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Abstract
Introduction Novel strategies are needed to address the rising burden of osteoporosis and fragility fractures. High-intensity resistance and impact (HiRIT) exercise has shown benefit in improving bone density in postmenopausal women with osteoporosis/osteopenia. Whether HiRIT can enhance the therapeutic effects of osteoporosis pharmacotherapy has not been established. ROLEX-DUO is a randomised controlled trial designed to assess the efficacy of romosozumab on various bone and muscle outcomes in combination with different exercise interventions in women with postmenopausal osteoporosis/osteopenia.
Methods and analysis ROLEX-DUO is an 8-month randomised placebo-controlled trial conducted at two tertiary referral centres for patients with osteoporosis/osteopenia in Sydney, New South Wales, Australia. The study is implementing the combination of romosozumab or placebo with different forms of exercise in postmenopausal women with osteoporosis/osteopenia without recent fragility fracture (n=102). Eligible women will be randomised 1:1:1 into one of three groups: (1) romosozumab with supervised HiRIT, (2) romosozumab with unsupervised low-intensity exercise or (3) placebo with unsupervised low-intensity exercise. Co-primary outcomes are the mean percentage change in lumbar spine bone mineral density (BMD), and mean change in five times sit-to-stand test performance (seconds) at 8 months. Secondary/exploratory outcomes include BMD changes at the femoral neck, total hip and distal radius, three-dimensional dual-energy X-ray absorptiometry (DXA) hip outcomes, DXA-derived lean and fat mass, serum markers of bone turnover (procollagen type 1 peptide, C-telopeptide of type 1 collagen) and bone biomarkers (dickkopf-1), serum extracellular vesicle analyses, 36-Item Short Form Survey (SF-36) quality-of-life scores, Menopause-Specific Quality Of Life (MENQOL) Questionnaire menopause symptom burden scores, number of falls and fractures. Mixed-effects models will be performed to compare longitudinal outcome results between groups using intention-to-treat analysis.
Ethics and dissemination The trial was approved by the Northern Sydney Local Health District Human Research Ethics Committee (2022/ETH01794, protocol V.8, dated 03 July 2024). Participants will provide written informed consent prior to inclusion. Findings will be disseminated via peer-reviewed journals, scientific conferences and summary reports to funding bodies.
Trial registration number ACTRN12623000867695.
- diabetes & endocrinology
- clinical trial
- calcium & bone
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Strengths and limitations of this study
This randomised controlled trial will assess the effects of combining exercise with osteoanabolic pharmacotherapy in improving bone density outcomes in postmenopausal women with osteoporosis or osteopenia and will assess the effects of osteoanabolic pharmacotherapy on muscle and physical function outcomes.
Participants and outcome assessors will be blinded to treatment allocation (other than blinding of participants to exercise programme allocation).
The study examines clinically relevant co-primary outcomes including lumbar spine bone mineral density (a surrogate marker for fracture risk) and five times sit-to-stand test performance (associated with disability and falls risk) and various secondary bone, muscle, physical function and patient-reported outcomes.
The study selection criteria focus on patients with less severe osteoporosis without recent fragility fracture, which may not represent the typical patient population for whom romosozumab is usually considered in clinical practice; however, this is also a strength as the effects of romosozumab on improving bone density in this less severe cohort are unknown.
The 8-month active study phase is shorter than the current approved 12-month treatment course of romosozumab; however, both romosozumab and high-intensity resistance and impact have been separately shown to improve bone density within this time frame.
Introduction
The health and financial burdens associated with osteoporosis/osteopenia and fragility fractures are substantial and novel strategies are needed to address this.1 It is unclear whether skeletal loading can enhance the therapeutic potential of osteoporosis pharmacotherapy. Two recent randomised controlled trials (RCTs) in postmenopausal women with osteoporosis (LIFTMOR, MEDEX-OP) demonstrated 8 months of supervised high-intensity resistance and impact training (HiRIT) is associated with over 4% net benefit in lumbar spine bone mineral density (BMD) compared with low-intensity exercise and greater improvements in markers of muscle strength and physical function.2 3 Exercise interventions were safe and adherence was high across both studies. A subsequent meta-analysis indicated high intensity exercise is required to notably increase BMD as low and moderate intensity exercise is relatively ineffective.4 Although exercise is often recommended as part of multidisciplinary care for patients with osteoporosis, data is scarce on the interaction between exercise and osteoporosis pharmacotherapy in improving bone density and associated outcomes.
