OSTEOPOROSIS

Question 1

Which of the following best defines osteoporosis according to the World Health Organization (WHO)?
A. Bone density that is 1.0 standard deviation below the mean for young healthy adults
B. Bone density that is 2.5 standard deviations below the mean for young healthy adults
C. Bone density that falls below the normal range without fracture risk
D. Bone density that leads to fractures only in the presence of severe trauma

Answer 1

Correct Answer: B. Bone density that is 2.5 standard deviations below the mean for young healthy adults
Rationale: The WHO defines osteoporosis as a bone density 2.5 standard deviations (T-score ≤ -2.5) below the mean for young healthy adults of the same sex and race.

Question 2

A 65-year-old postmenopausal woman with a T-score of -1.8 has no history of fractures. How should her bone health be categorized?
A. Normal
B. Osteoporosis
C. Low bone density (osteopenia)
D. Severe osteoporosis

Answer 2

Correct Answer: C. Low bone density (osteopenia)
Rationale: A T-score between -1.0 and -2.5 is defined as low bone density or osteopenia. This group is at an increased risk for developing osteoporosis and related fractures.

Question 3

Osteoporosis-related fractures typically occur under which of the following circumstances?
A. High-impact trauma such as a car accident
B. A fall from standing height or lower
C. Repeated stress or overuse
D. Fractures of the skull, fingers, or toes

Answer 3

Correct Answer: B. A fall from standing height or lower
Rationale: Osteoporosis-related fractures are defined as fractures occurring from trauma less than or equal to a fall from standing height, except for fractures of the fingers, toes, face, or skull.

Question 4

Which of the following is the best approach to identifying osteoporosis-related fracture risk?
A. Measuring bone mineral density alone
B. Estimating 10-year fracture risk using BMD, age, and clinical factors
C. Screening all postmenopausal women regardless of BMD
D. Evaluating trauma history alone

Answer 4

Correct Answer: B. Estimating 10-year fracture risk using BMD, age, and clinical factors
Rationale: The risk of osteoporosis-related fractures is best assessed by combining BMD measurements with clinical factors such as age and gender to calculate a 10-year fracture risk.

Question 5

Which of the following techniques is considered the gold standard for measuring bone mineral density (BMD)?
A. Single-energy X-ray absorptiometry (SXA)
B. Quantitative computed tomography (CT)
C. Dual-energy X-ray absorptiometry (DXA)
D. Ultrasound

Answer 5

Correct Answer: C. Dual-energy X-ray absorptiometry (DXA)
Rationale: DXA is a highly accurate X-ray technique and is considered the gold standard for measuring bone density. It is commonly used to assess the lumbar spine and hip for clinical determinations of BMD.

Question 6

What effect do bone spurs in osteoarthritis have on DXA measurements of the spine?
A. They increase the accuracy of the results.
B. They falsely decrease BMD measurements.
C. They falsely increase BMD measurements.
D. They have no impact on BMD measurements.

Answer 6

Correct Answer: C. They falsely increase BMD measurements.
Rationale: Bone spurs, which are common in osteoarthritis, can falsely elevate BMD measurements, especially in the spine, making interpretation more challenging in older individuals.

Question 7

Which tool is often used alongside DXA to estimate the 10-year risk of major osteoporosis-related fractures?
A. Z-score
B. BMD chart
C. FRAX
D. Serial DXA scans

Answer 7

Correct Answer: C. FRAX
Rationale: The FRAX tool is used to calculate the 10-year fracture risk by incorporating factors such as age, gender, fracture history, hip fracture in a parent, steroid use, and femoral neck BMD.

Question 8

Why is the hip the preferred site for BMD measurement in most individuals?
A. It is easier to access for DXA scans compared to other sites.
B. It predicts the risk of spinal fractures more accurately.
C. It predicts the risk of hip fractures better than other measurement sites.
D. It is less affected by degenerative changes than the spine.

Answer 8

Correct Answer: C. It predicts the risk of hip fractures better than other measurement sites.
Rationale: The hip is the preferred site for BMD measurement because hip fractures are the most significant consequence of osteoporosis, and the hip measurement predicts this risk more effectively than other sites.

Question 9

In which group of individuals might spine measurements be more sensitive than hip measurements for detecting bone loss?
A. Older individuals with degenerative spine disease
B. Young adults with a history of fractures
C. Perimenopausal or early postmenopausal women
D. Individuals with severe scoliosis

Answer 9

Correct Answer: C. Perimenopausal or early postmenopausal women
Rationale: Spine measurements are often more sensitive in detecting early bone loss in younger individuals, such as perimenopausal or early postmenopausal women.

