A 73 year old lady presented with severe back pain without significant trauma. She was a current smoker and alcoholic drinker. She had a past medical history of chronic obstructive pulmonary disease, previous distal radius fracture one year ago, diabetes mellitus, chronic kidney disease (estimated glomerular filtration rate (eGFR) 40 ml/min), gastroesophageal reflux disease and hypothyroidism. The X-ray of lumbar spine showed vertebral fractures at 12th thoracic vertebra (T12) and 1st lumbar vertebra (L1). The bone mineral density (T-score) of the lumbar spine and femoral neck measured by a dual-energy X-ray absorptiometry were -2.5 and -2.4 respectively. 

The patient had no known drug allergies. Her medications included salbutamol 2 puffs four times a day, tiotropium 18 microgram daily, pioglitazone 15 mg daily, pantoprazole 40 mg daily and levothyroxine 75 microgram daily.

a) Discuss the patient’s diagnosis based on the clinical presentation and bone mineral density results. (2 marks)

b) What modifiable contributing factors for the above condition could be found in the patient? (3 marks)

c) Advise the patient FOUR bone healthy lifestyle modifications (2 marks)

d) The patient was treated with alendronic acid 70 mg once weekly and calcium carbonate 1500 mg once daily. What are your recommendations on drug administration? (2 marks)

e) List TWO biochemical tests which should be monitored during alendronic acid treatment in this patient? Suggest the management if these test results are abnormal (2 marks)

f) The patient had been taking alendrotnic acid and calcium supplement correctly as recommended but she complained of severe heartburn symptom. Discuss THREE medicine alternatives and their contraindications. (6 marks)

g) The American Association of Clinical Endocrinologist/American College of Endocrinology Clinical Practice Guidelines for the diagnosis and treatment of postmenopausal osteoporosis - 2020 update suggested that drug holidays after a treatment period might be considered. Complete the following table.