Romosozumab (an anti-sclerostin monoclonal antibody) is a well-tolerated osteoanabolic agent that has led to robust BMD gains at the lumbar spine and hip (~13% and ~7% at 12 months, respectively) when compared with placebo and has also shown superiority in fracture risk reduction compared with the oral bisphosphonate alendronate.5 6 Sclerostin is secreted by osteocytes and reduces bone formation by negatively regulating canonical Wnt signalling in osteoblasts.7 Downregulation of sclerostin (SOST) expression is the leading hypothesis for the osteogenic effects of skeletal loading.7 Hence, skeletal loading and romosozumab both promote bone formation through similar biomolecular pathways; sclerostin downregulation and inhibition, respectively. It is unclear whether the addition of exercise would provide further skeletal benefit (via sclerostin downregulation) in patients receiving romosozumab whereby the sclerostin molecule is pharmacologically inhibited. Mice overexpressing SOST have shown diminished local osteogenic responses to ulnar bone loading with reduced bone formation rate on histomorphometry.8 SOST knockout mice have shown enhanced local osteogenic responses to tibial bone loading compared with wild-type mice based on tibial BMD, bone volume on micro-CT and bone formation rate.9 Whether sclerostin downregulation by osteogenic exercise has added osteoanabolic effects above sclerostin inhibition by romosozumab has not been studied in humans, despite promising preclinical results. The ROLEX-DUO study will be the first to investigate whether skeletal loading may enhance the bone density response to romosozumab. There is minimal data regarding bone density response after simultaneously commencing any osteoporosis pharmacotherapy with exercise,10 11 and hence this study represents a significant advance in knowledge in the musculoskeletal field.
A vast majority of fragility hip fractures (>90%) occur secondary to falls.1 Emerging evidence supports the concept of the bone/muscle interface including shared embryogenesis, synergistic roles in locomotion and molecular interactions via muscle-derived/bone-acting myokines (eg, myostatin, interleukin (IL)-6) and bone-derived/muscle-acting osteokines (eg, receptor activator of nuclear factor kappa-B ligand (RANKL), sclerostin).12 To date, osteoporosis pharmacotherapy trials have focused on fracture risk reduction via bone density gains however, evaluation of muscle, physical function and fall outcomes could indicate novel integrated mechanisms for fracture risk reduction. Beyond its role as an osteoanabolic treatment, romosozumab may also have clinically relevant effects on muscle health, a hypothesis that has never been examined in a clinical trial. A meta-analysis of romosozumab RCTs in postmenopausal osteoporosis found 20% fall risk reduction versus controls (n=11 211, p<0.01).13 Low-density lipoprotein receptor-related protein (LRP)5/6, sclerostin’s target receptor, is expressed in human skeletal muscle and Wnt canonical signalling has been shown to be anabolic in muscle.14 In vitro evidence suggests sclerostin is a candidate myokine and in mice, muscle-derived sclerostin and bone-derived sclerostin both demonstrate similar effects on bone tissue.15 Sclerostin-antibody treatment has been shown to reduce bone metastases and restore muscle function in rats with metastatic cancer and muscle weakness.16 In humans, serum sclerostin concentrations have negatively correlated with muscle mass in a sarcopenic population.17 The current study is the first to investigate the effects of romosozumab on muscle and physical performance outcomes in humans and the first RCT to investigate this in relation to any osteoporosis pharmacotherapy.
Recent research has demonstrated an increased circulating concentration of small extracellular vesicles (EVs) immediately after exercise in predominantly young healthy exercising men. Whitham et al isolated such EVs providing an avenue to identify novel myokines potentially involved in muscle-bone crosstalk which may play a role in mediating some positive impacts of exercise on bone health.18 Preclinical work suggests muscle-derived EVs may exert positive effects on osteoblastogenesis and bone formation in mice.19 The ROLEX-DUO study will analyse circulating EVs in a postmenopausal population of women with osteoporosis/osteopenia undergoing high-intensity exercise, representing a novel advance in the field.
Hence, the ROLEX-DUO study is a novel RCT being conducted in postmenopausal women with low bone density. The primary objectives are to determine whether combining romosozumab with high-intensity resistance and impact exercise is associated with greater percentage gains in lumbar spine BMD than romosozumab with low-intensity exercise, and whether romosozumab is associated with improved muscle and physical performance compared with placebo over an 8-month period.