Question 10

What is a common alternative site for BMD measurement when the spine or hip cannot be measured due to conditions like severe degenerative spine disease or scoliosis?
A. Wrist
B. Femur
C. Total body
D. Tibia

Answer 10

Correct Answer: A. Wrist
Rationale: When the spine or hip cannot be measured, the wrist is a common alternative site for BMD measurement, as it can still provide valuable information about bone density.

Question 11

When performing DXA scans of the hip, what additional measurement is typically performed at the same time?
A. Wrist
B. Spine
C. Femur
D. Total body

Answer 11

Correct Answer: B. Spine
Rationale: When DXA scans are performed to measure the hip, spine measurements are usually taken concurrently to provide a more comprehensive assessment of bone density.

Question 12

According to the National Osteoporosis Foundation (NOF), at what age should bone mass measurement be considered for all women, regardless of risk factors?
A. 55 years
B. 60 years
C. 65 years
D. 70 years

Answer 12

Correct Answer: C. 65 years
Rationale: The NOF recommends that all women undergo bone mass measurement by age 65, even if they do not have additional risk factors. This guideline is supported by the U.S. Preventive Health Services Task Force.

Question 13

In men, at what age is bone density measurement recommended in the absence of multiple risk factors or a history of osteoporosis-related fractures?
A. 50 years
B. 60 years
C. 65 years
D. 70 years

Answer 13

Correct Answer: D. 70 years
Rationale: Bone density measurement is not recommended for men until age 70 unless they have multiple risk factors for osteoporosis or a prior osteoporosis-related fracture.

Question 14

What is the threshold FRAX 10-year risk percentage for major osteoporotic fractures at which treatment is considered cost-effective in the United States?
A. 5%
B. 10%
C. 20%
D. 25%

Answer 14

Correct Answer: C. 20%
Rationale: In the United States, it is considered cost-effective to treat if the 10-year risk for major osteoporotic fractures, as calculated by FRAX, is ≥20%. For hip fractures, the threshold is ≥3%.

Question 15

Which of the following individuals should undergo BMD testing according to clinical guidelines?
A. A 55-year-old postmenopausal woman with no risk factors
B. A 65-year-old man with no history of fractures or risk factors
C. A 45-year-old woman with rheumatoid arthritis
D. A 40-year-old man without any fractures or risk factors

Answer 15

Correct Answer: C. A 45-year-old woman with rheumatoid arthritis
Rationale:
Indications for Bone Mineral Density Testing * 1. Women aged ≥65 and men aged ≥70; regardless of clinical risk factors
2. Younger postmenopausal women, women in the menopausal transition, and men aged from 50 to 69 with clinical risk factors for fracture
3. Adults who have a fracture at or after age 50
4. Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids at a daily dose >5 mg prednisone or equivalent for >3 months associated with low bone mass or bone loss

Question 16

For adults who experience a fracture, at what age is bone mineral density testing recommended?
A. 40 years or older
B. 50 years or older
C. 60 years or older
D. 65 years or older

Correct Answer: B. 50 years or older
Rationale: BMD testing is recommended for adults who have a fracture at or after the age of 50, as this may indicate underlying osteoporosis or low bone mass.

Answer 16

Correct Answer: B. 50 years or older
Rationale:
Indications for Bone Mineral Density Testing * 1. Women aged ≥65 and men aged ≥70; regardless of clinical risk factors
2. Younger postmenopausal women, women in the menopausal transition, and men aged from 50 to 69 with clinical risk factors for fracture
3. Adults who have a fracture at or after age 50
4. Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids at a daily dose >5 mg prednisone or equivalent for >3 months associated with low bone mass or bone loss

Question 17

Which medication use is an indication for BMD testing?
A. Glucocorticoids at a daily dose of ≤5 mg prednisone for 1 month
B. Glucocorticoids at a daily dose of >5 mg prednisone for >3 months
C. NSAIDs used for arthritis for >6 months
D. Short-term use of corticosteroids for <1 month

Answer 17

Correct Answer: B. Glucocorticoids at a daily dose of >5 mg prednisone for >3 months
Rationale:
Indications for Bone Mineral Density Testing * 1. Women aged ≥65 and men aged ≥70; regardless of clinical risk factors
2. Younger postmenopausal women, women in the menopausal transition, and men aged from 50 to 69 with clinical risk factors for fracture
3. Adults who have a fracture at or after age 50
4. Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids at a daily dose >5 mg prednisone or equivalent for >3 months associated with low bone mass or bone loss

Question 18

What is the recommended daily calcium intake for most adults?
A. 500 mg/day
B. 800 mg/day
C. 1000 mg/day
D. 1500 mg/day

Answer 18

Correct Answer: C. 1000 mg/day
Rationale: The recommended daily intake of calcium for most adults is approximately 1000 mg/day, which helps prevent bone loss and maintain bone health.

