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Refractory Osteoporosis — RACP Adult Medicine MCQ

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ModerateEndocrinology & DiabetesRefractory OsteoporosisRACP Adult Medicine

A 68-year-old woman with osteoporotic vertebral fractures (T-score -3.8) has been on alendronate for 2 years with no improvement in BMD and a new fracture. She has adequate calcium and vitamin D levels. What is the most appropriate next treatment?

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Correct answer: A — Switch to teriparatide

For severe osteoporosis with ongoing fractures despite bisphosphonate therapy, anabolic therapy with teriparatide (recombinant PTH 1-34) is the most appropriate option. Teriparatide stimulates new bone formation (unlike bisphosphonates which only inhibit resorption). It is given as a daily SC injection for 18–24 months. PBS listing in Australia requires at least 2 fractures despite adequate treatment with another osteoporosis medication. After completing teriparatide, an antiresorptive agent (bisphosphonate or denosumab) should be commenced to maintain gains.

Reference: RACGP – 2017 – Osteoporosis Clinical Guideline; PBS – 2025 – Teriparatide Criteria