Methods and analysis
Study aims
ROLEX-DUO is a prospectively registered study being conducted in postmenopausal women with low bone density to compare the efficacy of romosozumab plus high-intensity exercise with that of romosozumab plus low-intensity exercise on 8-month percentage changes in lumbar spine BMD. The study will also assess the efficacy of romosozumab plus low-intensity exercise compared with placebo plus low-intensity exercise on 8-month changes in five times sit-to-stand test performance. Longitudinal changes in various other bone, muscle, functional performance and patient-reported outcomes will also be examined (figures 1 and 2).
Consolidated Standards of Reporting Trials diagram for ROLEX-DUO. ITT, intention-to-treat.
Flowchart of study visits and outcome assessments. All eligible participants will be randomised (1:1:1) into one of three groups resulting in different drug/placebo and exercise allocations. The active study phase is 8 months during which participants will undergo monthly study visits. Various musculoskeletal and patient-reported outcomes will be assessed every 4 months while serum will be collected monthly for the first 4 months and then second monthly thereafter. DXA, dual-energy X-ray absorptiometry.
Study design and setting
ROLEX-DUO is an 8-month, placebo-controlled, double-blinded, randomised, controlled trial being undertaken at Royal North Shore Hospital and Westmead Hospital; two tertiary referral centres for patients with osteoporosis in Sydney, New South Wales.
Trial status
The first participant was enrolled in the study on 04 April 2024. Recruitment is planned until December 2025. Study completion is planned for September 2026.
Inclusion criteria
Eligible participants must meet all the following inclusion criteria:
Postmenopausal women aged between 50 years old and 80 years old (inclusive).
At least 2 years since menopause.
Any baseline dual-energy X-ray absorptiometry (DXA) BMD T-score at total lumbar spine, total hip or femoral neck between −1.5 SD and −3.5 SD in women aged younger than 70 years or between −1.5 SD and −2.5 SD in women aged 70 years and older.
To be eligible, participants must have at least two interpretable lumbar vertebrae on DXA without grossly spuriously elevated results or hardware. The BMD T-score cut-offs for inclusion in the study are derived from Australian government subsidisation regulations for osteoporosis pharmacotherapy such that we deemed it unethical to randomise women to placebo if they would have been likely to qualify for government-funded pharmacotherapy for fracture risk reduction.
Exclusion criteria
Participants will be excluded from the study if any of the following exclusion criteria apply:
Any baseline DXA BMD T-score at total lumbar spine, total hip or femoral neck less than −3.5 SD in women aged younger than 70 years or less than −2.5 SD in women aged 70 years and older.
Prior fragility fracture sustained after the age of 50 years, including:
Any fragility hip or vertebral fracture.
Any non-hip non-vertebral fragility fractures after the age of 50 years and in the past 3 years.
For non-hip non-vertebral fragility fractures after the age of 50 years sustained over 3 years ago, an informed discussion with the prospective participant is required regarding alternative government-funded osteoporosis treatment options prior to further consideration of inclusion in the study.
Use of recent osteoporosis pharmacotherapy including intravenous bisphosphonates in the last 2 years, oral bisphosphonates in the last 12 months, denosumab in the last 2 years, menopausal hormone therapy, raloxifene or tibolone in the past 6 months and any prior use of romosozumab, teriparatide or strontium.
Regular steroid use equivalent to at least 5 mg daily prednisone.
Active untreated secondary osteoporosis.
Untreated baseline vitamin D deficiency (<50 nmol/L) or albumin-corrected hypocalcaemia (<2.10 mmol/L).
Baseline renal impairment (estimated glomerular filtration rate (eGFR)<30 mL/min/1.73 m2).
Any prior history of coronary artery or cerebrovascular event.
Active malignancy other than non-melanoma skin cancer or ductal carcinoma in situ.
Already participating in resistance or high-impact exercise at least once per week.
Unable to ambulate independently without aids.
Any contraindication to being able to participate in an exercise programme.
Planned leave for ≥4 weeks total (or ≥3 weeks continuous) during the 8-month study period.
Non-fluent in speaking and understanding English.
Washout periods for previous osteoporosis treatment are based on selection criteria used in the FRAME study (placebo-controlled study using romosozumab in postmenopausal osteoporosis).7 Participants unable to perform movements that are involved in the exercise interventions, such as a squat or overhead press, will be ineligible.
