MANAGEMENT OF OSTEOPOROSIS Osteoporosis 10_11_19.pdfWhy should we treat osteoporosis? • Estimated that 10 million Americans have osteoporosis – 44 million with low bone density

NY ACP Annual Scientific Meeting

October 12, 2019

Stan Klek, MD, CDE

MANAGEMENT OF OSTEOPOROSIS

Goals

• 1. Identify appropriate patients to screen for osteoporosis

• 2. Describe how to interpret DXA scans appropriately

• 3. Compare and contrast the 2017 ACP Osteoporosis Treatment Guidelines with the

2019 Endocrine Society Osteoporosis Management Guidelines

• 4. Formulate pharmacologic treatment plans for patients with osteoporosis

NYU Winthrop Hospital2

• Systemic skeletal disease with reduced

bone mass and bone microarchitecture

deterioration

• Results in bone fragility and

increased risk of fracture

What is osteoporosis?

A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. Figure 2-5, Normal vs.

Osteoporotic Bone.


ASSESSMENT OF OSTEOPOROSIS

Who should be screened for osteoporosis?

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/osteoporosis-screening1

Screening Tools

1. SCORE

2. ORAI

3. OSIRIS

4. OST – Cutoff < 2

5. FRAX

Ensrud KE, Crandall CJ. Osteoporosis Ann Intern Med. 2017; 167(3):ITC17-.


• FRAX was initially developed to assess 10 year fracture risk

for hip or major osteoporotic fractures in those who would be

left untreated

– Guides decision making process for treatment

• FRAX can also be used to assist in determining who would

benefit from screening of BMD

– T2DM increases risk of fracture

• Substitute history of RA with T2DM to reflect increased risk

• Should use country and population specific FRAX tool

Fracture Risk Assessment Tool (FRAX)



FRAX Tool

https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9NYU Winthrop Hospital7

https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9

Who should be screened for osteoporosis?

• General screening recommendations are for older, healthy individuals

• DO NOT APPLY TO:

– Those with fragility fractures

– Secondary causes of osteoporosis: Metabolic bone disease, untreated hyperthyroidism,

hyperparathyroidism, multiple myeloma

– Certain medication usage: Long term steroid usage, aromatase inhibitors, GnRH agonists


Why not start screening all patients at age 50?

• Fracture risk for any BMD is lower in younger post menopausal women

– 5-year probability of hip fracture < 1.0% until age 70–79 years

• Beginning treatment in younger women limits options for pharmacotherapy in their 70s

• Data on the risks and benefits of long term pharmacotherapy in younger patients (50–64

years) are unavailable

Doherty DA et al. Lifetime and five-year age-specific risks of first and subsequent osteoporotic fractures in postmenopausal women. Osteoporosis international. 2001; 12(1):16-23.


• Dual energy X-ray absorptiometry

scan (DXA or DEXA) measures bone

mineral density (BMD) at the hip and

lumbar spine

– Gold Standard

• Clinical diagnosis is made with fragility

fracture at the spine, hip, wrist,

humerus, rib, or pelvis

– Fragility fractures - Spontaneous or minor

trauma

Alternate Methods

• Quantitative CT – Measures volumetric

bone density

– Clinical research

• Heel Ultrasound

– Not generally recommended as criteria for

osteoporosis and treatment threshold is not

well validated

• Peripheral DXA

– BMD measured via these techniques can

not be used interchangeably

How do we screen for and diagnose osteoporosis?


When to repeat screening with DXA?

• Baseline T scores should dictate how often DXA scan should be repeated

Gourlay ML, Fine JP, Preisser JS, et al. Bone-Density Testing Interval and Transition to Osteoporosis in Older Women N Engl J

Med. 2012; 366(3):225-233.


INTERPRETING DXA SCANS

• BMD – Quantity not quality

• T Scores used in postmenopausal

women > 50

– T Score – BMD compared to average

healthy 30 year old adult

• Use Z Scores in women < 50

– Z Score - Age matched comparison

• T and Z Scores are not the whole

story

WHO Diagnostic Criteria



• Important to read entire

reports and review imaging

Newer Reports

• Trabecular Bone Score

(TBS) – Assessment of

microarchitecture

Interpreting DXA Scans





• Trabecular Bone Score

– Utilizes data obtained from DXA images

– Software calculates a TBS

– Provides information related to

microarchitecture

• Can potentially help identify individuals

who are at higher fracture risk despite

similar BMD

Silva BC, et al. Trabecular Bone Score: A Noninvasive Analytical Method Based Upon the DXA Image J Bone

Miner Res. 2014; 29(3):518-530.


