Osteoporosis Lecture 2024 PDF

Osteoporosis Luis Trejo, PharmD [email protected] 11/19/24 Learning Objectives  Recognize the prevalence of and risk factors for osteoporosis  Describe the negative outcomes of osteoporosis  Interpret T-scores to determine diagnosis of osteoporosis/osteopenia ...

Osteoporosis Luis Trejo, PharmD [email protected] 11/19/24 Learning Objectives  Recognize the prevalence of and risk factors for osteoporosis  Describe the negative outcomes of osteoporosis  Interpret T-scores to determine diagnosis of osteoporosis/osteopenia  Calculate FRAX scores and determine if a patient with osteopenia should be treated  Identify non-pharmacological strategies to decrease risk of falls and fractures  Compare and contrast the pharmacological agents for treatment of osteoporosis  Recommend non-pharmacological strategies and pharmacological agents for treatment of osteoporosis 2 Meet Mrs. Miller 72-year-old white female PMH: HTN, type 2 diabetes, GERD, no hx of fractures DXA Report 10/31/2022 FH: mother had osteoporosis and had a hip fracture T-score total hip: – 0.9 SH: non-smoker, occasional alcohol (1 glass of wine with dinner 3 times per week) T-score femoral neck: – 1.8 Medications: lisinopril, metformin, pioglitazone, T-score vertebrae: – 2.2 famotidine Vitals: weight 125 lbs; height 5’4’’ 3  Osteoporosis – “Porous Bone” Bone disease that occurs when the body loses bone, makes too little bone, or both Bones become weak and may fracture Bone strength: bone density and bone quality Akkawi, 2018 Image: https://www.vectorstock.com/royalty-free-vector/healthy-bone-and-osteoporosis-bone-vector-13913902 4  Bone Remodeling Exp Mol Med 2019 5  Bone Remodeling Exp Mol Med 2019 6  Natural History of Bone Mineral Density Bone loss rate of 0.2 - 0.5% per year Bone loss rate of 1 - 5% per year during 10 years after menopause Schepper, 2019 7  Common Sites of Fracture NOF 2004 8 Poll Question What percent of women will have an osteoporosis-related fracture during their lifetime? A. 10% B. 25% C. 50% D. 75% 9  Osteoporosis Statistics Most Common Bone Disease 10 million Americans have osteoporosis 44 million Americans have low bone density Osteoporosis is common A woman’s risk of fracture = combined risk of breast, uterine and ovarian cancer A man is more likely to break a bone than he is to get prostate cancer National Osteoporosis Foundation 10  Negative Outcomes of Osteoporosis 24 % 40% 80% 33% Die within one year Unable to walk Restricted in activities of Placed in a nursing independently daily living home About Osteoporosis: International Osteoporosis Foundation National Osteoporosis Foundation 11  Risk Factors for Osteoporosis Postmenopausal Ethnicity Low body weight Family history women Calcium or Vitamin D Inactivity Smoking Excess alcohol deficiency About Osteoporosis: International Osteoporosis Foundation 12  Risk Factors: Diseases and Medications Diseases Medications Rheumatoid arthritis Steroids (>5mg daily of prednisone for >3 months) Diabetes Aromatase inhibitors – anastrozole Secondary hyperparathyroidism Proton pump inhibitors – omeprazole, pantoprazole, esomeprazole Hyperthyroidism Glitazones – pioglitazone, rosiglitazone Anorexia nervosa Antiepileptics – carbamazepine, phenobarbital, phenytoin Celiac disease Medroxyprogesterone injections Vitamin D deficiency Heparin Immobilization Lithium Depression SSRIs – citalopram, escitalopram, sertraline About Osteoporosis: International Osteoporosis Foundation 13  NOF Screening Recommendations Women age 65 years and older and men age 70 years and older, regardless of clinical risk factors Younger postmenopausal women, women in the menopausal transition, and men age 50 to 69 years with clinical risk factors for fracture Adults who have a fracture after age 50 years Adults with a condition (rheumatoid arthritis) or taking a medication (steroids) associated with low bone mass or bone loss NOF 2013 14  Screening Modalities Image: https://americanbonehealth.org/bone-density/heel-ultrasound-is-not-the-best-screening/ Image: https://www.nhs.uk/conditions/dexa-scan/what-happens/ 15  T-Score vs Z-Score Used for diagnosis Used to determine if further work-up is needed Image: https://www.cover-tek.com/interpreting-bone-density-test-results/ 16  Interpreting T-Scores Image: https://americanbonehealth.org/what-you-should-know/about-t-scores 17  Candidates for Treatment 1. Osteoporosis by T-score 2. Patients with fragility fracture 3. Osteopenia who “FRAX” in AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 