Recruitment and informed consent
Participants will be recruited through various avenues. Healthcare professionals at local endocrinology clinics, densitometry locations and general practice clinics will identify potentially eligible participants and notify the lead study investigator if the participant is willing to be contacted for further information. Advertisement posters will also be distributed in clinical rooms, outpatient waiting areas, communal areas (eg, libraries), pharmacies, community noticeboards, newsletters and social media channels. Prospective participants can either contact the lead investigator using the contact details provided or register interest in the study by accessing the quick response code. The lead investigator will then discuss the trial further with potential participants in detail and perform preliminary phone screening for eligibility. If still eligible after preliminary screening, prospective participants will be invited to attend a screening visit including physical assessment, DXA BMD scan and secondary osteoporosis screening bloods. All potentially eligible participants will be required to provide written informed consent prior to undergoing screening procedures and within 30 days of enrolment. The latest approved version of the MASTER consent form is provided as online supplemental material (MASTER PICF, V.5, dated 07 October 2023).
Supplemental material
Randomisation
After providing informed consent and undergoing screening procedures, eligible participants will be randomised (1:1:1) to one of three different groups:
Romosozumab plus high-intensity exercise.
Romosozumab plus low-intensity exercise.
Placebo plus low-intensity exercise.
Randomisation will occur using the strategy of maximum tolerated imbalance to minimise the risk of investigators predicting the randomisation sequence, using the National Cancer Institute online clinical trial randomisation tool, available at https://ctrandomization.cancer.gov/tool/. Randomisation will be performed by a single investigator who is uninvolved in any outcome assessments or study visits. This investigator will then notify the study coordinator (also uninvolved in outcome assessments or study visits) of the participant’s allocated exercise intervention, who will then advise the participant of their exercise (but not drug/placebo) allocation. The randomisation process will be concealed from all other study investigators including the investigator performing study visits and outcome assessments. Randomisation will be stratified by the study centre. Participants will be allocated a unique study identification number.
Blinding
Participants will be blinded to receipt of romosozumab or placebo subcutaneous injections. Although participants cannot be blinded to their exercise intervention, they will be blinded to which type of exercise is hypothesised to provide greater skeletal benefit, that is, hypothesis-blinding, which is the highest level of participant blinding obtained during exercise allocation. Subcutaneous injections will be prepared by unblinded trial pharmacy personnel and provided to unblinded nursing staff who will administer the romosozumab or placebo injections. Outcome assessors and investigators performing study visits will remain blinded to participant drug and exercise treatment allocation. The study statistician will be blinded to treatment allocation.
Withdrawal
The following reasons could lead to early discontinuation of participation in the study:
Withdrawal of consent.
Post-enrolment detection of exclusion criteria.
Commencing alternative osteoporosis medications.
Adverse event.
Loss to follow-up.
Advised to cease drug and/or exercise intervention by a medical professional.
Participants with early discontinuation of study interventions will be encouraged to still attend study visits if safe and feasible to do so. If prior to commencing study interventions a participant is found to have an exclusion criterion not previously detected or disclosed, then that participant will be replaced.
Interventions
The dose of romosozumab will be 210 mg (two injections of 105 mg each) subcutaneous injections monthly as per the manufacturer guidelines and no dose modifications will be permitted. Placebo will be administered as two volume-matched (1.0 mL) subcutaneous injections of 0.9% sodium chloride solution (normal saline) monthly.
HiRIT involves twice weekly 45 min sessions fully supervised by trained and licenced exercise physiologists and/or physiotherapists consistent with interventions used in the LIFTMOR and MEDEX-OP trials.2 3 Exercise facilities delivering HiRIT will be calibrated by study investigators prior to the commencement of recruitment to ensure exercises are being conducted safely and with sufficient load stimulus. The first month will involve a familiarisation period with lifting exercises performed with body weight or minimal weight to ensure safe correct technique. The fundamental exercises in the HiRIT programme include three resistance exercises (deadlift, overhead press and back squat) and one impact exercise (jumping chin-ups). During the study period, participants will perform five sets of five repetitions of each resistance exercise at each session aiming to progressively increase the load to maintain an intensity of >80% of their one repetition maximum. Participants will also perform five sets of five repetitions of jumping chin-ups at each session. The HiRIT exercise intervention is described in further detail in the MEDEX-OP study protocol.20
The low-intensity exercise involves twice weekly 45 min sessions of unsupervised home-based exercises focused on balance and mobility. The exercises have been adapted from a New South Wales Health state-wide standard of care home-based exercise programme ‘Active and Healthy’ similar to the low-intensity exercise control intervention used in the LIFTMOR study,2 which demonstrated these interventions are safe and feasible to perform at home and provide minimal stimulus in improving bone density. At baseline, participants will have a one-on-one session with an investigator on how to perform the exercises safely and will be provided with written instructions on how to perform the home-based exercise. The exercises include heel-to-toe standing and walking, knee raises, side leg raises, sideways walking, stepping and sit-to-stand.