Errors in DXA Scan Imaging

Nat Clin Pract Rheumatol. 2008 Dec; 4(12): 667–674.


Take Home Points on Screening with DXA

• All postmenopausal women > 65 should have a DXA scan

– Younger women (50-64) may be considered if fracture risk is high

• FRAX Score or OST can help identify higher risk patients

• Repeat screening determined by baseline DXA scan and risk factors

• When interpreting DXA scans review images

– BMD and T Scores may be deceiving


TREATMENT

Majority of Patients

• Postmenopausal Women

– Treat all high and very high risk patients

• Focus of the remainder of this

session will be appropriate treatment

of osteoporosis in postmenopausal

woman

Rarer Patients

• Medication Induced

– Steroids, Aromatase inhibitors

• Less common medications such as

anticonvulsants, excess thyroid hormone,

PPIs, TZDs

• Men

Who do we treat for osteoporosis?


• Low Risk

– No previous fractures and

– T Score at spine and hip > -1.0 and

– 10 year FRAX < 3% at hip and < 20% MOF

• Moderate Risk

– No previous fractures and

– T Score at spine and hip > -2.5 or

– 10 year FRAX < 3% at hip and < 20% MOF

• High Risk

– Prior vertebral or hip fracture or

– T Score at spine or hip < -2.5 or

– 10 year FRAX ≥ 3% at hip and ≥ 20% MOF

• Very High Risk

– Multiple fractures and

– T Score at spine or hip < -2.5

How do we define risk?

General Guidelines

J Clin Endocrinol Metab, May 2019, 104(5):1623–1630


Why should we treat osteoporosis?

• Estimated that 10 million Americans have osteoporosis

– 44 million with low bone density

• 2 million osteoporotic fractures annually – 50% of women with osteoporosis will suffer a

fracture

– 80% of Americans are either not tested or appropriately treated for osteoporosis

• Annul cost to patients, families and health system is estimated at $19 billion

– 2025 estimated cost will increase to $25.3 billion

• Goal of treatment is to reduce fractures!https://cdn.nof.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf


https://cdn.nof.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf

How should we treat osteoporosis?

• All appropriate patients should be treated

– In the US pharmacological treatment of postmenopausal women is recommended for:

• Hip or vertebral fractures

• T-scores of -2.5 or less in the femoral neck, total hip, or lumbar spine

• Low bone mass (osteopenia) + US FRAX demonstrating >20% for major osteoporotic fractures or >3% for hip

fractures

• All patients should receive counseling on lifestyle management

• What medication should we offer?

– Use evidence based guidelines, clinical judgement and Shared Decision Making

• ACP 2017 Guidelines

• Endocrine Society 2019 Guideline


ACP – 2017 Endocrine Society – 2019

• 11 Recommendations

– 1. Who to treat

– 2-7. Pharmacologic treatment

• Bisphosphonates, denosumab, PTH related

protein analogues, SERMs, menopausal

hormone therapy, calcitonin

– 8. Calcium and Vitamin D

– 9. Approach to choosing agents

– 10. Duration of treatment and Drug

Holidays

– 11. Monitoring on treatment

ACP & Endocrine Society Guidelines

• 6 Recommendations

– 1. Pharmacologic treatment

– 2. Duration of treatment

– 3. Osteoporosis in men

– 4. Monitoring on treatment

– 5. Usage of raloxifene and estrogen

– 6. Osteopenia/low bone mass


TREATMENT OPTIONS

Lifestyle and Nutritional Management

• Calcium

– Women > 50 and Men > 70 – 1200 mg/d (Combined diet and supplements)

• Vitamin D

– Screen with Vitamin D level and ensure adequate level > 20 ng/dL

• Endocrine Society - > 30 ng/dL

– General recommendation is 800-1000 IU of vitamin D daily

• Weight Bearing and Balance Exercises

– Resistance and weight-bearing exercise can increase BMD

– Yoga and Thai Chi – Reduce fall risk

• Smoking cessation and reduction in alcohol consumption

Preferable to

obtain Calcium

and Vitamin D via

diet versus

supplementation

Black DM, Rosen CJ. Postmenopausal Osteoporosis N Engl J Med. 2016; 374(3):254-262.


