Accreditation/Credit Designation

Physicians' Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians' Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Physicians’ Education Resource®, LLC, is approved by the California Board of Registered Nursing, Provider #16669, for 1.5 Contact Hours.

Acknowledgment of Commercial Support

This activity is supported by an educational grant from Amgen Inc.

Medical Crossfire®: Osteoporosis: Identifying, Treating, and Coordinating Care for Patients at High Risk

Release Date: October 31, 2019
Expiration Date: October 31, 2020
Media: Internet - based

Activity Overview

Osteoporosis is the most common metabolic bone disease and is characterized by low bone mass, which leads to reduced bone strength and a higher risk for fracture. Although most commonly seen in postmenopausal women, osteoporosis can also be associated with a range of conditions in both men and women, including chronic kidney disease, any condition causing an estrogen (or testosterone) deficiency, malabsorption disorders, hyperparathyroidism, Alzheimer disease, and chronic obstructive pulmonary disease, as well as with treatment with glucocorticoids and other medications. Prevalence in the United States is estimated at 9.9 million individuals, with another 43.1 million having low bone mass or osteopenia. These numbers will continue to expand as baby boomers (now aged 55-73 years) grow older. Despite the recommendations of the US Preventive Services Task Force to screen all women 65 years or older and any woman younger than 65 years with risk factors, screening rates are abysmal. Even when individuals are appropriately screened and the disease is diagnosed, both adherence to available treatments and clinician follow-up are poor.

During this Medical Crossfire®, an expert multidisciplinary faculty consisting of a geriatrician, an endocrinologist, a rheumatologist, and primary care providers will examine missed opportunities for screening and identify the myriad risk factors for osteoporosis along with the impact of fractures on future quality of life. The faculty will also discuss benefits and safety of long- and short-term treatments as well as strategies to improve adherence. Case presentations will exemplify interpretation of screening data and incorporation of treatment.

Benefits of Participating

  • Expand awareness of patient populations at high risk for osteoporosis
  • Increase knowledge of risk factors and comorbidities that contribute to osteoporosis in order to incorporate screenings into routine patient encounters
  • Learn how to establish treatment regimens that include disease education in shared decision making in order to maintain adherence
  • Gain familiarity with newer treatments as add-on therapy to improve long-term patient outcomes

Acknowledgement of Commercial Support

This activity is supported by an educational grant from Amgen Inc.

Instructions for This Activity and Receiving Credit

  • You will need to log in to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review videos/content until you finish the presentation.
  • At the end of the activity, “Educational Content/Video” will be available for your reference.
  • In order to receive a CME/CE Certificate, you must complete the activity.
  • Complete the Posttest and pass with a score of 70% or higher, complete the Evaluation, and then click on “Request for Credit.” You may immediately download a CME/CE Certificate upon completion of these steps.

Target Audience

This online educational activity is directed toward primary care clinicians, endocrinologists, geriatricians, rheumatologists, nurse practitioners, nurses and physician assistants, and other health care professionals interested in the treatment of osteoporosis.

Learning Objectives

Upon successful completion of this educational activity, you should be better prepared to:

  • Assess best practices for screening and assessment of patients at high risk of osteoporosis
  • Evaluate the efficacy and safety of current and developing agents for treatment of patients with osteoporosis
  • Apply multidisciplinary patient-centered strategies to take care of patients with or at risk for osteoporosis

Faculty, Staff, and Planners’ Disclosures

Faculty

Paul P. Doghramji
Paul P. Doghramji, MD, FAAFP
Attending Physician
Collegeville Family Practice
Medical Director of Health Services
Ursinus College
Collegeville, PA

Disclosures: Consultant: Jazz Pharmaceuticals, Harmony Biosciences, Eisai; Shareholder: Pfizer.

Nelson B. Watts
Nelson B. Watts, MD, FACP, MACE, FASBMR
Director, Osteoporosis and Bone Health Services
Cincinnati, OH

Disclosures: Consultant: AbbVie, Sanofi; Speakers Bureau: Amgen, Radius.

Nancy E. Lane
Nancy E. Lane, MD
Director, Center for Musculoskeletal Health
Distinguished Professor of Medicine, Rheumatology, and Aging
University of California, Davis, School of Medicine
Sacramento, CA

Disclosures: Consultant: Amgen; Speakers Bureau: Amgen.

Beatrice J. Edwards
Beatrice J. Edwards, MD, MPH
Deputy, Associate Chief of Staff
Geriatrics and Extended Care at
Central Texas Veterans Healthcare System and
The University of Texas Dell Medical School
Temple, TX

Disclosures: no relevant financial relationships with commercial interests.