Exercise session attendance for both high-intensity and low-intensity exercise will be recorded by participants using a study logbook and monitored by HiRIT instructors. Template for Intervention Description and Replication (TIDieR) checklists for both exercise interventions are provided as online supplemental material.
Supplemental material
Supplemental material
Study visits
Study visits will be conducted monthly (±7 days). Procedures including drug or placebo administration, DXA scans and serum collection may be performed across different days so long as the procedures are all completed within the study visit window. The schedule of study visits and associated outcome assessments is summarised in figure 2.
Co-primary outcomes
The co-primary outcomes include (1) a percentage change in lumbar spine BMD at 8 months, and (2) the change in five times sit-to-stand time (seconds) at 8 months. These co-primary outcomes were selected because lumbar spine BMD is a surrogate marker for fracture risk,21 and five times sit-to-stand time has been associated with falls risk and disability.22 23
DXA outcomes
Participants will undergo BMD scans (DXA; Hologic, Waltham, Massachusetts, USA) at baseline, 4 months and 8 months, which will be analysed using system software to assess areal BMD in g/cm2 at the lumbar spine (L1-L4), and lumbar spine trabecular bone score, and BMD at the total hip and femoral neck from both proximal femora, and left distal radius. Analysis of parameters of cortical and trabecular bone volume and geometry of the proximal femur will be derived from the DXA scan using three-dimensional shaper software. The DXA device will be calibrated daily using a Hologic spine phantom. BMD assessments will be performed according to standard manufacturer operating procedures on the same densitometer by the same licenced blinded investigator to minimise inter-assessor variance. DXA whole body assessment to derive body fat mass (kg), fat percentage (%), lean mass (kg), lean appendicular mass (kg) and skeletal muscle index (lean appendicular mass (kg)/height (m2) will be conducted at baseline, 4 and 8 months.
Muscle and physical performance outcomes
Participants will also complete various 4-monthly musculoskeletal, balance and postural assessments conducted by the same trained investigator. Assessments include handgrip strength (right and left arm) using isometric hydraulic hand-held dynamometer (JAMAR Plus, S.I. Instruments, Hilton, South Australia, Australia), leg extensor strength using an isometric dynamometer platform (TTM Muscular Metre, Tokyo, Japan), five times sit-to-stand (secs), timed up and go (secs), tandem walk (secs and errors), 6 metre gait speed (secs), functional reach distance (cm) and tragus-to-wall distance (cm), described in detail in the MEDEX-OP study protocol.20 The best out of three repeated measures will be recorded for each assessment other than gait speed (average), tragus-to-wall distance (average), handgrip and leg extensor strength (average and best of three measures). Muscle and physical performance outcomes will be performed according to standard operating procedures by the same trained blinded investigator to minimise inter-assessor variance.
Laboratory assays
Various serum parameters will be measured as part of screening procedures including renal function (creatinine, eGFR), total alkaline phosphatase (ALP), albumin-corrected calcium, magnesium, phosphate, 25-hydroxyvitamin D3 (25-OHD3), intact parathyroid hormone, thyroid stimulating hormone, free thyroxine, coeliac serology including total IgA, deamidated gliadin peptide IgG and tissue transglutaminase IgA, myeloma screen including serum-free light chain ratio, electrophoresis and immunofixation, and assessment of cardiovascular risk factors including fasting glucose, glycated haemoglobin and fasting cholesterol and triglycerides. Calcium, magnesium and phosphate will be repeated at 1, 4 and 8 months, while renal function and 25-OHD3 will be repeated at 4 and 8 months as part of safety analyses. Fasting serum samples will be collected monthly from baseline until 4 months and then at 6 and 8 months, including assessment of the bone resorption marker C-telopeptide of type 1 collagen, the bone formation markers procollagen type 1 peptide and bone-specific ALP and bone biomarker dickkopf-1. Serum sclerostin concentrations will also be assessed at baseline to assess correlation with 4-month and 8-month BMD outcomes. Serum (collected in serum separator tubes) and plasma (collected in EDTA-coated tubes) will be centrifuged at 3000×g for 15 min and then aliquoted and stored at −80°C until assays are performed in batches. Exploratory serum inflammatory (IL-1, IL-6 and tumour necrosis factor alpha), bone (osteoprotegerin, RANKL) and muscle biomarkers (myostatin) will also be analysed. Reference ranges for assays will be as per manufacturer guidelines. All biochemical analyses will be conducted in the Endocrinology Research Laboratory, Royal North Shore Hospital, Sydney, by senior medical laboratory scientists.