• Bisphosphonates

• Denosumab

• PTH-related protein analogs

• Sclerostin inhibitor

• SERMs

• Estrogen Replacement

• Calcitonin

– Should only be offered to those who are

intolerant of all other treatment

Pharmacological Agents – Drug Classes

Anabolic Agents

ACP Guidelines

recommend against

use of these agents


Evidence for Pharmacologic Treatment


Meta Analysis of 107 trials

Postmenopausal women with primary osteoporosis

Trial duration ranged from 3-120 months

50-80% risk reduction

Each trial agents were compared to placebo – direct comparison

should not be made between treatments



After 2 Years

Start treatment

with antiresorptive

agent


Romosozumab - Evenity

• Monoclonal antibody binds sclerostin

– Sclerostin is normally produced by osteocytes to

inhibit osteoblasts

• Monthly injection for 1 year

• Adverse Effects – Arthralgias, headaches,

hypersensitivity reactions, hypocalcemia

– Increases risk of MI, CVA and CV Death

• Should not be started in those who have had MI or CVA in

the past year

Lim SY, Bolster M. Profile of romosozumab and its potential in the management of osteoporosis DDDT. 2017; Volume11:1221-1231.

210 mg monthly for 1 year

Initiate antiresorptive agent to

preserve new bone

• Either a bisphosphonate or

denosumab


What are patients hearing?


• Rare insufficiency fractures of femoral shaft associated

with long term bisphosphonate usage (> 5 years)

– Has been noted with other osteoporosis medications including

denosumab and romosozumab

• Majority of fractures are preceded by pain in hip or groin

• Not always well visualized by X-Ray

– Diagnosed by bilateral MRI or Bone Scan

• Contralateral fracture present in about 25%

Atypical Femoral Fractures (AFF)

MULGUND M, BEATTIE KA, ANASPURE R,

MATSOS M, PATEL A, ADACHI JD. Atypical

Femoral Fractures in Patients Taking Longterm

Alendronate J Rheumatol. 2011; 38(12):2686-

2687.


Atypical Femoral Fractures (AFF)

Black DM, Rosen CJ. Postmenopausal Osteoporosis N Engl J Med. 2016; 374(3):254-262.

Take Home Point

• For every 1 atypical

fracture, 100

osteoporotic fractures

are prevented per

1000 women treated


• ONJ defined as nonhealing wound in oral mucosa with exposed

bone lasting > 8 weeks

– Typically associated with dental procedures

• Estimated incidence range from 1 in 10,000 to 100,000

– Higher and more frequent dosing can increase the risk

– Long term bisphosphonate use risk can increase to 21 in 10,000

• ADA does not recommend stopping bisphosphonates for dental

procedures

• AAOMS recommends 2 month drug holiday in those on

bisphosphonates > 4 years

Osteonecrosis of the Jaw (ONJ)

https://www.researchgate.net/figure/Patient-with-ONJ-lesion-in-

the-right-maxilla-Abbreviation-ONJ-osteonecrosis-of-the-

jaw_fig1_234143090

Khan AA, Morrison A, et al. International Task Force on

Osteonecrosis of the Jaw. Diagnosis and management of osteonecrosis of the jaw: a systematic review and international

consensus. J Bone Miner Res. 2015;30(1):3–23.



Patient Preferences in Treatment of Osteoporosis

• Efficacy and Adverse Effects

• Administration

– Oral preferred over injectable

– Less frequent administration is preferred

• Other Factors

– Cost, duration of treatment, hormonal therapy



Take Home Points on Pharmacologic Treatment

• Most studies of pharmacologic agents are done with the background of calcium and

vitamin D

• Strong data for reducing fractures when treating with bisphosphonates, denosumab and

PTH related peptide analogues

• Benefits of treatment strongly outweigh the risks

– Utilize shared decision making


MANAGEMENT CASES

• JO is a 66 year old woman who presents to

discuss the results of her screening DXA

exam.