18  FRAX Score Decision-making tool to decide whether to treat patients with osteopenia Takes into account multiple risk factors beyond BMD Determines 10-year risk of facture including: hip fracture risk and major osteoporotic risk 10-year hip fracture risk 10-year major osteoporotic risk > 3% > 20% AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 19 Poll Question Mrs. Miller’s DXA scan report is shown below. What is her diagnosis? DXA Report 10/31/2022 A. Osteoporosis T-score total hip: – 0.9 B. Osteopenia T-score femoral neck: – 1.8 C. Normal bone mineral density T-score vertebrae: – 2.2 20 FRAX Score Exercise Go to: https://www.sheffield.ac.uk/FRAX Calculate Mrs. Miller’s FRAX score 72-year-old white female DXA Report 10/31/2022 PMH: HTN, type 2 diabetes, no hx of fractures T-score total hip: – 0.9 FH: mother had osteoporosis and had a hip fracture T-score femoral neck: – 1.8 Medications: lisinopril, metformin, pioglitazone, T-score vertebrae: – 2.2 famotidine Vitals: weight 125 lbs, height 5’4’’ SH: non-smoker, occasional alcohol (1 glass of wine w/dinner 3 times per week) 21 Poll Question Should Mrs. Miller receive treatment at this time? A. Yes B. No 22  Treatment of Osteopenia and Osteoporosis Calcium Vitamin D Risk Reduction Falls Reduction Exercise Pharmacotherapy AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 23  Calcium Supplementation Patients with osteopenia or osteoporosis should receive adequate calcium intake from diet and supplements Calcium from the diet is preferred over supplements Group Calcium Women < 50 1000 mg per day Women over 50 1200 mg per day Men 50-70 1000 mg per day Men over 70 1200 mg per day National Osteoporosis Foundation AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 24  Sources of Calcium Natural sources Beans and lentils Canned sardines and salmon Collard greens, spinach, turnip greens Seeds (poppy, sesame, chia) Fortified foods Milk, yogurt, cheese Orange juice Cereal Supplements Multivitamins Calcium Carbonate Calcium Citrate AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update https://www.hsph.harvard.edu/nutritionsource/calcium/ 25  Calcium in Foods 20% calcium = 200 mg 30% calcium = 300 mg 40% calcium = 400 mg Image: https://ohioline.osu.edu/factsheet/hyg-5506 26  Calcium Supplementation Pearls Only 500 mg of calcium is absorbed at a time Calcium carbonate requires acid for absorption and may not be absorbed as well in geriatric patients or those on a PPI or H2 antagonist  40% elemental calcium  Must take with meals Calcium Citrate does not require acid for absorption  21% elemental calcium Some patients may have difficulty swallowing calcium pills Calcium may bind certain medications including levothyroxine, quinolones, tetracyclines, HIV medications AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 28  Common Supplements Image: Pharmacy Times 29  Sources of Vitamin D Natural sources Salmon and saltwater fish Liver Shitake mushrooms Egg yolk Sun exposure Fortified foods Milk Orange juice Yogurt Butter Cheese Supplements Multivitamins RX Ergocalciferol 50,000 IU OTC Cholecalciferol 1000 IU AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 30  25-OH Vitamin D Levels Concentration Interpretation Above 150 ng/mL Toxicity Above 30 ng/mL Optimal 21 - 29 ng/mL Insufficient Less than 20 ng/mL Deficient AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 31  Vitamin D Supplementation Cholecalciferol (Vitamin D3) OTC Daily dose of 1,000 to 2,000 international units per day Ergocalciferol (Vitamin D2) Prescription only 50,000 IU once weekly for 8-12 weeks to treat deficiency (25-OH vitamin D < 20 ng/mL) AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 32  Falls Reduction – Statistics #1 > 25% < 50% 20 minutes 95% Falls are the leading of people over 65 fall of people who fall tell an older adult dies from of hip fractures are cause of death and each year their doctor about their a fall caused by falling disability in seniors fall Lee R, 2017 33  Risk Factors for Falls Gait and Lower body Vitamin D Medications balance weakness deficiency disturbances Home hazards History of recent Vision Improper (rugs, steps, falls impairment footwear handrails, poor lighting) CDC STEADI Guidelines 34  Lifestyle Measures Weight-bearing Muscle- Smoking Limiting alcohol exercise strengthening Cessation exercise AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 35  Pharmacotherapy First- Line: bisphosphonates and denosumab Second-Line: calcitonin, raloxifene, estrogen