Extracellular vesicle analyses
Blood samples will also be obtained from all consenting participants undergoing HiRIT immediately before, immediately after and 4 hours after exercise at 2–4 months and 8 months. Blood will be collected in EDTA-coated tubes and centrifuged twice at 2500×g for 10 min at room temperature and then plasma stored at −80°C. EV analyses will be conducted in batches in the Cellular and Molecular Metabolism Laboratory, Monash University, Melbourne, Australia, by senior molecular laboratory scientists. EVs will be isolated using well-established techniques including:
Size exclusion chromatography (SEC) was performed using an IZON Science Automatic Fraction Collector and qEV10 columns, according to manufacturer instructions (IZON Science, New Zealand). Following SEC, EV-rich and non-EV fractions will be combined and concentrated using Amicon Ultra-15 Centrifugal Filter Units at 4000×g for 50 min, resulting in a final volume of approximately 500 µL.
Ultracentrifugation will also be performed, consisting of two 2-hour spins at 100 000×g with a filtered phosphate-buffered saline wash during the second spin.24
Immunoprecipitation will be performed using the EasySep Human Pan-Extracellular Vesicle Positive Selection Kit according to the manufacturer instructions (STEMCELL Technologies Canada).
To characterise EVs and their cargo, consistent with recommendations of the International Society for Extracellular Vesicles25 we will use the following techniques:
Nanoparticle tracking analysis (ZetaView ×30 system, Particle Metrix, Germany).
Transmission electron microscopy (JEOL JEM-2010, USA).
Western blot analysis for markers consistent with small EVs, including CD81, CD9, TSG101, syntenin-1, GAPDH and exclusion markers including calnexin and SERBP1.26
Proteomic analysis—EVs will be prepared using the S-Trap protocol (ProtiFi, USA), wherein EV samples are subjected to sonification, reduction, alkylation and digestion. An in-house stage-tip method will then be used for further purification and sample preparation, with mass spectrometry parameters described in further detail elsewhere.18
Patient-reported outcomes, lifestyle factors, falls and fractures
Participants will also complete quality of life (36-Item Short Form Survey (SF-36)-derived specific domain scores) and menopause symptom burden questionnaires (Menopause-Specific Quality Of Life (MENQOL) Questionnaire-derived specific vasomotor, physical, psychosocial and sexual domain scores) at baseline, 4 and 8 months. Relevant lifestyle factors will be assessed at baseline and 8 months to adjust for between-group differences. Daily dietary calcium intake (mg/day) will be estimated using an online calculator based on a validated Australian calcium-specific diet questionnaire (AusCal), available at http://calciumcalculator.com.au.27 Historical bone-relevant physical activity will be assessed using the Bone-specific Physical Activity Questionnaire (BPAQ) including participation in activity over the past 12 months (current – cBPAQ) and lifelong (tBPAQ), with scores calculated using established algorithms.28 The frequency of falls (n), vertebral and non-vertebral fractures (reported and clinically detected) will be recorded at each monthly study visit.
Statistical plan
Results will be reported as per Consolidated Standards of Reporting Trials guidelines and analyses conducted on an intention-to-treat basis. Per-protocol analyses will also be conducted for participants who completed at least 75% of both exercise sessions and romosozumab/placebo injections. Baseline characteristics will be tabulated by the treatment group with categorical data summarised as n (%) and continuous data summarised as mean (±SD) if approximately normally distributed, or median (IQR) if not. To maintain an overall 5% level of significance, each co-primary outcome will be tested at the 2.5% two-sided significance level. All other analyses will be considered exploratory and a 5% two-sided significance level will be used with no correction for multiple comparisons.
Linear and generalised linear mixed effects models (LME and GLME, respectively) will be used to analyse the longitudinal continuous outcome measures. In each model, the subject will be the group identifier, time will be considered as a random effect with a general positive-definite covariance structure and as a fixed effect and treatment together with its interaction with time will be fixed effects. The models will be adjusted for the fixed effects of potential confounding variables which demonstrate an imbalance at baseline across treatment groups. The interaction between time and treatment will be used to test for differences in changes over time between treatment groups. Unlike analysis of variance, mixed effect models do not exclude participants with missing values. Patient profile plots will be used to illustrate the changes in an outcome over time for individual participants by treatment group. Diagnostic plots of residuals will be used to check the adequacy of the fitted mixed effects models.