– T Score Spine = -2.3

– T Score Total Hip = -2.4

– T Score Femoral Neck = -2.9

• No history of fractures and no additional

risk factors present

• BMI is 22 kg/m2, EGFR is 87, Vitamin D

and Calcium are normal

• What would you recommend?

Treatment Choices

• A. No treatment recommended at this

time, repeat DXA scan in 1-2 years

• B. Recommend she begin calcium,

vitamin D, and weight bearing exercises

but not other treatment for now

• C. Begin an oral bisphosphonate

• D. Begin an intravenous

bisphosphonate

• E. Begin detumomab

• F. Begin a PTH related peptide

analogue

Case 1 - JO


• JO is a 66 year old woman who presents to

discuss the results of her screening DXA

exam.




• No history of fractures and no additional

risk factors present

• BMI is 22 kg/m2, EGFR is 87, Vitamin D

and Calcium are normal


Treatment Choices

• A. No treatment recommended at this

time, repeat DXA scan in 1-2 years

• B. Recommend she begin calcium,

vitamin D, and weight bearing exercises

but not other treatment for now

• C. Begin an oral bisphosphonate

• D. Begin an intravenous

bisphosphonate

• E. Begin denosumab

• F. Begin a PTH related peptide

analogue

Case 1 - JO


ACP Endocrine Society


Ann Intern Med. 2017;166:818-839.

First Line Treatment

Oral Bisphosphonate for 5 years


• JO returns two months later and reports

she has developed GERD like

symptoms on the day she takes the

medication and persists for several days

after. She is uncertain if she will be able

to continue oral alendronate weekly.

• What would you recommend at this

time?

Treatment Choices

• A. Change to risedronate monthly so the

frequency of GERD is decreased

• B. Change to an intravenous

bisphosphonate

• C. Change to denosumab

• D. Change to a PTH related analogue

• E. Stop treatment and recommend

weight bearing exercises, calcium and

vitamin D

Case 1 - JO


• JO returns two months later and reports

she has developed GERD like

symptoms on the day she takes the

medication and persists for several days

after. She is uncertain if she will be able

to continue oral alendronate weekly.

• What would you recommend at this

time?

Treatment Choices

• A. Change to risedronate monthly so the

frequency of GERD is decreased

• B. Change to an intravenous

bisphosphonate

• C. Change to denosumab

• D. Change to a PTH related analogue

• E. Stop treatment and recommend

weight bearing exercises, calcium and

vitamin D

Case 1 - JO


IV Bisphosphonates vs. Denosumab


Case 1 JO

First Line Treatment

Oral Bisphosphonate for 5 years

Intravenous Bisphosphonate for 3 years

and reassess

High risk individuals may benefit from longer

duration of treatment



• JO presents for follow up of

osteoporosis. She has now received

zoledronic acid annually for the past two

years and is scheduled to receive her 3rd

injection in the upcoming month. She

reports to feeling well and has not

suffered any fractures. She would like

to know if her osteoporosis has

improved.


Treatment Choices

• A. Reassure her that the treatment is

working and order no additional testing

• B. Obtain a DXA scan now

• C. Wait another year prior to obtaining a

DXA scan

• D. Order bone turnover markers

• E. Begin a PTH related analogue in

addition to intravenous bisphosphonate

Case 1 - JO




zoledronic acid annually for the past two

years and is scheduled to receive her 3rd

injection in the upcoming month. She

reports to feeling well and has not

suffered any fractures. She would like

to know if her osteoporosis has

improved.


Treatment Choices

• A. Reassure her that the treatment is

working and order no additional

testing

• B. Obtain a DXA scan now

• C. Wait another year prior to

obtaining a DXA scan

• D. Order bone turnover markers

• E. Begin a PTH related analogue in

addition to intravenous bisphosphonate

Case 1 - JO


Monitoring BMD on Treatment How often should we be monitoring BMD in patients on

treatment?

• ACP – Do not monitor BMD with DXA while on 5 year

treatment period

– Reduction in fracture risk without changes in BMD

• Endocrine Society – DXA every 1-3 years

– BMD increase expected around 2 years

• Assess those who are not compliant with medication or treatment failure

– Retrospective studies showed that BMD monitoring was

associated with improved compliance

Wade SW, et al. Impact of medication adherence on health care utilization and productivity: self-reported data from a cohort of

postmenopausal women on osteoporosis therapy. Clin Ther. 2011;33(12):2006–2015.