Question 19

Why should calcium supplements be taken in doses of ≤600 mg per single dose?
A. Larger doses may cause kidney stones.
B. Calcium absorption decreases at higher doses.
C. Larger doses are associated with gastrointestinal discomfort.
D. Larger doses suppress bone turnover.

Answer 19

Correct Answer: B. Calcium absorption decreases at higher doses.
Rationale: The fraction of calcium absorbed decreases as the dose increases beyond 600 mg per single dose, making smaller, divided doses more effective.

Question 20

Which calcium supplement is best taken with food for optimal absorption?
A. Calcium carbonate
B. Calcium citrate
C. Calcium phosphate
D. Calcium gluconate

Answer 20

Correct Answer: A. Calcium carbonate
Rationale: Calcium carbonate supplements require stomach acid for solubility and absorption, so they are best taken with food.

Question 21

What is the recommended daily intake of vitamin D for adults aged 50–70 years according to the National Academy of Medicine?
A. 200 IU
B. 400 IU
C. 600 IU
D. 1000 IU

Answer 21

Correct Answer: B. 400 IU
Rationale: The National Academy of Medicine recommends 400 IU of vitamin D daily for adults aged 50–70 years to maintain adequate serum 25(OH)D levels.

200 IU for adults <50 years of age
400 IU for those 50–70 years
600 IU for those >70 years

Question 22

What is the safe upper limit of vitamin D intake according to the National Academy of Medicine?
A. 1000 IU/day
B. 2000 IU/day
C. 3000 IU/day
D. 4000 IU/day

Answer 22

Correct Answer: D. 4000 IU/day
Rationale: The National Academy of Medicine considers up to 4000 IU of vitamin D per day to be safe, which is well above the typical recommended intake for most adults.

Question 23

What is the target serum level of 25(OH)D for most health guidelines?
A. 10 ng/mL
B. 20 ng/mL
C. 30 ng/mL
D. 50 ng/mL

Answer 23

Correct Answer: C. 30 ng/mL
Rationale: Health guidelines typically aim for a serum 25(OH)D level greater than 30 ng/mL to ensure sufficient vitamin D for bone health and overall well-being.

Question 24

What is the recommended administration method for alendronate to avoid esophageal irritation?
A. With food, after a meal
B. With a full glass of water, before breakfast, and after an overnight fast
C. With any beverage, at any time of day
D. With a full glass of water, at dinner

Answer 24

Correct Answer: B. With a full glass of water, before breakfast, and after an overnight fast
Rationale: Alendronate is poorly absorbed, so it should be taken with a full glass of water before breakfast and after an overnight fast. Additionally, patients should remain upright for at least 30 minutes afterward to avoid esophageal irritation.

In the United States, the 70-mg weekly dose is approved for treatment of osteoporosis and the dose of 35 mg per week is approved for prevention, with those doses showing equivalence to daily dosing based on bone turnover and bone mass response. Consequently, once-weekly therapy generally is preferred because of lower incidence of gastrointestinal side effects and ease of administration. Alendronate should be taken with a full glass of water before breakfast after an overnight fast, as bisphosphonates are poorly absorbed. Because of the potential for esophageal irritation, alendronate is contraindicated in patients who have stricture
or inadequate emptying of the esophagus

Question 25

What is a unique feature of risedronate compared to other bisphosphonates? A. It is administered intravenously only. B. It can be taken after breakfast. C. It requires a fasting period before taking. D. It is the only bisphosphonate with a daily dosing regimen.

Answer 25

Correct Answer: B. It can be taken after breakfast. Rationale: Risedronate is the only bisphosphonate with the flexibility of being taken after breakfast, whereas other bisphosphonates require fasting before administration.

Question 26

Which bisphosphonate has been shown to reduce vertebral fracture risk by approximately 70% in a large clinical trial? A. Alendronate B. Ibandronate C. Zoledronic acid D. Risedronate

Answer 26

Correct Answer: C. Zoledronic acid Rationale: Zoledronic acid has been shown in clinical trials to reduce vertebral fracture risk by 70%, nonvertebral fractures by 25%, and hip fractures by 40%. Zoledronic acid is a potent bisphosphonate with a unique administration regimen (5 mg by 30-min IV infusion at most annually).

