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Severe postmenopausal osteoporosis at imminent fracture risk — SCE Rheumatology MCQ

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ModerateMetabolic Bone DiseaseSevere postmenopausal osteoporosis at imminent fracture riskSCE Rheumatology

A 72-year-old postmenopausal woman is assessed after a painful T12 vertebral fracture sustained 8 months ago following a fall from standing height. DXA shows a femoral-neck T-score of −3.2. She has not previously received pharmacological treatment for osteoporosis. Albumin-adjusted calcium, 25-hydroxyvitamin D and renal function are satisfactory. She has no history of myocardial infarction or stroke, and cardiovascular risk assessment identifies no major uncontrolled risk factors. Following discussion of the available options, she wishes to proceed with a bone-forming/dual-action treatment strategy. Which planned pharmacological sequence is most appropriate?

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Correct answer: E — Romosozumab 210 mg monthly for 12 months, then alendronic acid 70 mg weekly

This woman has severe postmenopausal osteoporosis and imminent fracture risk: her clinical vertebral fracture is a major osteoporotic fracture and occurred within the preceding 24 months. She therefore meets the NICE eligibility criterion for romosozumab. Hypocalcaemia and previous myocardial infarction or stroke would preclude treatment, but these are absent. Romosozumab is administered as 210 mg subcutaneously once monthly for 12 months. Its effects are reversible after withdrawal, so the course should be followed by an antiresorptive such as alendronic acid to maintain the skeletal benefit; a planned treatment pause is inappropriate. Treatment beyond 12 monthly doses is not the licensed regimen. Option C reverses the evidence-based sequence and delays the rapid bone-forming strategy during the period of highest recurrent-fracture risk. Option A is a credible anabolic alternative, but this treatment-naive woman with one fracture and a T-score of −3.2 does not meet the more restrictive NICE secondary-prevention criteria for teriparatide. Option D omits the required antiresorptive consolidation. Option B exceeds the licensed romosozumab treatment duration. Thus, romosozumab for 12 months followed promptly by alendronic acid is the best planned sequence.

Reference: Romosozumab for treating severe osteoporosis (TA791): Recommendations (25 May 2022) — https://www.nice.org.uk/guidance/ta791/chapter/1-Recommendations EVENITY 105 mg solution for injection: Summary of Product Characteristics (4 November 2024) — https://www.medicines.org.uk/emc/product/10956/smpc Raloxifene and teriparatide for secondary prevention of osteoporotic fragility fractures (TA161): Recommendations (7 February 2018) — https://www.nice.org.uk/guidance/ta161/chapter/1-Recommendations