Given that romosozumab is a monoclonal antibody, it is likely to have a high price tag. Alendronate is the cheap, first-line agent that most current insurance coverages favor over other agents as long as there aren't compelling contraindications. In "real-world" severe osteoporosis patients, it seems unlikely that patients will be alendronate (or other bisphosphonate) naive for very long after diagnosis. A recent analysis by Cosman, Nieves, and Dempster (JBMR 2017) suggested that sequence of use does have clinically important implications for a currently approved anabolic agent. Do you think that the likely sequence of alendronate first, followed by a switch to or addition of romosozumab would have considerably different results from what was shown by the romosozumab-then-alendronate sequence used in this trial?
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