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Severe osteoporosis — SCE Rheumatology MCQ

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ModerateMetabolic bone diseaseSevere osteoporosisSCE Rheumatology

A 69-year-old postmenopausal woman has severe osteoporosis with three low-trauma vertebral fractures. Two of the fractures occurred during 24 months of alendronic acid treatment. Her adherence and administration technique are confirmed, and her lowest DXA T-score has declined from −3.3 before treatment to −3.7. Corrected calcium, vitamin D and renal function are satisfactory, and secondary causes of osteoporosis have been excluded. What is the most appropriate next management step?

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Correct answer: C — Refer for specialist anabolic treatment

The correct answer is C. She has sustained further vertebral fractures after more than 1 year of confirmed adherence to alendronic acid, accompanied by a decline in BMD. This constitutes an unsatisfactory treatment response. At age 69, with a T-score below −3.5 and more than two fragility fractures, she meets NICE criteria for specialist consideration of teriparatide and is at very high fracture risk, for which an anabolic strategy is appropriate. Selection among teriparatide, abaloparatide and romosozumab depends on contraindications, fracture timing and local commissioning, and anabolic treatment must subsequently be consolidated with an antiresorptive. Switching directly to zoledronate or denosumab may be appropriate in some high-risk patients but is less suitable than anabolic treatment in this specified very-high-risk treatment failure. Continuing alendronate unchanged or using supplements alone would leave the fracture risk inadequately treated.

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