Rank the following agents in order of most frequent dosing to least frequent dosing when treating osteoporosis.

A. Evista

B. Boniva

C. Prolia

D. Reclast

Answer with rationale: The correct answer is A-B-C-D. There are a number of agents involved in the treatment of osteoporosis with a variety of dosage frequencies given orally, IV, and SQ. Answer A is first as Evista (raloxifene) is dosed once daily. It is not a first line agent due to lack of data demonstrating hip fracture prevention. Next is Boniva which is a bisphosphonate that can be dosed once monthly (orally) or IV q 3 months. Bisphosphonates are typically first line options for osteoporosis due to excellent data demonstrating decreased overall fracture risk including hip fractures. Boniva however is not a first line option compared to other bisphosphonates as its data for hip fracture prevention is not as robust as others such as alendronate. Next is Prolia (denosumab) which is dosed 60mg SQ q 6 months. Finally Reclast (zoledronic acid) is dosed once yearly for the treatment of osteoporosis (every 2 years for prevention). Zoledronic acid is also used for other indications such as multiple myeloma and hypercalcemia of malignancy under the brand name Zometa.