Management of osteoporosis

Recent Advances in Diagnosis and Management of Osteoporosis

1. Recent Advances in Diagnosis
&Management of Osteoporosis
Dr. Ashok Bhatt
Consultant Orthopedic Surgeon

3. Osteoporosis
Osteoporosis is defined as a systemic skeletal disorder
characterized by reduced bone mass and compromised
micro architectural structure resulting into reduced bone
strengthpredisposing to an increased risk of Fragility
fracture.
OP is uncoupling of Osteclastic(bone resorption)
and Osteoblastic (bone formtation) acitivity
Normal Bone Osteoporotic Bone

4. Changes in Bone Density with Age
6/2/2021 4
Peak Bone is achieved at around age of 30 years
Peak Bone Mass(PBM) -Protein, Vitamin D and Calcium intake
during childhood has role in PBM

5. Risk Factors
Major
•History of fracture as an
adult
•Fragility fracture in first
degree relative
•Caucasian/Asian
postmenopausal woman
•Low body weight (< 127 lb)
•Current smoking
•Use of oral corticosteroids >
3 mo.
Additional
•Impaired vision
•Estrogen deficiency at early
age (< 45 YO)
•Dementia
•Poor health/frailty
•Recent falls
•Low calcium intake (lifelong)
•Low physical activity
•> 2 alcoholic drinks per day

6. Factors Associated with Bone Loss in Men
•Genetics
•Smoking/alcohol
•Calcium intake
•Physical
activity/strength
•Testosterone
production
•Estrogen production

7. Medical Conditions Associated with
Increased Risk of Osteoporosis
•COPD
•Cushing’s syndrome
•Eating disorders
•Hyperparathyroidism
•Hypophosphatasia
•IBS
•RA, other autoimmune
connective tissue
disorders
•Insulin dependent
diabetes
•Multiple sclerosis
•Multiple myeloma
•Stroke (CVA)
•Thyrotoxicosis
•Vitamin D deficiency
•Liver diseases
Not an inclusive list

8. Drugs Associated with
Reduced Bone Mass
•Aluminum
•Anticonvulsants
•Cytotoxic drugs
•Glucocorticosteroids
(oral/high dose inhaled)
•Immunosuppresants
•Gonadotropin-releasing
hormone (e.g. Lupron)
•Lithium
•Heparin (chronic use)
•Supraphysiologic
thyroxine doses
•Aromatase inhibitors
•Depo-Provera
Not an inclusive list

9. Risk Assessment/Diagnosis
•After menopause, all women should be evaluated
clinically for osteoporosis risk to determine need for BMD
testing
•50-60% of men with osteoporosis have disorders known
to reduce bone mass, such as hyperparathyroidism,
intestinal disorders, malignancies, conditions resulting in
immobilization
•BMD recommended in men with known risk factors and
who have lost > 1.5 inches in height
•Diagnosis can be established in patients who have never
had a fragility fracture by BMD measurement

10. New Assessment Tools for
Fracture Risks & Treatment Decisions
•FRAX
The WHO developed a computer-generated algorithm.
Provides country-and ethnic-specific 10-year hip and major osteoporotic
fractures.
Obtained from simple questioning; it includes age, sex, weight, height,
personal and family history of fracture, current tobacco and alcohol
consumption, corticosteroid usage, previous conditions,& RA
•SOF
based only on BMD and age
•QFracture
Based on some enlisted risk factors
Does not need BMD

11. Who Should be Tested?
•Decision to test based on individual risk profile,
never indicated unless resultsinfluence
treatment decision
•BMD testing should be performed on:
1.All women 65 YOA and older regardless of risk
factors*
2.Younger postmenopausal women with one or more
risk factors (other than being white, postmenopausal
and female)
3.Postmenopausal women who present with fractures
(confirm diagnosis, determine disease severity)
*Medicare permits repeat BMD testing every 2 years.

12. Everything about BMD
•Gold standard for diagnosis of Osteopenia and
Osteoporosis & “ At risk “ patients.
•Gives clear picture about Bone density
•Machine specific, position specific, variable with
subjective factor.
•Repeat BMD should be done at least after 2 yrs.
•Compare BMD and not T score
•Does not reveal about quality & architecture of bone.
•Risk factors for low BMD are not the same as for
Fragility fracture.
•Researchers are developing tool based on CT of spine &
hip with 3D images and computer modeling, to study the
architecture of bone and predict fragility #s.

