MCQs on Osteoporosis

Written by Dr. James Whitfield (MBBS, FRACGP) – General Practitioner

Question 1

Three months ago you started Mary, aged 73, on residronate 35 mg weekly, after she was diagnosed with osteoporosis confirmed with bone mineral density (BMD). Her presenting symptom at that time was back pain. Examination revealed height decrease and mild kyphosis, as well as tenderness over thoracic vertebrae. Despite being on residronate, her symptoms persisted and she also developed pain over new areas of her thoracic vertebrae. A new X-ray established new osteoporotic fractures. Which one of the following would be the most appropriate management option for her?

A) Continue residronate at the same dose.
B) Switch to alendronate.
C) Increase the dose of residronate.
D) Switch to zoledronic acid.
E) Switch to teriparatide.

Correct Answer: E) Switch to teriparatide.

Explanation:
Bisphosphonates are the most commonly prescribed first-line anti-resorptive agents for osteoporosis, including alendronate, residronate, and zoledronic acid. They should be used for at least 12 months before assessing their efficacy.

In cases where the patient suffers two or more minimal trauma fractures despite adequate doses of bisphosphonates, starting teriparatide is justified as the most appropriate option. Teriparatide is a synthetic parathyroid hormone that works by increasing the number and activity of osteoblasts (bone-forming cells), promoting new bone formation. It requires at least 18 months of continuous use to be effective and is typically reserved for patients with severe osteoporosis and very high fracture risk.

Mary has developed new osteoporotic fractures despite being on an appropriate dose of residronate. Continuing the same treatment (option A) is not appropriate. Switching between bisphosphonates such as alendronate (option B) or zoledronic acid (option D) offers no additional benefit as their effectiveness is similar. Increasing the residronate dose (option C) is not indicated as she is already on the recommended dose.

Question 2

Jane, a 65-year-old patient of yours, is being assessed for osteoporosis. A Dual Energy X-ray Absorptiometry has revealed T-scores of -2.5 and -2.7 for the femoral neck and the vertebral column, respectively. She was diagnosed with cancer of her right breast 6 years ago for which she underwent right mastectomy, chemotherapy, and radiation therapy. In addition to advice regarding calcium and vitamin D, which one of the following medications would be the best option for treatment of her osteoporosis?

A) Raloxifene.
B) Alendronate.
C) Teriparatide.
D) Strontium ranelate.
E) Hormone replacement therapy (HRT).

Correct Answer: B) Alendronate.

Explanation:
According to WHO criteria and based on Jane’s T-scores at the vertebra and femoral neck, she has osteoporosis. Bisphosphonates are the first-line treatment option for primary and secondary prevention of vertebral and non-vertebral fractures due to osteoporosis. In Australia, alendronate, residronate, and zoledronic acid are commonly used bisphosphonates.

Raloxifene is a selective estrogen receptor modulator (SERM) that reduces the risk of vertebral fractures and has a preventive effect on breast cancer, making it suitable for some postmenopausal women with breast cancer history. However, its efficacy on non-vertebral fractures is limited. Since Jane has osteoporosis at the femoral neck (a non-vertebral site), raloxifene is not the best first-line option for her.
Teriparatide is a synthetic parathyroid hormone that increases osteoblast activity. It is reserved for patients with severe osteoporosis and very high fracture risk (e.g., T-score ≤ -3, multiple fractures, or new fractures despite treatment). Jane does not meet these criteria.
Strontium ranelate is a second-line option used only when other treatments are unsuitable, especially contraindicated in patients with cardiovascular disease or uncontrolled hypertension.
Hormone replacement therapy (HRT) is contraindicated in patients with a personal or strong family history of breast cancer because breast cancer is estrogen dependent.

Therefore, alendronate remains the most appropriate medication for Jane’s osteoporosis treatment.

Question 3

An 83-year-old man fell off a slippery toilet bowl in the bathroom while trying to reach toilet paper and had his left femoral neck fractured. He was treated with open reduction and internal fixation. Today, he is being discharged. Which one of the following pieces of advice is most important to give?

A) He should start alendronate.
B) He should have a bone scan.
C) He should take low molecular weight heparin (LMWH) for 6 weeks.
D) He should take warfarin for 6 months.
E) He should take supplemental calcium and vitamin D.

Correct Answer: A) He should start alendronate.

Femoral neck fracture following a fall from a short height is considered a fracture following minor trauma, which is often pathologic. Osteoporosis is the most common cause of pathologic fractures. Unlike in women, osteoporosis in men is often secondary and a manifestation of an underlying cause such as renal or liver disease, hyperparathyroidism, Cushing’s syndrome, celiac disease, malabsorption, or hypercalciuria.

Initial evaluation in men should include routine biochemical tests for renal or hepatic disease, full blood count, serum testosterone, calcium, alkaline phosphatase, 25-hydroxyvitamin D, and 24-hour urine calcium.

In addition to assessing and treating underlying causes, patients with pathologic fractures due to osteoporosis should be started on osteoporosis-specific treatment to prevent further fractures and improve bone density. Bisphosphonates (e.g., alendronate, risedronate, zoledronic acid) are the first-line treatment options.

(Option B) Although a bone mineral density scan is recommended, treatment can be started without waiting for it.

(Option C) Patients undergoing hip fracture surgery have a high risk of venous thromboembolism (VTE). Thromboprophylaxis with low molecular weight heparin (LMWH) is recommended for up to 35 days postoperatively. However, LMWH is usually started and continued during hospital stay (10–14 days), and 6 weeks of LMWH is beyond the recommended duration.

(Option D) Warfarin is less preferred than LMWH due to monitoring needs and delayed onset, and 6 months duration is excessive for prophylaxis.

(Option E) Calcium and vitamin D supplementation is advised if dietary intake is inadequate, but supplementation alone has not been shown to reduce the risk of further fractures.

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5. Endocrine Module

5.1 Diabetes

5.2 Thyroid

5.3 Breast

5.4 Adrenals

5.5 Osteoporosis

5.6 Other Endocrine Disorders

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