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Postmenopausal osteoporosis — SCE Rheumatology MCQ

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ModeratePostmenopausalPostmenopausal osteoporosisSCE Rheumatology

A 77-year-old postmenopausal woman was diagnosed with osteoporosis 5 years ago after DXA showed a femoral-neck T-score of −2.8. She had no previous fragility fracture and commenced alendronic acid 70 mg once weekly. She has taken treatment correctly and consistently. She has sustained no fractures and has no thigh or groin pain, upper gastrointestinal adverse effects or planned invasive dental treatment. She does not take systemic glucocorticoids. Renal function, albumin-adjusted calcium and 25-hydroxyvitamin D are satisfactory. Repeat DXA now shows T-scores of −2.2 at the femoral neck and −2.0 at the total hip. Which osteoporosis treatment strategy is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Continue alendronic acid with periodic reassessment

Explanation lettering: E = shown as A · C = shown as B · D = shown as C · A = shown as D · B = shown as E

Bisphosphonate therapy should be reviewed after 5 years of oral treatment, but an improved T-score does not by itself mandate a treatment pause. NICE identifies age over 75 years as a factor favouring continuation because fracture risk remains high. This woman is 77, tolerates alendronic acid, adheres correctly and has no treatment complication; continuing it with periodic evaluation, potentially up to 10 years in total, is therefore appropriate. B would be appropriate after 5 years for a person without specified high-risk features whose T-score had improved above −2.5; her age is the decisive discriminator against a pause. C is unnecessary because denosumab is generally used when bisphosphonates are unsuitable or another clinical indication supports changing treatment. It would also create a requirement for uninterrupted dosing and planned antiresorptive therapy when eventually discontinued. D offers no advantage because oral treatment is tolerated and adherence is reliable; intravenous zoledronic acid is useful when oral administration is unsuitable or impractical. E is less appropriate because raloxifene primarily reduces vertebral fractures and is generally reserved for postmenopausal women in whom other treatments are contraindicated or unsuitable. Continued treatment should still undergo periodic clinical review rather than being regarded as an automatic indefinite prescription.

Reference: Osteoporosis QS149: Quality statement 4 — Long-term follow-up (Published 28 April 2017; checked 19 August 2026) — https://www.nice.org.uk/guidance/qs149/chapter/quality-statement-4-long-term-follow-up