Osteoporosis Treatment for Postmenopausal Women at High Risk for Fracture
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Recall which postmenopausal women should be offered medical therapy to prevent fractures due to osteoporosis 2. Discuss the various pharmacologic options available to women at high risk of fractures due to osteoporosis
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 7/1/2019 through 1/25/2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
High risk should continue therapy while low-to-moderate risk may be candidates for ‘bisphosphonate holiday’
Ibandronate not recommended for nonvertebral or hip fracture risk reduction
of the jaw (ONJ) and bisphosphonates: Absolute risk ranges from 1 in 10,000 to
1 in 100,000 | Higher risk in oncology setting | Risk may be as high as 21 in
10,000 if on medication >4 years | Increased risk with tooth extraction (0.5%)
Alternative initial treatment: Denosumab
60 mg subcutaneously every 6 months
Reassess risk at 5 to 10 years as to whether patient should remain on denosumab
Consider SERMs (raloxifene or bazedoxifene)
Low risk of DVT and bisphosphonates/ denosumab not appropriate or
High risk of breast cancer
Consider menopausal hormone therapy (estrogen only for women with hysterectomy) if
Cannot tolerate bisphosphonates/ denosumab or bisphosphonates/ denosumab not appropriate
<60 years of age or <10 years beyond menopause
Low risk of deep vein thrombosis | No contraindications | No previous history of MI or stroke | No breast cancer
Symptomatic vasomotor symptoms and/or other menopausal symptoms
Note: Tibolone may used based on the above clinical scenarios as
well | Tibolone not currently available in the US or Canada)
In women >60 who cannot tolerate
bisphosphonates/ denosumab or bisphosphonates/
denosumab not appropriate, consider the following (in order)
HT or tibolone
Calcium and vitamin D
Very High Risk of Fracture
Severe osteoporosis (ie, low BMD T-score <−2.5 and fractures) or multiple vertebral fractures
Teriparatide and abaloparatide
These medications are parathyroid hormone and parathyroid hormone–related protein analogs
Anabolic agents that increase bone formation
Recommended for up to 2 years
Follow up using antiresorptive osteoporosis therapies to maintain gains
Monoclonal antibody that blocks sclerostin and increases new bone formation
Recommended for up to 1 year
Recommended dosage is 210 mg monthly by subcutaneous injection
Women at high risk of cardiovascular disease and stroke: Should not be considered for romosozumab
Calcitonin (nasal spray) may be an option only if patients can not tolerate or
should not be prescribed the following
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Jointly provided by
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