13. “THE CARE GAP”
IN OSTEOPOROSIS
Despite the introduction of methods to
identify those with osteoporosis and
despite effective treatment, a large
‘care gap’ continues to exist for
these patients.

14. Male Osteoporosis: Morbidity and
Mortality
As compared to women, while lifetime
fracture risk may be less,
–Men have higher rates of morbidity and
mortality due to fractures
–Men are twiceas likely to die in hospital
after a hip fracture
–Men have a higher mortality rate than
women one year after a hip fracture
Cooper C, et al. Osteoporos Int 1992;2:285-9; Singer BR, et al. J Bone Joint Surg
Br 1998;80:243-8; Center JR, et al. The Lancet 1999;353:878-82; orsen L, et al.
Osteoporos Int 1999;10:73-8; Johnell O., et al. Calcif Tissue Int 2001;69:182-4;
Amin S. Curr Osteoporos Rep 2003;1:71-7; Campion JM, et al. Am Fam Phys
2003;67:1521-6.

15. HIP FRACTURES
MORBIDITY AND MORTALITY
“One-third of all hip fractures occur in men and are
associated with as much illness and increased risk
of deathas those that occur in women .”
“The average 50-year-old Caucasian man has a 13
per cent chance of having a fracturerelated to
osteoporosis sometime in his remaining lifetime. A
60-year-old Caucasian man has a 29per cent
chance.”
Dr. John Schousboe, Minneapolis 2007

16. Vertebral Fracture Cascade

17. THE HUMAN COST -Downward Spiral

18. Organizations involved in rationalization of
Osteoporosis Management :
IOF : International Osteoporosis Foundation
NOF : National Osteoporosis Foundation
ISCD : International Society for Clinical
Densitometry
ISBMR: Indian Society for Bone Mineral Research
IOM : Institute of Medicine
AACE American Association of Clinical
Endocrinologists
Prevention of Osteoporosis
Medical Management
Management during treatment of Fragility fractures

19. Explore Non Pharmacologic
Preventive measures
Life Style
Nutrition
Calcium and Vitamin D
Good protein Diet
Fall prevention –Hip Protectors

20. Prevention and Treatment Goals
Decrease fracture risk
Stabilize or increase bone mass
Maintain or improve bone quality
Prevent falls:Fall prevention strategies are not in place in India
Risk of fall can be evaluated by:
Patient can’t walk and talk simultaneously
Ask patient to sit, walk for 10 m, comeback and sit again. Slowness
in such patients is indicative of risk of fall
Fracture management
Relieve pain
Stabilize fracture and restore anatomy
Manage co-morbidities, Treat Osteoporosis aggressively
Restore level of function
Psychosocial support

21. Non-Pharmacological Therapy
NOF Recommendations
Adequate intake of dietary calcium and vitamin D
Calcium: at least 1200 mg/day in divided doses
Vitamin D: at least 800-1000 IU/day
Regular weight-bearing and muscle-strengthening
exercise including walking
Avoidance of smoking and excess alcohol
Fall prevention esp in Elderly
Cordless phone near bed at night, towel at floor of bathroom,
light in staircase, correct sights etc..
Hip Protectors (Hip Pelvis Arms useful, may not be in leg
and trunk )

22. Recommended Calcium Intake per
2010 IOM Report
RDA (mg)Upper limit (mg)
9-18 (boys/girls)1300 3000
Women 19-50 1000 2500
Pregnancy No adjustments
Women over 50 1200 2000
Men 19-50 1000 2500
Men 50-70
1000 2000
Men over 70 1200 2000

23. Calcium Reduces Bone Loss and
Fracture Risk: A Meta-Analysis
Calcium or calcium with vitamin D
BMD: reduced rate of bone loss
23 trials (n = 41,419)
Hip: reduced loss 0.54% (0.35-0.73%, p < 0.0001)
Spine: reduced loss 1.19% (0.76-1.61%, p < 0.0001)
Fractures: reduced fracture risk
17 trials (n = 52,625)
RR 0.88 (CI 0.83-0.95, p = 0.0004)
Best results with calcium 1200 mg or more and vitamin D
800 IU or more
WHI study conclusion