Ann Intern Med. 2017;166:818-839.




zoledronic acid annually for the past

three years. She has obtained a repeat

DXA scan at this time with the results

below. BMD has increased by

approximately 10% at the at the spine

and 8% in the spine, 7% in the femoral

neck.





Treatment Choices

• A. Continue zoledronic acid for 1 more

year

• B. Continue zoledronic acid for 2 more

years

• C. Introduce a bisphosphonate “holiday”

• D. Change treatment to denosumab

• E. Change treatment to a PTH related

analogue

Case 1 - JO




zoledronic acid annually for the past

three years. She has obtained a repeat

DXA scan at this time with the results

below. BMD has increased by

approximately 10% at the at the spine

and 8% in the spine, 7% in the femoral

neck.





Treatment Choices

• A. Continue zoledronic acid for 1 more

year

• B. Continue zoledronic acid for 2 more

years

• C. Introduce a bisphosphonate

“holiday”

• D. Change treatment to denosumab

• E. Change treatment to a PTH related

analogue

Case 1 - JO


• Bisphosphonate “holiday” is a temporary

discontinuation in therapy meant to

reduce the risk of AFF

• Intended for those patients not at high

risk of fracture

– Low or moderate risk

• Not all bisphosphonates are the same

Bisphosphonate Holiday


Ann Intern Med. 2017;166:818-839.


Bisphosphonate Holiday

Compston JE, McClung MR, Leslie WD. Osteoporosis The Lancet. 2019; 393(10169):364-376.

Consider Bisphosphonate Holiday

3 Years after IV Bisphosphonate

5 Year with Oral Bisphosphonate


• AP is a 78 year old woman who has

recently moved into the area and

presents to establish care. She was

diagnosed with osteoporosis at age 69

and was monitored for 3 years. At age

72 she began treatment with

denosumab and has been taking it

every 6 months for the past 6 years.

She is concerned regarding atypical

fractures with prolonged use of

denosumab and would like to stop this

medication.


Treatment Choices

• A. Recommend she continue

denosumab without interruption

• B. Continue denosumab for 4 more

years for a total of 10 years to treatment,

and then stop

• C. Discontinue denosumab now

• D. Discontinue denosumab and begin

alendronate

• E. Discontinue denosumab and begin

zolendronate in 6-8 months

Case 2 - AP


Treatment Choices

• A. Recommend she continue

denosumab without interruption

• B. Continue denosumab for 4 more

years for a total of 10 years to treatment,

and then stop

• C. Discontinue denosumab now

• D. Discontinue denosumab and begin

alendronate

• E. Discontinue denosumab and begin

zolendronate in 6-8 months

Case 2 - AP

• AP is a 78 year old woman who has

recently moved into the area and

presents to establish care. She was

diagnosed with osteoporosis at age 69

and was monitored for 3 years. At age

72 she began treatment with

denosumab and has been taking it

every 6 months for the past 6 years.

She is concerned regarding atypical

fractures with prolonged use of

denosumab and would like to stop this

medication.



Pharmacotherapy with DenosumabPreserving BMD After

Denosumab

Newer evidence has demonstrated

that the increase in bone turnover

markers and decline in BMD is

associated with a potential “rebound”

effect or rapid return to baseline risk

resulting in increased risk of vertebral

fractures

May be avoided by starting a

bisphosphonate for 1 -2 years after

discontinuing bisphosphonate

- Alendronate or zolendronic acidBone HG, Bolognese MA, Yuen CK, et al. Effects of Denosumab Treatment and Discontinuation on Bone Mineral Density and

Bone Turnover Markers in Postmenopausal Women with Low Bone Mass. JCEM. 2011; 96(4):972-980.


Although denosumab is very effective in

increasing BMD and reducing fracture

risk, discontinuation or delay of therapy

results in rapid BMD loss and increased

vertebral fracture risk.

