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Question 1

Which statement regarding the treatment of osteoporosis is true?
Question 1
- A. There is no additional benefit in continuing alendronate beyond 5 years.
- B. Teriparatide is preferred over Alendronate for patients whose FRAX score is 35% or more for major osteoporotic fracture risk.
- C. If a patient has multiple fragility fractures while being on denosumab, switching to teriparatide will significantly increase bone mineral density and reduce fracture risk within the first year.
- D. Romosozumab should be avoided in patients with poorly controlled diabetes.
Answer with a detailed explanation
B. Teriparatide is preferred over Alendronate for patients whose FRAX score is 35% or more for major osteoporotic fracture risk.

Explanations:
- FLEX study demonstrated a significantly reduced risk of vertebral fractures in the alendronate-continuation group with an absolute risk reduction of 2.9%.
- Patients with FRAX score of 35% or more for major osteoporotic fracture risk belong to a high-risk group. Teriparatide in comparison with alendronate is associated with greater increases in hip and vertebral BMD and less vertebral fractures in this group of patients.
- In the DATA SWITCH study, switching from denosumab to teriparatide resulted in transient decrease in vertebral and hip BMD in the first 6 to 12 months.
- An increased number of ischemic cardiac events and cerebrovascular events were reported in the ARCH trial, leading to the black box warning. However, poorly controlled diabetes is not a contraindication to the use of romosozumab.
References:
Black DM, Schwartz AV, Ensrud KE, et al. Effects of Continuing or Stopping Alendronate After 5 Years of Treatment: The Fracture Intervention Trial Long-term Extension (FLEX): A Randomized Trial. JAMA. 2006;296(24):2927–2938.
Saag KG, Shane E, Boonen S, Marín F, Donley DW, Taylor KA, Dalsky GP, Marcus R. Teriparatide or alendronate in glucocorticoid-induced osteoporosis. N Engl J Med. 2007 Nov 15;357(20):2028-39.
Leder BZ, Tsai JN, Uihlein AV, Wallace PM, Lee H, Neer RM, Burnett-Bowie SA. Denosumab and teriparatide transitions in postmenopausal osteoporosis (the DATA-Switch study): extension of a randomised controlled trial. Lancet. 2015 Sep 19;386(9999):1147-55
Saag KG, Petersen J, Brandi ML, Karaplis AC, Lorentzon M, Thomas T, Maddox J, Fan M, Meisner PD, Grauer A. Romosozumab or Alendronate for Fracture Prevention in Women with Osteoporosis. N Engl J Med. 2017 Oct 12;377(15):1417-1427.
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Question 2

Which of the following statements is true regarding osteoporosis?
Question 2
- A. Fracture risk is not affected by diabetes mellitus.
- B. Any fracture that ensues after a fall from less than one’s body height is regarded as a fragility fracture.
- C. Later age of menarche is associated with a higher risk of osteoporosis.
- D. FRAX score is adjusted for glucocorticoid use (≥5 mg of prednisolone or equivalent per day) by multiplying the major osteoporotic fracture risk by 1.15 and the hip fracture risk by 1.2.
Answer with a detailed explanation
C. Later age of menarche is associated with a higher risk of osteoporosis.

Explanations:
- Epidemiological studies show that both types 1 and 2 diabetes mellitus are associated with higher risks of hip fractures.
- Later age of menarche is associated with a reduced bone mineral density and an increased risk of fractures later in life.
- Fragility fractures are fractures secondary to low energy trauma. However, fractures of the face, skull and phalanges are not considered fragility fractures.
- Adjustment is only made for glucocorticoid use ≥7.5mg/day.
References:

Mohsen Janghorbani, Rob M. Van Dam, Walter C. Willett, Frank B. Hu, Systematic Review of Type 1 and Type 2 Diabetes Mellitus and Risk of Fracture, American Journal of Epidemiology, Volume 166, Issue 5, 1 September 2007, Pages 495–505
Jean-Philippe Bonjour, Thierry Chevalley, Pubertal Timing, Bone Acquisition, and Risk of Fracture Throughout Life, Endocrine Reviews, Volume 35, Issue 5, 1 October 2014, Pages 820–847
https://www.nice.org.uk/guidance/cg146/documents/osteoporosis-final-scope2
2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis
Kanis, J.A., Johansson, H., Oden, A. et al. Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int 22, 809–816 (2011).
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Question 1

Which statement regarding the treatment of osteoporosis is true?

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Question 2

Which of the following statements is true regarding osteoporosis?

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