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Osteoporosis — SCE Rheumatology MCQ

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ModerateMetabolic Bone DiseaseOsteoporosisSCE Rheumatology

A 68-year-old postmenopausal woman was started on oral alendronic acid after a low-trauma distal radial fracture 4 years ago. She has taken it fully adherently and with the correct administration technique, and she is calcium and vitamin D replete. She develops persistent midthoracic pain after bending forward. Radiography shows a new T8 anterior wedge fragility fracture with 30% vertebral height loss. Repeat DXA shows a femoral-neck T-score of -4.1 and bone mineral density below her pretreatment baseline. Investigations have excluded a secondary cause of osteoporosis. Which of the following is the most appropriate management change?

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Correct answer: A — Switch to teriparatide

The correct answer is A. She has an unsatisfactory response to alendronic acid: a further fragility fracture despite more than 1 year of full adherence, accompanied by BMD falling below the pretreatment baseline. At age 68 with a T-score of -4.1, she also meets the NICE severity threshold for teriparatide after inadequate bisphosphonate response. Continuing alendronic acid unchanged would not address documented treatment failure. Raloxifene is less appropriate for this very-high-risk phenotype, while calcium and vitamin D are adjuncts rather than adequate fracture-prevention treatment. Stopping pharmacological therapy would leave her at substantial imminent fracture risk. Teriparatide is given for a maximum total of 24 months, after which antiresorptive treatment should be considered to preserve skeletal gains.

Reference: NICE. TA161, Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women, sections 1.4 and 1.8; updated 2018. https://www.nice.org.uk/guidance/ta161/chapter/1-Recommendations