24. Calcium Citrate MalateVs
Calcium Carbonate
Calcium salt per
tablet
% of elemental
calcium
Elemental
calcium
% bioavailable
Mg of
elemental
calcium
absorbed
Calcium
carbonate
(500mg)
40% 200mg 26% 52
Calcium citrate
malate(1250
mg)
20% 250mg 40% 100
Other Benefits of CCM over Calcium Carbonate
•Does not increase the risk of kidney stones
•CCM can be consumed with or without food
•Does not interfere with Fe absorption and retention

25. 2010 Institute Of Medicine Report:
Vitamin D
Practically all persons are sufficient at 25-OH vitamin D levels of
20 ng/mL (50 nmol/L) or above
No consistent evidence for extra-skeletal benefits above a level of
20 ng/mL
Levels between 20-50 ng/mL appear to be safe
RDA to cover 97.5% of the population
0-12 months 400 IU daily
1-70 years old 600 IU daily
Over 70 years old800 IU daily
AACE response to IOM report emphasis on clinical judgment
Dosage recommendation varies with different guidelines of
association/inst

26. D-hormone analogs vs.
Native vitamin D
One meta-analysis in 2008 showed that D-hormone analogs
(Calcitriol & Alfacalcidiol) may prevent falls and
fractures to a greater extentcompared to their native
compound(Vitamin D)
Richy F et al. Differential effects of D-hormone analogs and native vitamin D on the risk of falls: a comparative
metaanalysis. Calcif Tissue Int 2008; 82: 102–7.

27. Summary: Calcium and Vitamin D
Low calcium intake and vitamin D deficiency should be corrected in all
patients
Hip fractures occur often in patients aged > 75-80 years and this population is
particularly prone to calcium and vitamin D deficiency
In patients with low calcium intake, calcium alone induces small increases in
bone mineral density and possibly reduces fracture incidence
Low-dose vitamin D (400 IU/d) alone did not reduce fracture incidence in a
free living population
Calcium and vitamin D supplementation in women living in nursing homes
decreases hip fracture incidence
Serum Vitamin D needs to be done in patients in whom
Bisphonates or Teriparatide has to be prescribed

28. Prevention of Falls
Correct visual and
hearing impairment
Optimize medications
Bathroom grab-bars
and nonskid mats
Avoid throw-rugs and
slippery mats
Keep electric and
telephone cords away
Reduce clutter from
walking areas
Nightlight in bedroom
and bathroom
Handrails on steps and
stairs
Walking aids, if needed
Exercise for strength
and balance (Tai Chi)
Michael, YL, et. al., AHRQ Publication # 11-05150-EF-1, Dec
2010

29. Pharmacologic Prevention
Calcium, Vitamin D supplementation
Treatment of co morbid conditions
Hormone Therapy
Estrogens
SERM, Raloxifen ( Selective Estrogen Receptor
Modulators)
Only indicated for Peri menopausal or post menopausal
women

30. Osteoporosis -Treatment
Ideal treatment:
Increase bone mass
Improve bone architecture and strength
Reduce the risk of fracture

31. Hormonal therapy
When No other rx available, or lot of toxicity with other drugs
then only preferred
Estrogen( .625 mg of oral conjugated equine estrogen or
equivalent taken daily) for prevention and not for treatment ,
Est fails to show reduces the #, can be taken 5 years after
menopause…taking longer than it would be weighed against
the risk,
SERM :
Tamoxifen : monitor uterine endothelium
Raloxifen :60 mg tablet daily adv. is inhibitory on uterine
endo, selective, little benefit for non vertebral #, reduces ER
positive breast cancer so start before 2 year of menopause to
take care of flushes.

32. Pharmacologic Treatment
Advances in Osteoporosis Medications
1984 :Estrogen
1986 :SC Calcitonin
1990 :Etidronate
1995 :Alendronate , Nasal calcitonin
1999 :Raloxifene , Tamoxifene
2000 :Risedronate
2002 :Teriparatide
2004 :Strontium Ranelate
2005 :Ibandronate ( IV 2006 )
2007 :Zoledronic Acid IV
2010 :Denosumab
2011 :Bazedoxifene

33. FDA-Approved Medications
Drug PMO GIO Men
PreventionTreatmentPreventionTreatment
Estrogen 
Calcitonin 
Alendronate    
Risedronate     
Ibandronate  
Zoledronic acid    
Raloxifene  
Denosumab  
Teriparatide   

