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Severe osteoporosis — SCE Rheumatology MCQ

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EasyMetabolic bone diseaseSevere osteoporosisSCE Rheumatology

A 74-year-old woman has multiple vertebral fragility fractures despite adherence to oral bisphosphonate. Examination shows there is thoracic kyphosis and height loss. Investigations show DXA confirms very low bone density. The diagnosis is established and symptoms remain clinically important despite initial supportive measures. There is no contraindication to disease-modifying or anti-inflammatory escalation. What is the most appropriate management?

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Correct answer: D — Teriparatide

Teriparatide is the best answer because teriparatide is the most appropriate next step for severe osteoporosis in this clinical setting. Mycophenolate mofetil is a plausible distractor, but it does not account for the key discriminator in the stem. Increase NSAID therapy and Vitamin D replacement would be more appropriate in a different clinical pattern or at another point in the pathway, while Hydroxychloroquine is suboptimal for this presentation. Clinical pearl: rheumatology management is generally treat-to-target, but infection risk, pregnancy plans and shared-care monitoring often determine the safest answer.

Reference: NICE CG146; NOGG guideline; BNF