IBM SPSS Statistics V.29 (SPSS, Chicago, Illinois, USA) and the R package lme4 for fitting mixed effects models, available at https://cran.r-project.org/web/packages/lme4/lme4.pdf will be used to analyse the data.
Sample size calculations for co-primary outcomes
Sample size calculations were based on results of the MEDEX-OP trial which compared high-intensity exercise to low-intensity exercise in patients with or without existing osteoporosis pharmacotherapy.3 In this trial, the pooled SD for the first co-primary outcome (percentage change in lumbar spine BMD at 8 months) was 2.4%, and that for the second co-primary (change in five times sit-to-stand time at 8 months) was 1.5 s. Assuming a drop-out rate of 15%, a sample size of 34 subjects per treatment group has:
80% power to detect a statistically significant mean difference of at least 2% between the percentage change in BMD observed in the romosozumab plus high-intensity exercise group versus that in the romosozumab plus low-intensity exercise group (α=0.025, SD=2.4%).
>90% power to detect a statistically significant mean difference of at least 1.5 s between the change in time for five times sit-to-stand observed in the romosozumab plus low-intensity exercise group versus that in the placebo plus low-intensity exercise group (α=0.025, SD=1.5 s).
Thus, a total of 102 participants (34 participants per group) will be required. Sample sizes were calculated using R software.
Safety considerations
Fracture assessment
Fractures will be assessed as part of screening procedures by electronic medical record review, self-reporting and a thoracolumbar spine X-ray scan with vertebral fracture defined as loss of height of 20% or greater. Thoracolumbar spine X-ray will be repeated at 8 months. During the active study period, participants will undergo height assessments 4-monthly to screen for ≥2 cm height loss in which case a thoracolumbar spine X-ray would be ascertained to assess for vertebral fracture. During each study visit, participants will be asked about recent onset midline back pain and all participants will be screened for midline spinal tenderness on examination. Further investigations may be requested according to the investigator’s discretion. Participants will also be asked about symptoms suggestive of an atypical femoral fracture, for example, anterior thigh or groin pain. In the event of a confirmed or highly suspected fragility fracture during the study, investigators will discuss implications for the participant’s individual fracture risk and alternative treatment options.
Cardiovascular safety
A higher proportion of patients treated with romosozumab compared with alendronate in the ARCH trial experienced a serious cardiovascular event (2.5% vs 1.9%).29 However, there was no increased risk of cardiovascular events in the large placebo-controlled trial FRAME.6 The significance of these findings are uncertain, however, authorities have recommended avoiding romosozumab in patients with a history of any prior coronary artery or cerebrovascular event. Therefore, in the current study participants with a prior cardiovascular event will be excluded. A baseline assessment of cardiovascular risk will be performed (using an online cardiovascular disease (CVD) risk calculator, available at https://www.cvdcheck.org.au/calculator) and participants deemed at high risk (>15% absolute CVD risk in 5 years) may require cardiac clearance before enrolment in the study. At baseline and each monthly study visit, participants will be interviewed regarding symptoms of cardiovascular disease and will undergo a 12-lead ECG with concerning findings reviewed by an independent cardiac safety monitor.
Adverse event reporting
Adverse events (AEs) will be assessed at monthly study visits and recorded by participants in their study logbooks. Serious adverse events (SAEs) will be defined as any unforeseen medical event occurring during the study that results in participant death, is life-threatening to the participant, requires hospitalisation or leads to the participant having a persistent or significant disability. SAEs will be promptly reported to the Northern Sydney Local Health District (NSLHD) Human Research Ethics Committee and an independent medical safety monitor. AEs of interest include injection site reactions, hypersensitivity reactions, bone pain, arthralgia, nasopharyngitis, hypocalcaemia, myocardial infarction, percutaneous coronary intervention, stroke, cancer, death, sudden death, osteonecrosis of the jaw, atypical femur fracture or any AE leading to discontinuation of drug or trial participation, as well as any falls or fractures occurring during an exercise session. The seriousness of AEs and their relation to the study drug will be adjudicated by an independent medical safety monitor. The frequency of AEs will be tabulated according to the group and summarised as n (%).