34. How Do Osteoporosis Medications
Work?
Anti-resorptive
Alter quality
Anabolic
Extra-skeletal
e.g. reduce falls
As a result, Fracture Risk is
reduced

35. Bisphosphonates: Alendronate(70 mg/wkly,
Risedronate ( 35 mg /wkly : Ibandronate
(150mg/monthly : Zoledronic Acid ( 5mg
iv/yrly )
Class: antiresorptive
BMD: increases BMD at various skeletal sites
Bone turnover markers: decreased
Fractures: reduces risk of fractures
Extra-skeletal considerations
Specific dosing requirements
Interval and IV/oral dosing available
Occasional GI irritation
Infrequent –musculoskeletal pain
Very rare -hypocalcemia, osteonecrosis of jaw, atypical femoral fracture
Effect on bone resorption persists after discontinuation
Unique to bisphosphonates

36. B.L.Riggs and M.Parfitt J Bone Miner Res. 2005;20:177
Bisphosphonates
Mechanism of Antifracture Efficacy
Refilling
Remodelingspace
Mineralization 
Remodeling
balancepositive
Prevents microstructural damage
•trabecular plate perforation
•loss of trabeculae
•resorption “stress risers“
IncreaseBMD
•trabecular+ to ++
•cortical0 to +
Preservationof
architecture
Fracture risk 
Bone remodeling


37. Bisphosphonate are Antiresorbers, Increase
BMD and Reduce Fracture Risk
Spine
Bone
Turnover
Bone Mineral Density
Time Time
Femur
BR
BF
Fracture
Rate
PreMP Range
Rapid decrease in bone
resorption (BR), followed by a
decrease in bone formation (BF)
Refill remodeling space +
secondary mineralisation 
Increase in BMD spine > hip
Reduction in
fracture risk
HOWEVER: trabecular thickness does not increase

38. Efficacy (Relative Risk Reduction
in %)
AlendronateRisedronateIbandronate
Efficacy (Relative Risk Reduction in %)
Vertebral # 47% 41% 62%
Non vertebral # 36% 40% 38-43%*
Hip # 51% 30%
decrease in bone
turnover markers
50-70 % 40-60 %
6/2/2021 38
Reginster J Y.Antifracture efficacy of currently available therapies for Postmenoapausal Osteoporosis.Drugs 2011; 71 (1): 65-78
*Cranney A et al. Ibandronate for the prevention of nonvertebral fractures:a pooled analysis of individual patient data.
Osteoporosis Int (2009) 20:291–297

39. Bisphosphonates –Side Effects
Oral
GI-Intolerance
Flu-like symptoms (myalgia, arthralgia,“fever“)
Intravenous
Flu-like symptoms (myalgia, arthralgia, “fever“)
In 12-48 hours after application
Lasts usually for 1-2 days, sometimes 1 week
Steroids reduce intensity and risk
Hypocalcemia
Ocular effects
Renal dysfunction
Segmental glomerulosclerosis (PAM)
Tubular dysfunction –interstitial nephritis (ZOL)
Osteonecrosis of the jaw
Atypical fractures
Check prior to IV Rx
-Calcium
-Creatinine
Serum Calcium & Serum Creatinine is mandatory with I.V. bisphosphonates

40. Calcitonin Nasal Spray
Class: anti resorptive, biologic agent
200 IU daily as nasal spray
BMD: slight increase
Bone turnover markers: decreased
Fractures: reduces risk of vertebral fractures, no proven
benefit for hip or non vertebral fractures
Extra-skeletal considerations
Possible analgesic effect
Occasional nasal irritation, rarely epistaxis
No known drug interactions

41. 5-year study of 1255 women, average age 68,
with 1-5 prevalent vertebral fractures
Nasal CalcitoninReduces Spine Fracture
Risk
Adapted from Chesnut CH III, et al. Am J Med. 2000;109:267. 0
5
10
15
20
25
30
35
Placebo 100 IU 200 IU 400 IU
% Subjects with New Vertebral
Fractures
No significant reduction in non-vertebral
fractures or hip fractures
36% 
P<0.05
PROOF Trial: Prevent Recurrence of Osteoporotic Fractures

