Patient case (clinical description): A 55-year-old white woman comes for a routine checkup.  She has no significant medical history and does not use tobacco, alcohol, or illicit drugs.  The patient's only medication is an over-the-counter multivitamin.  Family history is notable for a hip fracture in her mother.  Blood pressure is 130/80 mm Hg and pulse is 112/min. She has occasional back pain and lives a sedentary lifestyle with the BMI of 24 Kg/m2. Plain X-ray of the spine shows mild compression fracture at the level of T10. X-ray absorptiometry studies demonstrate abnormally low bone density in the lumbar vertebrae and T-score values below -2.5, which confirms the diagnosis of osteoporosis.

Patient's own account: I'm a 55-year-old white woman and I recently visited my family doctor. I don't smoke anything or drink. I don't have any remarkable medical history. I only use over-the-counter multivitamins to keep myself fresh and energized. My mom had a hip fracture. The doctor took my blood pressure and it was 130/80 and my pulse was 112/min. I have annoying back pain from time to time and to be honest I don't exercise much or move much. My BMI is 24. I did a spine X-ray a while ago and my doctor showed me that I have a fracture on one of my vertebrae. I also have a low bone density in my lumbar vertebrae and T-score values below -2.5. The doctor diagnosed me with osteoporosis.

Clinical trial: Enhancing Osteoporosis Therapy: Can We Open the Anabolic Window?

Eligibility criteria:
Inclusion Criteria:

          -  Generally healthy, community-dwelling ambulatory post-menopausal women.

          -  Able and willing to sign informed consent.

          -  Age 60 to 89.

          -  Have osteoporosis defined as follows:

          -  BMD T-score of the lumbar spine, femur neck, total proximal femur or .3 radius of -2.5
             to -4.0; note: the lumbar spine must include two vertebrae that are evaluable by DXA
             in the opinion of the investigator.

        OR

          -  BMD T-score of the lumbar spine, femur neck, total proximal femur or .3 radius of -1.5
             or lower and either an atraumatic (in the opinion of the investigator) nonvertebral
             fracture; [note: nonvertebral fracture sites include the wrist, hip, pelvis, ribs,
             humerus, clavicle, femur, tibia and fibula] or a minimum of two mild or one moderate
             or severe atraumatic vertebral fractures (defined using the Genant visual
             semi-quantitative scale).

          -  Baseline serum 25(OH)D concentration > 20 ng/ml and < 60 ng/ml.

          -  Able and willing to receive daily subcutaneous injections using a Forteo® pen.

        Exclusion Criteria:

          -  History of exposure to external beam or implant radiation therapy involving the
             skeleton.

          -  Paget's disease or unexplained elevations of alkaline phosphatase.

          -  Any history of venous thrombosis including deep vein thrombosis, pulmonary embolism,
             retinal vein thrombosis and superficial phlebitis.

          -  Documented atherosclerotic vascular disease, including but not limited to prior
             myocardial infarction, angina, atrial fibrillation, stroke and TIA.

          -  Marked hypertriglyceridemia (>500 mg/dl).

          -  History of prior treatment with estrogen resulting in hypertriglyceridemia (> 500
             mg/dl).

          -  Serum calcium, alkaline phosphatase, PTH or TSH outside the normal reference range.

          -  History of nephrolithiasis or urolithiasis within 10 years prior to enrollment; those
             with a history of nephro- or urolithiasis must have an appropriate radiology study
             (e.g., IVP or KUB) within six months documenting absence of stones.

          -  Baseline 24-hour urine calcium > 250 mg.

          -  Known risk factors for hypercalcemia, e.g., malignancy, tuberculosis, sarcoidosis.

          -  History of any form of cancer except adequately treated squamous cell or basal cell
             skin carcinoma.

          -  Use of active vitamin D analogs or high dose vitamin D (≥50,000 IU weekly) in the last
             year.

          -  Active or suspected diseases (within 1 year prior to enrollment) that affect bone
             metabolism, e.g., renal osteodystrophy, hyperthyroidism, osteomalacia,
             hyperparathyroidism.

          -  Known allergy, hypersensitivity, contraindication or intolerance to teriparatide or
             raloxifene.

          -  History of vaginal bleeding within the past year.

          -  Renal failure or substantial hepatic impairment. Note "renal failure" is defined as a
             calculated creatinine clearance (using the Cockroft-Gault formula) of ≤ 35 ml/minute.

          -  Severe disease, e.g., cardiac, hepatic, pulmonary, etc., which may limit ability to
             complete this study. Specifically, significantly impaired hepatic function (ALT or GGT
             3x the upper limit of normal.

          -  Known malabsorption syndromes, e.g., celiac disease, active inflammatory bowel
             disease, gastric bypass, etc.

          -  Use of anion exchange resins (e.g., cholestyramine) in the past month.

          -  Current use of warfarin (coumadin).

          -  Current use of highly protein-bound drugs including diazepam, diazoxide and lidocaine.

          -  Current use of digoxin.

          -  Any prior use of bisphosphonates, denosumab, strontium, fluoride, teriparatide or
             parathyroid hormone.

          -  Prior use of estrogen, raloxifene, calcitonin or testosterone will be allowed if
             discontinued more than six months previously. Low dose intra-vaginal estrogens (0.3 mg
             or less of conjugated equine estrogen or equivalent) may be continued throughout the
             study.

          -  Treatment with glucocorticoids in doses ≥ 5 mg prednisone daily for > 30 days in the
             prior year.

          -  Treatment with other drugs known to affect bone metabolism, e.g., anticonvulsants
             except benzodiazepines or gabapentin, within the prior year. Note: oral calcium
             supplementation, vitamin D supplementation or diuretic use that has been stable for
             six months are allowed).

          -  Treatment within the last 30 days with any drug that has not received regulatory
             approval.

          -  Metal in spine precluding spine QCT.

          -  Any condition that may interfere with evaluation of at least two lumbar vertebrae
             determined on VFA performed at time of screening. Examples include confluent aortic
             calcification, severe osteoarthritis, spinal fusion and lumbar spine fractures.
Female
Accepts Healthy Volunteers
Subject must be at least 60 Years old.
Subject must be at most 89 Years

Eligibility (NLI label): Contradiction