Severe Osteoporosis: PTH analogs and sclerostin inhibitor AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 36  Bisphosphonates First-line treatment in most patients Approved for women, men, and for steroid induced osteoporosis Decreases hip and vertebral fractures  No hip fracture data with ibandronate Zoledronic acid decreases mortality when administered after a hip fracture Cost-effective AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 37  Bisphosphonates: MOA Image: Solomon, Caren G, 2002 38  Bisphosphonates: Dosing Oral IV Alendronate (Fosamax) - Ibandronate (Boniva) - 3 70 mg once weekly mg IV push every 3 Ibandronate (Boniva) - 150 months mg once monthly Zoledronic acid (Reclast) – Risedronate (Actonel) - 35 5 mg IV infusion once a mg once weekly or 150 year mg once monthly  Pre-medicate with APAP or IBU and continue for 3-5 days after infusion AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 39  Bisphosphonates: Adverse Effects Adverse Effect Comments Esophagitis Drink 8 oz of water, do not lie down for 30 - 60 min Acute phase reaction More common with IV therapies, caused by cytokine release, improves over time, pre-treat with APAP or IBU with zoledronic acid Muscle, bone, and joint pain Mild-severe, can occur anytime, may resolve with discontinuation Hypocalcemia Calcium and SCr should be checked prior to starting AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 40  Bisphosphonates: Rare Adverse Effects Adverse Effect Comments Osteonecrosis of the jaw Occurs in 1/10,000 – 1/100,000 of patients treated for (ONJ) osteoporosis (American Society of Bone and Mineral Research) Risk Factors: age >65, periodontitis, poor dental hygiene, dental surgery, high dose of antiresorptive, treatment duration >2 years, smoking, cancer, chemotherapy, corticosteroid use and diabetes Risk Reduction: dental care prior to initiating bisphosphonate Atypical Femoral Fracture Rare type of fracture that occurs in 1/10,000 – 1/100,000 patients (AFF) (thigh pain may precede fracture) Risk factors: steroids and PPIs AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update Hellstein JW, 2011 41  ONJ and AFF Annu Rev Med. 2009 42  American Dental Association Prevention of ONJ Risk of ONJ is low Morbidity and mortality of osteoporosis is significant and outweighs the risk of ONJ Recommend regular dental visits and adequate oral hygiene Discontinuing bisphosphonate therapy may not eliminate the risk of ONJ Do not modify the dental treatment plan for patients on antiresorptive therapy Use chlorhexidine mouth rinse before and after dental surgery Hellstein JW, 2011 43  Bisphosphonates: Contraindications Hypocalcemia Inability to stand or sit upright for 30 minutes (60 minutes for ibandronate) Esophagitis Esophageal strictures Barrett’s esophagus Swallowing disorders CrCl less than 35 mL/min (alendronate, zoledronic acid) CrCl less than 30 mL/min (ibandronate, risedronate) AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 44  Starting a Bisphosphonate Baseline lab tests: calcium, vitamin D, SCr DXA scan in 2 years to monitor response to therapy Counseling points: Appropriate administration  8 ounces of water and wait 30 minutes before first food  Stay sitting or upright for at least 30 minutes (60 minutes for ibandronate)  Separate from calcium, iron, magnesium, antacids, and multivitamins by at least 2 hours Take missed dose the next morning, do not take 2 doses on the same day Receive routine dental care Report muscle or joint pain Ensure adequate calcium and vitamin D intake AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 45  Bisphosphonate Holidays Consider holiday for low-risk patients after 3 years (zoledronic acid) or 5 years (alendronate/ibandronate) At risk for vertebral fracture but not hip fracture Restart bisphosphonate if the patient fractures or has a decline in BMD Treat high-risk patients for up to 10 years Low-Risk Patients High-Risk Patients No history of fragility fracture History of fragility fracture T-score in osteopenia range T-score in osteoporosis range Steroid use AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 46  Denosumab (Prolia) Image: https://www.nonamedicalarts.com/prolia-injections/ 47  Denosumab (Prolia): MOA Receptor Activator of Nuclear Factor kappa-B Ligand (RANKL) Inhibitor Osteoblasts secrete RANKL, which activates osteoclast precursors AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update Image: Stepwards, Denosumab 48  Denosumab (Prolia): Dosing Dose 60 mg subcutaneously