Question 27

What is the primary mechanism of action of denosumab in the treatment of osteoporosis? A. Increases osteoblast activity to promote bone formation B. Inhibits osteoclast activity to decrease bone resorption C. Stimulates calcium absorption in the intestines D. Enhances vitamin D production in the skin

Answer 27

Correct Answer: B. Inhibits osteoclast activity to decrease bone resorption Rationale: Denosumab works by inhibiting osteoclast activity, which leads to decreased bone resorption and an increase in bone mass.

Question 28

What risk is associated with denosumab that is similar to bisphosphonates? A. Increased risk of cardiovascular events B. Osteonecrosis of the jaw (ONJ) and atypical femur fractures C. Increased risk of gastrointestinal bleeding D. Hypercalcemia

Answer 28

Correct Answer: B. Osteonecrosis of the jaw (ONJ) and atypical femur fractures Rationale: Like bisphosphonates, denosumab is associated with an increased risk of osteonecrosis of the jaw (ONJ) and atypical femur fractures.

Question 29

What is a potential consequence of discontinuing denosumab treatment? A. Decreased bone mass B. Rebound increase in bone turnover and accelerated bone loss C. Immediate increase in fracture risk D. No effect on bone mass

Answer 29

Correct Answer: B. Rebound increase in bone turnover and accelerated bone loss Rationale: Discontinuation of denosumab can lead to a rebound effect, with an increase in bone turnover and rapid bone loss, increasing fracture risk, particularly vertebral fractures.

Question 30

Which type of bone is most severely affected by glucocorticoid therapy? A. Cortical bone B. Trabecular bone C. Long bone D. Flat bone

Answer 30

Correct Answer: B. Trabecular bone Rationale: Trabecular bone is affected more severely by glucocorticoid therapy compared to cortical bone, leading to a greater risk of fractures, especially in the early months of treatment.

Question 31

How soon after starting glucocorticoid therapy can fractures increase due to bone loss? A. Within 6 months B. Within 12 months C. Within 3 months D. Within 1 year

Answer 31

Correct Answer: C. Within 3 months Rationale: Fractures have been shown to increase within 3 months of starting glucocorticoid therapy due to rapid bone loss, particularly during the early months of treatment.

Question 32

Which part of the skeleton is most affected by glucocorticoid-induced osteoporosis (GCIO)? A. Appendicular skeleton B. Axial skeleton C. Both axial and appendicular skeleton D. Only the hip

Answer 32

Correct Answer: C. Both axial and appendicular skeleton Rationale: Glucocorticoid-induced osteoporosis increases fracture risk in both the axial skeleton (such as the spine) and the appendicular skeleton (including the risk of hip fractures).

Question 33

Which of the following is the most common cause of glucocorticoid-induced osteoporosis (GCIO)? A. Cushing's syndrome B. Chronic use of inhaled glucocorticoids C. Therapeutic use of glucocorticoids D. High-dose intra-articular injections of glucocorticoids

Answer 33

Correct Answer: C. Therapeutic use of glucocorticoids Rationale: The most common cause of glucocorticoid-induced osteoporosis is the therapeutic use of glucocorticoids, which are widely used for conditions such as chronic lung disorders, rheumatoid arthritis, and inflammatory bowel disease.

Question 34

For patients on long-term glucocorticoids, what is the recommended skeletal measurement site using DXA? A. Only the spine B. Only the hip C. Both the spine and hip D. The wrist

Answer 34

Correct Answer: C. Both the spine and hip Rationale: All patients on long-term (>3 months) glucocorticoids should have bone mass measured at both the spine and the hip using DXA to evaluate bone health comprehensively.

Question 35

For patients over 60 years of age on long-term glucocorticoids, which skeletal site is preferred for DXA measurement if only one site can be assessed? A. The wrist B. The hip C. The spine D. The shoulder

Answer 35

Correct Answer: B. The hip Rationale: For individuals over 60 years, if only one skeletal site can be measured, the hip is the preferred site, as it better predicts fracture risk in older individuals.

Question 36

If only one skeletal site can be measured in a patient on long-term glucocorticoids, which site is preferred for individuals <60 years of age? A. The wrist B. The hip C. The spine D. The ankle

Answer 36

Correct Answer: C. The spine Rationale: For individuals under 60 years, if only one skeletal site can be measured, the spine is the preferred site, as it is more sensitive to changes in bone mass at younger ages.