A 72-year-old woman sustains her second vertebral compression fracture in 18 months while on alendronate. She has chronic kidney disease (eGFR 25 mL/min/1.73m²). Which anti-osteoporotic agent is CONTRAINDICATED at this eGFR level?
- A Denosumab (anti-RANKL monoclonal antibody)
- B Teriparatide (recombinant PTH 1-34)
- C Alendronate and other oral bisphosphonates (contraindicated at eGFR <30-35 mL/min) ✓
- D Romosozumab (anti-sclerostin antibody)
Explanation
Oral bisphosphonates (alendronate, risedronate, ibandronate) and intravenous zoledronic acid are contraindicated when eGFR <30-35 mL/min due to risk of renal accumulation and worsening CKD. Denosumab is safe in CKD (does not require renal excretion) but can cause severe hypocalcemia in CKD, requiring careful calcium/vitamin D supplementation. Teriparatide is cleared by the liver and kidneys but has no specific CKD contraindication (used with caution in severe CKD). Romosozumab has limited data in CKD stage 4-5 but is not contraindicated at eGFR 25. This patient failing alendronate with eGFR 25 should switch to denosumab with calcium/D3 supplementation, monitored carefully.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.