42. Calcitonin and Cancer Risk?
European Medicines Agency Committee for Medicinal
Products for Human Use recommended that calcitonin
should no longer be used for osteoporosis (July 2012)
1
Meta-analysis finds increased overall cancer risk (2012
ASBMR abstract # 1234, Heep, et. al.)
Not yet published in peer-reviewed literature
Future of calcitoninunclear
1
www.ema.europa.eu/ema/index.jsp?curl=pages/medicines/human/referrals
/Calcitonin/human_referral_000319.jsp&mid=WC0b01ac0580024e99

43. Teriparatide: rhPTH (1-34)
Class: anabolic, hormone
20 mcg SC injdaily for at least 6 months. Maximum
period of treatment is two years with stringent monitoring.
BMD: increases at spine and hip
Bone turnover markers: increased
Fractures: decreases at spine and non vertebral, no
proven benefit for hip
Extra-skeletal considerations:
Osteosarcomain rats, daily subcutaneous injection,
refrigeration, hypercalcemia, leg cramps, dizziness, high
cost, limit of 2 years of therapy

44. PTH Treatment
Mechanism of Antifracture Efficacy
B.L.Riggs and M.Parfitt J Bone Miner Res. 2005;20:177
Bone Remodleing

(formation>resorption
)
Renewedperiosteal
remodeling
Positive remodeling
balance
Microstructurerepair
Renewedtrabecular
modeling
Improvedbonegeometry
IncreaseBMD
trabecular+++
cortical++
Improved
architecture
Fx risk 
stimulates osteoblast function, increases gastrointestinal calcium
absorption, increases renal tubular reabsorption of calcium
Enhances bone turnover by initiating greater bone formation

45. TeriparatideIncreases BMD
Adapted from Neer RM, et al. N Engl J Med. 2001;344:1434.
RCT of 1637 women with postmenopausal osteoporosis and 1 vertebral fractures
treated an average of 18 months with placebo, 20 µg PTH (1-34)-4
-2
0
2
4
6
8
10
12
Spine Total Hip Distal RadiusShaft Radius
% Change in BMD
Placebo
PTH 20 mcg
NSNS
P<0.001
P<0.001

46. RCT of 1637 women with postmenopausal osteoporosis and 1 vertebral fractures
treated an average of 18 months with placebo, 20 µg PTH (1-34)
TeriparatideReduces Fracture Risk
Adapted from Neer RM, et al. N Engl J Med. 2001;344:1434.
65%**
53%*
*P<0.02
**P<0.001

47. Effects of PTH (1-84) on Bone Mineral Density
S.Greenspan et al. Ann Int Med. 2007;146:326
n=2532, age 64.5±7.9, T-score ≤ -3.0
-2
-1
0
1
2
3
4
5
6
7
0 6 12 18 0 6 12 18
% Change from baseline
Months
Lumbar Spine Total Femur
PTH
Placebo

48. Recent Reports Do Not Find Increased
Osteosarcoma Risk With PTH/Teriparatide
No cases of teriparatideuse among over 1400 cases
of osteosarcomaseen over a 7-year period.
1
Extensive review of overall safety data with
teriparatideand PTH (1-84) did not reveal any risk of
osteosarcoma.
1
Andrews EB, Gilsenan AW, Midkiff K, Sherrill B, Wu Y, Mann BH,
Masica D. The US postmarketing surveillance study of adult
osteosarcoma and teriparatide: study design and findings from the first 7
years. J Bone Miner Res, 2012, Sept. 2012 [Epub ahead of print]
2
Cipriani C, Irani D, and Bilezikian JP. Safety of Osteoanabolic therapy: a
decade of experience. J Bone Miner Res (in press), 2012.

49. Strontium
Discovered in 1790 and isolated in 1808 (near
Scottish village Strontian)
Divalent cation
Resembles calcium and often mimics action of
calcium
Participates in bone mineralization
Anabolic properties
Uncoupling of BF and BR
Stimulates osteoblast proliferation
Inhibits osteoclast activity
Activation of signaling pathways through CaSR (?)