every 6 months Administration Administered by a health care professional Administered in the upper arm, thigh, or abdomen Must be refrigerated Allow to come to room temperature prior to administration AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 49  Denosumab (Prolia): Adverse Effects Contraindications Hypocalcemia (correct prior to using) Pregnancy Side effects HTN, fatigue, edema, dyspnea, headache, N/V/D, rash and infections Rare side effects: ONJ and atypical femur fractures Baseline labs Baseline calcium and vitamin D SCr Use in patients with CrCl < 30 mL/min is limited Avoid in patients with CrCl < 15 mL/min due to risk of hypocalcemia AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 50  Denosumab (Prolia): Cost List price ~ $1,500 per dose Medicare Part B or Part D Part B: Ordered by the physician’s office and administered in clinic Part D: Obtained at the pharmacy and administered in clinic, can place patient into the Medicare Part D donut hole Uninsured or Underinsured Manufacturer Savings Coupon Prescription Assistance Programs https://www.prolia.com/paying-for-prolia 51  Denosumab (Prolia): Discontinuation BMD decreases rapidly upon discontinuation Bone turnover markers increased above baseline by 12 months Rebound fracture risk Alternative agents to maintain BMD if discontinuing (bisphosphonate) AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 52  Second Line Agents Calcitonin Raloxifene Estrogen Osteopenia of the Women with Vertebral fracture spine and high vasomotor pain risk for breast symptoms cancer AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 53  Calcitonin (Miacalcin) Inhibits bone resorption by osteoclasts and not preferred for long-term therapy Indication: Treatment of women with osteoporosis who are more than 5 years post- menopause Dosing Nasal spray – 1 spray (200 units) in one nostril once daily (alternate nostrils daily) IM or SC – 100 units daily Side effects: rhinitis, sinusitis, nose bleeds, nasal ulcerations, hypersensitivity reactions to salmon-derived products Increased risk for malignancy with use greater than 6 months AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 54  Raloxifene (Evista) Selective estrogen receptor modulator (SERM) that decreases bone resorption Indication: Treatment and prevention of osteoporosis in postmenopausal women and reduction of invasive breast cancer in high-risk women Contraindications: history or current VTE, pregnancy Dosing: 60 mg PO once daily Side effects: hot flashes, leg cramps, cataracts, peripheral edema, arthralgia Boxed Warnings: increases risks of DVT, PE and death d/t stroke in women with CHD or at risk for coronary events AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 55  Conjugated Estrogens/Bazedoxifene (Duavee) Equine estrogen/SERM combination Indication: Prevention of osteoporosis in postmenopausal women with a uterus Contraindications: breast cancer (d/t unopposed estrogen), pregnancy, undiagnosed uterine bleeding, history or active VTE, MI or stroke; protein C, S or antithrombin deficiency, hepatic impairment Dosing: 1 tablet (0.45/20 mg) PO once daily Boxed Warnings: endometrial cancer (d/t unopposed estrogen); increased risk of DVT and stroke in postmenopausal women 50-79 years of age; dementia (women > 65 years) Use for shortest duration possible and not recommended for women >75 years of age AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 56  PTH Analogs Images: https://www.empr.com/drug/tymlos/; https://www.goodrx.com/forteo/what-is 57  PTH Analogs Analogs of human parathyroid hormone, which stimulates osteoblast activity and increases bone formation Decreases risk of vertebral and non-vertebral fractures Used in patients with a very high risk of fracture History of vertebral fracture or multiple fractures Fracture on bisphosphonate or denosumab T-score < -3 Due to safety issues, the cumulative lifetime treatment duration is restricted to 2 years or less Followed by a bisphosphonate or denosumab to maintain BMD that is gained AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 58  PTH Analogs Teriparatide (Forteo) Abaloparatide (Tymlos) Treatment for post-menopausal Treatment for post-menopausal women with osteoporosis women with osteoporosis Treatment of osteoporosis in men 80 mcg subcutaneously daily Steroid induced osteoporosis 20 mcg subcutaneously daily AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 59  PTH Analogs – Adverse Effects Side Effects Transient orthostasis/dizziness - administer