Nancy R. Berman
Nancy R. Berman, MSN, ANP-BC, NCMP, FAANP
Nurse Practitioner
Michigan Healthcare Professionals
Farmington Hills, MI
Clinical Instructor
Department of Obstetrics and Gynecology
Wayne State University School of Medicine
Detroit, MI

Disclosures: Consultant: Amgen, Radius Health; Speakers Bureau: TherapeuticsMD.

The staff of Physicians' Education Resource®, LLC (PER®), have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, PER® makes it a policy to ensure fair balance, independence, objectivity, and scientific rigor in all its CME/CE activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME/CE activity to disclose all relevant financial relationships with commercial interests. The ACCME defines relevant financial relationships as financial relationships in any amount occurring within the past 12 months that create a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME/CE activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME/CE activity is for continuing medical and nursing education purposes only and is not meant to substitute for the independent clinical judgment of a physician or nurse relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER® or the company that provided commercial support.

PER Pulse™ Recaps

1 of 3

In the certified continuing medical education activity Medical Crossfire™, Osteoporosis: Identifying, Treating, and Coordinating Care for Patients at High Risk, an expert panel discusses osteoporosis risk factors; frequently missed screening opportunities; benefits and safety of long- and short-term treatments and new agents; and multidisciplinary strategies to improve screening, treatment, and compliance. Case scenarios highlight up-to-date treatment approaches.

This first of 3 PER Pulse™ Recaps focuses on the top risk factors among women and men, the impact of osteoporosis on patient quality of life (QOL), and screening and assessing patients at high risk. Some key points are below.

  • Osteoporosis is linked to more than 2 million fractures annually, with care costs exceeding $76.3 billion annually. Patient mortality rates 1 year after hip fracture exceed 20%. Fractures and disability decrease patient QOL.
  • High-risk groups include:
    • Postmenopausal women
    • Women and men with certain diseases such as
      • Chronic kidney disease
      • Chronic obstructive pulmonary disease
      • Dementia
      • Hyperparathyroidism
      • Malabsorption disorders
    • Patients with estrogen or testosterone deficiency from any cause
    • Patients treated with medications that can increase bone loss, such as glucocorticoids, proton pump inhibitors, selective serotonin reuptake inhibitors, and immunosuppressants
    • Cancer survivors
  • A previous fracture is the biggest risk factor for a second fracture.
    • However, frequently, a clinician doesn’t link an initial fracture to a likelihood that it was related to osteoporosis, and an opportunity for future fracture risk assessment and treatment is missed
  • Effective screening of high-risk patients is well below recommendations by the US Preventive Services Task Force.
    • For the following patients, screening is recommended using dual-energy x-ray absorptiometry scan of the hip and lumbar spine1:
      • All women 65 years and older
      • Women <65 years who are at high risk
      • Men at high risk
  • The FRAX: Fracture Risk Assessment Tool calculates 10-year probability of a fracture.2
    • Based on clinical risk factors and bone mineral density score
    • May also guide treatment decisions in3:
      • Postmenopausal women, or men 50 years or older
      • Individuals with osteopenia
      • Individuals prior to initiation of treatment

“We’re finding that patients who are healthier are likely to be screened, but screening rates are often lowest among individuals with medical conditions that put them at high risk for osteoporosis.”
‒ Beatrice Edwards, MD

References

  1. Osteoporosis to prevent fractures: screening. US Preventive Services Task Force website. www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/osteoporosis-screening1?ds=1&s=osteoporosis. Published June 2018. Accessed December 24, 2019.
  2. FRAX: Fracture Risk Assessment Tool. University of Sheffield website. sheffield.ac.uk/FRAX/. Accessed December 24, 2019.
  3. Risk assessment (FRAX). National Osteoporosis Foundation website. Accessed December 24, 2019.

2 of 3

In the certified continuing medical education activity Medical Crossfire™, Osteoporosis: Identifying, Treating, and Coordinating Care for Patients at High Risk, an expert panel discusses osteoporosis risk factors; frequently missed screening opportunities; benefits and safety of long- and short-term treatments and new agents; and multidisciplinary strategies to improve screening, treatment, and compliance. Case scenarios highlight up-to-date treatment approaches.

This second of 3 PER Pulse™ Recaps focuses on current long- and short-term treatments for osteoporosis. Some key points are below.

