalumboA and Anderson K. Multiple myeloma. N Engl J Med 2011 Mar 18; 364:1046.
RajeN et al. Denosumab versus zoledronic acid in bone disease treatment of newlydiagnosed multiple myeloma: an international, double-blind, double-dummy,randomised, controlled, phase 3 study. Lancet Oncol 2018 Mar; 19:370.
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Alpha Jun
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文章已于2019-01-05修改