first dose under medical supervision Arthralgias, leg cramps Injection site reactions, nausea Hypercalcemia Osteosarcoma (bone cancer) Previously Black Box Warning – has been removed for both Tymlos and Forteo Dose-dependent increase in osteosarcoma in rats – increased risk not seen in human observational studies Avoid use in patients at high risk of osteosarcoma: Paget’s Disease Bone metastases or a history of skeletal malignancies History of external beam or implant radiation involving the skeleton Hereditary disorders predisposing to osteosarcoma Treatment duration limited to 2 years AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 60  PTH Analogs - Cost The cost of the PTH analogs are a significant barrier to their use ~$2,000 - $4,000 per month PA required - insurance companies often require first-line agents used first Often filled in specialty pharmacies Considerations: Savings Cards for commercially insured patients Patient assistance programs for uninsured patients Billed under Medicare Part D https://www.forteo.com/savings-and-support https://www.tymlos.com/savings-support 61  Romosozumab (Evenity) Approved April 2019 Dose: 210 mg subcutaneously once monthly Administered by a healthcare professional Keep refrigerated and let it sit at room temperature for 30 mins Duration of treatment: 12 months Followed by an antiresorptive Image: Fierce Pharma 62  Romosozumab (Evenity) Mechanism Sclerostin inhibitor – sclerostin is a regulatory factor in bone metabolism Dual effect: increases bone formation and to a lesser extent, decreases bone resorption Indication Postmenopausal women at high risk of fracture defined as history of fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other treatments Efficacy Significant reductions in vertebral fractures Significant gains in bone mineral density AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 63  Romosozumab (Evenity) – Adverse Effects Boxed Warnings: increased risk of MI, stroke and CV death Do not use in patients with a history of MI or stroke in the past year Consider risk vs benefits in patients with risk factors for CV disease Contraindications Hypocalcemia Side Effects Arthralgia Headache Injection site reactions AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 64  Romosozumab (Evenity) - Cost The cost of romosozumab (Evenity) is a significant barrier ~$2,000 per dose Prior authorization required Considerations: Co-pay Card for commercially insured patients ($25 per dose) Patient assistance program for uninsured/underinsured patients Can be billed through Medicare Part B or D (specialty pharmacy) https://evenitysupport.com https://www.amgensafetynetfoundation.com/resources-forms.html 65  Monitoring Therapy DXA 1 to 2 years after initiation of therapy DXA should occur at the same facility Medicare covers testing every 2 years Assess for proper administration, tolerability, and side effects Assess medication adherence AACE/ACEA Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update 66 Mrs. Miller 72-year-old white female PMH: HTN, type 2 diabetes, no hx of fractures DXA Report 10/31/2022 FH: mother had osteoporosis and had a hip fracture T-score total hip: – 0.9 SH: non-smoker, occasional alcohol (1 glass of wine with dinner 3 times per week) T-score femoral neck: – 1.8 Medications: lisinopril, metformin, pioglitazone, T-score vertebrae: – 2.2 famotidine Vitals: weight 125 lbs; height 5’4’’ 67 Mrs. Miller What labs would you obtain today before starting treatment? What other information would you ask about before selecting her treatment? 68 Mrs. Miller Labs: 25-hydroxy vitamin D: 25 ng/mL Serum calcium: 9.0 mg/dL CrCl 50 mL/min What non-pharmacologic treatments would you recommend? What drug treatment would you start? What if she has esophagitis and has trouble swallowing tablets? 69 Take Home Points Osteoporosis is a common disease in older adults that is associated with significant morbidity and mortality Patients are frequently undertreated due to concerns with side effects First-line treatment includes bisphosphonates or denosumab PTH analogs can be considered in severe osteoporosis Other interventions Calcium, vitamin D, exercise, smoking cessation, and falls reduction 70 Guidelines and Resources AACE/ACE Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis - 2020 National Osteoporosis Foundation Clinician’s Guide to Prevention and Treatment of Osteoporosis - 2014 71 Kahoot Time! https://kahoot.it 72 Osteoporosis Luis Trejo, PharmD [email protected] 11/19/24