Pharmacotherapy with Denosumab



• BB is a 71 year old woman who was diagnosed with

osteoporosis at the age of 57 following a wrist fracture

she sustained after a fall. She is a recovering

alcoholic, smoker, has a history of COPD treated

frequently with high dose steroids and her mother had

an osteoporotic hip fracture. She has been treated

with alendronate for 10 years beginning at age 59, off

all treatment for the past 2 years. She has had severe

back pain for the past month and was found to have

multiple vertebral compression fractures. Her BMI is

18 kg/m2. DXA scan results are below.





Treatment Choices

• A. Restart alendronate

• B. Start zolendronate

• C. Start denosumab

• D. Start a PTH related analogue

• E. Start raloxifene

Case 3 - BB


Treatment Choices

• A. Restart alendronate

• B. Start zolendronate

• C. Start denosumab

• D. Start a PTH related peptide

analogue

• E. Start raloxifene

Case 3 - BB

• BB is a 71 year old woman who was diagnosed with

osteoporosis at the age of 57 following a wrist fracture

she sustained after a fall. She is a recovering

alcoholic, smoker, has a history of COPD treated

frequently with high dose steroids and her mother had

an osteoporotic hip fracture. She has been treated

with alendronate for 10 years beginning at age 59, off

all treatment for the past 2 years. She has had severe

back pain for the past month and was found to have

multiple vertebral compression fractures. Her BMI is

18 kg/m2. DXA scan results are below.






• At the time of guideline publication, these

agents were the only anabolic agents available

• Meta-analysis demonstrated 87% reduction in

vertebral fractures

– Reduction in hip fracture not statistically significant

but trended towards reduction

• Requires daily injections

– After 2 years, follow up with antiresorptive agent

Side Effects

• Hypercalcemia

• Osteosarcoma in rats – limit usage for 24 months in

humans – Black Box Warning

– Only 1 reported human case thus far

Pharmacotherapy with PTH Related Analogues



Endocrine Society Treatment Algorithm

Eastell et al Osteoporosis in Postmenopausal Women J Clin Endocrinol Metab, May 2019, 104(5):1595–1622


Summary

• Screen age appropriate post menopausal women for osteoporosis with DXA scan

– Repeat screening interval based upon initial T Scores

– Review DXA scan images

• Used shared decision making and evidence based guidelines to determine appropriate pharmacologic

treatment for patients

– Treatment should be individualized

– Generally bisphosphonates are first line agents with denosumab as a reasonable alternative

• Denosumab use should not be abruptly discontinued

• PTH related proteins (anabolic agents) should be used in very high risk individuals or those with multiple

vertebral fractures for up to 2 years

– Follow up treatment with an antiresorptive agent


THANK YOU

References

• Camacho PM, Petak SM, Binkley N, et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF

ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS — 2016

Endocrine Practice. 2016; 22(Supplement 4):1-42.

• Qaseem A, Forciea MA, McLean RM, Denberg TD. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical

Practice Guideline Update From the American College of Physicians Ann Intern Med. 2017; 166(11):818-.

• Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in Postmenopausal Women: An

Endocrine Society* Clinical Practice Guideline . 2019; 104(5):1595-1622.

• Compston JE, McClung MR, Leslie WD. Osteoporosis The Lancet. 2019; 393(10169):364-376.

• Cosman F. Long-term treatment strategies for postmenopausal osteoporosis Current Opinion in Rheumatology. 2018; 30(4):420-426.

• Russell LA. Management of difficult osteoporosis Best Practice & Research Clinical Rheumatology. 2018; 32(6):835-847.

• Barrionuevo P, Kapoor E, Asi N, et al. Efficacy of Pharmacological Therapies for the Prevention of Fractures in Postmenopausal Women: A Network Meta-

Analysis . 2019; 104(5):1623-1630.

• Black DM, Rosen CJ. Postmenopausal Osteoporosis N Engl J Med. 2016; 374(3):254-262.

• Ensrud KE, Crandall CJ. Osteoporosis Ann Intern Med. 2017; 167(3):ITC17-.

• Tella SH, Gallagher JC. Prevention and treatment of postmenopausal osteoporosis The Journal of Steroid Biochemistry and Molecular Biology. 2014; 142:155-

170.


MANAGEMENT OF OSTEOPOROSIS Osteoporosis 10_11_19.pdfWhy should we treat osteoporosis? • Estimated that 10 million Americans have osteoporosis – 44 million with low bone density

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