  • Lifestyle modifications can reduce fracture risk in all patients with low bone mass
    • Exercise, balance training, good nutrition, smoking cessation, and reducing alcohol intake help maintain bone density
    • Biomechanical protection (eg, hip protectors) can prevent fractures in the patients at highest risk
  • Supplementation with calcium and vitamin D
    • Calcium: 600 mg daily (calcium carbonate or calcium citrate) is sufficient for patients with typical American diet
    • Vitamin D when serum levels are below normal
  • Osteoporosis medications can reduce fracture risk by up to 70%. Different mechanisms of actions and administration routes of agents can enhance outcomes and patient compliance
    • Bisphosphates are first-line therapy to slow bone loss
      • Oral bisphosphonates (alendronate, risedronate)
        • Safe and effective in studies up to 10 years
        • Gastrointestinal (GI) upset a common adverse effect (AE)
      • Infused bisphosphonates (ibandronate, zoledronate)
        • Administered monthly to yearly
        • Infusion avoids GI upset; improves medication compliance, particularly for patients with memory problems
        • Can cause flu-like symptoms
      • Rare AEs associated with long-term use of bisphosphonates (jaw osteonecrosis and atypical femoral fracture) have unfortunately reduced compliance; patient selection, education, and preventive strategies are essential
    • Human monoclonal antibody (denosumab)
      • Blocks osteoclast formation, decreasing bone resorption
      • Administered subcutaneously twice yearly
      • Most common AEs in clinical trials were fatigue/asthenia, hypophosphatemia, and nausea
    • Agents that slow bone loss and/or stimulate bone formation
      • For time-limited use; may combine with bisphosphonates
      • Teriparatide and abaloparatide are given by injection, improving compliance. Affects osteoblasts to stimulate bone formation. Adverse effects (AEs) include arthralgia, pain, and nausea (teriparatide) and hypercalciuria, dizziness, and nausea (abaloparatide).
      • Romosozumab: recently approved injectable monoclonal antibody agent; stimulates bone formation plus inhibits bone loss. The most common AEs observed in clinical trials were arthralgia and headache.
  • Clinical follow-up on osteoporosis medication includes dual-energy x-ray absorptiometry bone density scanning every 1 to 2 years

“[For best fracture prevention], combine osteoporosis treatment with fall prevention, weight-bearing resistance exercise, and balance training: These are very important in reducing falls. … And, typically, treatment compliance is very low, at 35%. You have to work your treatment into patients’ lifestyles for good compliance.”
‒ Beatrice Edwards, MD


3 of 3

In the certified continuing medical education activity Medical Crossfire™, Osteoporosis: Identifying, Treating, and Coordinating Care for Patients at High Risk, an expert panel discusses osteoporosis risk factors; frequently missed screening opportunities; benefits and safety of long- and short-term treatments and new agents; and multidisciplinary strategies to improve screening, treatment, and compliance. Case scenarios highlight up-to-date treatment approaches.

This third of 3 PER Pulse™ Recaps describes how multidisciplinary care promotes best outcomes for patients with, or at high risk for, osteoporosis. Some key points are below.

  • Once diagnosed, treatment adherence among patients at high risk for osteoporotic fracture is very often poor, with incomplete clinical follow-up.
  • Multidisciplinary strategies that promote clinician communication improve patient outcomes.
    • Primary care clinicians are ideally positioned to identify and screen high-risk patients and begin treatment.
      • Specialists, nurse practitioners, and physician assistants can reinforce education from primary clinicians to enhance treatment adherence.
      • Multiple patient encounters are necessary when initiating treatment, and specific disease education can empower patients to self-manage and improve outcomes.
    • Comorbidities are common (eg, >82% of patients with a history of cancer experience reduction in bone mass) and specialists (eg, oncologists, rheumatologists, pulmonologists) with patients at increased risk can help prevent fractures by referring them for bone-density screening and osteoporosis treatment as needed.
      • Obtain baseline dual-energy x-ray absorptiometry bone density scans prior to initiation of glucocorticoid (or other therapy known to reduce bone mass).
    • Primary care/geriatrician co-management with orthopedic surgeons post fracture can guide optimal follow-up, treatment, and preservation of patient’s independence.

“A team approach [to identifying and monitoring high-risk patients] makes sure patients are not lost in the system. Right now, we haven’t got the system working correctly to identify patients at risk. We don’t have them identified when they leave the hospital so that they get follow-up care.”
‒ Nancy E. Lane, MD

“[When primary care providers] have patients coming to their office for follow-up of hip fractures, it’s essential that they get a bone-density test.”
‒ Paul P. Doghramji, MD


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