Unblinding
Unblinding of participants will be carried out in the case of SAEs where knowledge of the study treatment is required to facilitate further management decisions for the patient. Unblinding may also be carried out if circumstances arise potentially warranting the commencement of alternative approved osteoporosis pharmacotherapy, for example, in cases of index fragility fracture or greater than 10% loss in BMD at the lumbar spine, total hip or femoral neck. Participants will also be unblinded following completion of the study (by an investigator not involved in outcome assessment or data analysis) and ongoing management of their bone and muscle health will be discussed on an individual basis.
Data handling and record keeping
Data from eligible participants will be collected and stored in a secure NSLHD database using a validated secure Research Electronic Data Capture portal with password-protected access only provided to study investigators. All participant data will be coded and stored in a re-identifiable format and backed up regularly onto a secure hard drive.
A Data Safety Monitoring Board (DSMB) has been established for the ROLEX-DUO study, consisting of two clinicians and one statistician with experience in clinical trial research, who are independent from the study team and have no conflicts of interest. DSMB meetings will occur on a 6-monthly basis from the date of the first participant being recruited to review interim trial data, recruitment rates, protocol adherence accuracy, completeness of collected data and AE outcomes. DSMB meetings will include a ‘closed’ session to review unblinded data during which study investigators will not be present. The DSMB will report to the lead investigator of the study after each meeting with any recommendations. A blinded study statistician will provide data in an unidentifiable format to the DSMB statistician prior to each meeting.
Patient and public involvement
A local consumer with osteoporosis was involved d uring the study design and various consumers with osteoporosis were involved in the design of the study advertisement flyer.
Ethics and dissemination
Ethics approval
The study will be conducted in line with the principles of the Declaration of Helsinki and according to the International Conference on Harmonisation Good Clinical Practice guidelines. The protocol and consent form were approved by the NSLHD Human Research Ethics Committee (Ref: 2022/ETH01794, latest protocol V.8, dated 03 July 2024). All participants will be required to provide written informed consent before undergoing screening procedures. ROLEX-DUO is an investigator-initiated trial sponsored by the Royal North Shore Hospital, NSLHD. Any modifications to the protocol, consent form or patient-facing documents that may impact study design or cause potential harm to participants will require approval of a formal amendment by the NSLHD Human Research Ethics Committee.
Publication plan
The results of the ROLEX-DUO study will be disseminated in national and/or international bone and musculoskeletal health scientific meetings and in scientific and medical peer-reviewed journals in the field of endocrinology, bone and musculoskeletal health. All data submitted to peer-reviewed journals will be presented in an unidentifiable format at the group level. The study investigators will be acknowledged as authors of publications stemming from this trial as well as any other investigators and personnel who meet requirements for journal article authorship as per the International Committee of Medical Journal Editors.
We used the Standard Protocol Items: Recommendations for Interventional Trials checklist when preparing this protocol manuscript.30
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors SK is the guarantor of the manuscript, conceptualised and designed the study, performed the literature review, drafted the manuscript, approves of the final version of the manuscript and is agreeable to be accountable for all aspects of the work. BRB assisted in the design of the study, undertook quality assurance of HiRIT delivery, critically reviewed the manuscript, approves of the final version of the manuscript and is agreeable to be accountable for all aspects of the work. LN critically reviewed the manuscript, approves of the final version of the manuscript and is agreeable to be accountable for all aspects of the work. KB led development of the statistical analysis plan, critically reviewed the manuscript, approves of the final version of the manuscript and is agreeable to be accountable for all aspects of the work. JE led development of the statistical analysis plan, critically reviewed the manuscript, approves of the final version of the manuscript and is agreeable to be accountable for all aspects of the work. CW and OKF assisted in design of the study, critically reviewed the manuscript, approves of the final version of the manuscript and is agreeable to be accountable for all aspects of the work. RJC-B and CMG conceptualised and designed the study, critically reviewed the manuscript, approves of the final version of the manuscript and is agreeable to be accountable for all aspects of the work.
Funding This work is a PhD project supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship (2022345), and by grant funding including the Healthy Bones Australia (HBA) & Australian & New Zealand Bone & Mineral Society (ANZBMS) Clinical Grant Program, Avant Mutual Early Career Research Program (2022/000291), NORTH Foundation Grants Program, and departmental research funding provided by the Department of Endocrinology, Royal North Shore Hospital.
Competing interests All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare: all authors had financial support from Healthy Bones Australia, Australian New Zealand Bone and Mineral Society, Avant Mutual and NORTH Foundation for grant funding for the submitted work. Belinda R Beck is owner and director of The Bone Clinic (TBC) which is the licensee of the HiRIT programme being used in this study. All other authors declare no financial relationships with any organisations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
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