<prompt> A 35-year-old woman with active lupus nephritis falls forward and lands on her left hand. She has immediate pain. On examination, there is crepitus at the wrist. A radiograph shows radial and navicular fractures along with marked osteopenia. Which of the following medications most likely contributed to the fracture?HydrocortisoneIbuprofenLisinoprilLosartan  <response>: Corticosteroids may be needed to treat severe lupus nephritis, and continuing therapy increases the risk for Cushing syndrome with osteoporosis. Corticosteroids stimulate RANKL expression, inhibit osteoblast osteoprotegerin OPG synthesis, and thereby enhance osteoclast proliferation to promote bone resorption. Ibuprofen and other nonsteroidal anti-inflammatory drugs NSAIDs should not be used with renal failure. Lisinopril, an angiotensin-converting enzyme ACE inhibitor, and losartan, an angiotensin receptor blocker ARB, may be used to treat hypertension with renal disease, but they do not directly affect bone density. Methotrexate is a chemotherapy agent that is best used with rheumatoid arthritis, not systemic lupus erythematosus, and at low doses is less likely to lead to osteoporosis. 