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Bone Metabolism Abnormalities
Monday, 1:30 - 3:30 pm
Background: Despite a high prevalence of decreased bone mineral density in HIV-infected patients, reports of fragility fractures are rare. We performed an analysis of such cases.
Methods: Cases of fragility fractures were reviewed from 9 large HIV clinics (~8600 patients). Clinical presentations, antiretroviral (ARV) data, laboratory and radiological work-up, and therapeutics were reviewed.
Results: We identified 49 patients with fractures which had occurred after no (n = 28) or minor (n = 21) trauma. Median date of fracture was August 2001 (February 1991 to August 2003); only 1 occurred before October 1997. Of the patients, 27 were white, 10 black, and 12 female. Median age at the time of fracture was 45 years (range 25 to 75); 48% (20/42) were current smokers and 15% (6/40) current excessive alcohol users. Median bone mineral density (n = 40) was 23.29 kg/m2 (range 15.81 to 32.25). At the time of fracture, the median (range) HIV-1 RNA and CD4 (n = 48) were 782 copies/mL (<50 to >750,000) and 216.5 cells/mm3 (7 to 908), respectively. Information regarding ARV therapy at the time of fracture was available on 46 patients; 2 were ARV-naïve and 38 were receiving therapy, including PI for 31 of them. Median cumulative duration of ARV and of PI therapy (n = 43) were 37 months (0 to 142) and 25 months (0 to 83), respectively. The median nadir CD4 was 50 cells/mm3 (range 0 to 498) and median duration of HIV 6 years (0.1 to 19). Seven patients had a history of steroid use (chronic use including at the time of fracture in only 2). Fractures occurred in vertebrae alone (22) or with foot, femur, or pelvis (in 1 case each); ribs (4); lower extremities (15); upper extremities (3); clavicle (2). Only 10 patients had documented 5-OH vitamin D levels; 30% (3/10) had levels <15 ng/mL. Only 10 cases had documented DEXA scan; median (range) of lumbar spine and hip t-scores were -2.43 (0.11 to -5.6) and -2.21 (-0.5 to -3.58), respectively. Calcium supplementation was prescribed in 16 patients, either alone (n = 3), with vitamin D (n = 7) or with alendronate (n = 6); 3 others were prescribed calcitonin spray. In 9 patients, fractures re-occurred at the same or different site(s).
Conclusions: The prevalent decreased bone mineral density found in HIV-infected patients may predispose them to fragility fractures. Fragility fractures appear to be under-reported. Given the low rates of appropriate evaluation and treatment, further education is needed for HIV providers to ensure management consistent with current standards of care.
Keywords: osteoporosis; fragility fractures; atraumatic fractures