Question of the Day
Thursday, November 12, 2026
A 68-year-old woman comes to the physician after a screening dual-energy x-ray absorptiometry study. She has no back pain and has never had a fracture. She has gastroesophageal reflux disease that is well controlled with as-needed antacids, and she is able to sit upright without difficulty. Her only medication is a daily multivitamin. Her estimated glomerular filtration rate is 78 mL/min/1.73 m2 and serum calcium and 25-hydroxyvitamin D concentrations are within the reference range. The DXA shows a lumbar spine T-score of -2.7 and a femoral neck T-score of -2.5. Her calculated 10-year probability of major osteoporotic fracture is 22%.
Which of the following is the most appropriate pharmacotherapy?
Answer: A. Alendronate
This postmenopausal woman has osteoporosis by T-score (<= -2.5) with a high fracture probability but no history of fracture and no very-high-risk features, making an oral bisphosphonate the first-line agent; alendronate is preferred given normal renal function and ability to remain upright, with mild controlled reflux not being a contraindication. Anabolic agents such as romosozumab (D) and teriparatide (E) are reserved for very-high-risk patients (e.g., very low T-score, prior severe or multiple vertebral fractures) rather than initial therapy here. Raloxifene (C) reduces vertebral but not hip fracture risk and is second-line. Calcitonin (B) is weakly effective and not recommended for primary osteoporosis treatment. Bisphosphonates require correction of any vitamin D deficiency first, which this patient does not have.
Just show me the answer
Answer: A. Alendronate
This postmenopausal woman has osteoporosis by T-score (<= -2.5) with a high fracture probability but no history of fracture and no very-high-risk features, making an oral bisphosphonate the first-line agent; alendronate is preferred given normal renal function and ability to remain upright, with mild controlled reflux not being a contraindication. Anabolic agents such as romosozumab (D) and teriparatide (E) are reserved for very-high-risk patients (e.g., very low T-score, prior severe or multiple vertebral fractures) rather than initial therapy here. Raloxifene (C) reduces vertebral but not hip fracture risk and is second-line. Calcitonin (B) is weakly effective and not recommended for primary osteoporosis treatment. Bisphosphonates require correction of any vitamin D deficiency first, which this patient does not have.
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