50. Denosumab
Class: anti resorptive, fully human monoclonal antibody,
binds and inhibits RANKL
BMD: increased at spine and hip
Indicated in PMO
Trials under way for its use in Men
60mg/ml Sc twice yearly
Bone turnover markers: decreased
Fracture: reduces spine, hip and non vertebral fractures
Extra-skeletal considerations
SQ injection every 6 months
Hypocalcemia, infection, ONJ likely adverse effect

51. Denosumab (RANK-Ligand
Antibody)
IgG2 immunoglobulin isotype
Its a bone metabolism regulator –a newer class
High affinity to human RANKL*
High specificity for RANKL
No neutralizing antibodies found in clinical trials
Effect on bone resorption = reversible
* does not bind to rat or mouse
RANKL

52. BMD Response
Medication Spine Hip
Estrogen  
Alendronate  
Risedronate  
Ibandronate  
Zoledronic acid  
Calcitonin ~ ~
Raloxifene  ()
Denosumab  
Teriparatide  

53. Fracture Risk Reduction in
PMO
Medication Spine Hip
Estrogen  
Alendronate  
Risedronate  
Ibandronate 
Zoledronicacid  
Calcitonin 
Raloxifene 
Denosumab  
Teriparatide 

54. Newer Molecules
•Cinacalcet
Calcium sensing receptor agonist, calcimimetics , Reduces PTH
•Ronacaleret
Calcium sensing receptor antagonist, calcilytics , Elevates PTH
•Ondanacatib
Anti resorptive molecule, Ondanacatib inhibits cathepsin K, acts on
osteoclasts
•Glucagon-like Peptide 2
intestinal polypeptide hormone , Bone resorption activity peaks
overnight; therefore, treatment with GLP-2 at bedtime will
achieve a substantial reduction in the bone resorption
•Monoclonal Antibodies
Regulates Bone cell pathophysiology
Drug action is monitored with C Telopeptide [CTx] a marker of bone resorption
And Osteocalcin a marker of bone formation

55. Osteoporosis –Treatment
How Long to Treat?
Optimal duration of treatment in women with
postmenopausal osteoporosis is unknown
Is prolonged treatment safe ?
Long term effects of chronically reduced bone
turnover: could skeletal health and repair mechanisms
be impaired?
Does long term beneficial antifracture efficacy require
long term use?

56. Effect of 3 vs. 6 Years of Annual
Zoledronic Acid Treatment
1233 postmenopausal women who received ZOL for 3 years
randomized to 3 additional years of ZOL or placebo (Z6 vsZ3P3)
In years 3-6 FN BMD remained constant with Z6 and dropped
slightly in Z3P3 (1.04%, p < 0.001)
Markers rose slightly in Z3P3 group but remained below
pretreatment levels
New morphometricvertebral fractures lower in Z6 vsZ3P3 but other
fractures were not different
Black, et. al., JBMR, 2012; 27, 243-254
“..after 3 years of annual ZOL, many patients may discontinue
therapy up to 3 years. However, vertebral fracture reductions
suggest that those at high fracture risk particular vertebral
fracture, may benefit by continued treatment.”

57. Bisphosphonates Have Been Reported
to Have Other Beneficial Effects
Decreased risk of breast cancer
1-5
Decreased risk of colorectal cancer
6
Decreased risk of stroke
7
Reduced risk of gastric cancer
8
Decreased overall mortality
9,10

58. Bisphosphonate Summary
Bisphosphonates appear to be safe and effective when
used long-term
Prolonged reduction of bone remodeling may be
associated with atypical femur fractures
Osteonecrosisof the jaw associated with bisphosphonate
treatment is rare when BPs are used in osteoporotic
patients
“Further investigation into the benefits and risks of long-
term therapy, as well as surveillance of fracture risk after
discontinuation of bisphosphonatetherapy, will be crucial
for determining the best regimen of treatment for
individual patients with osteoporosis.”
1
1
Whitaker, et. al, NEJM, 2012; 366:22, 2048-2051

59. THE TIP OF THE ICEBERG
ASSESSMENT
MANAGEMENT

60. Summary
The different therapeutic options include several anti-
resorptivedrugs and more recently new anabolic compounds
Bisphosphonates reduce fracture risk for vertebral and non-
vertebral fractures
Anti-fracture efficacy is already evident after one year of
treatment
Raloxifene(SERM) has skeletal effects similar to those of
estrogen and reduces vertebral fracture risk
Parathyroid hormone treatment induces significant increases
in bone mass and decreases fracture risk. Used as last resort
and those extreme cases with advanced osteoporosis and
already with Fragility fractures
In postmenopausal women with low bone mass, denosumab
(RANKL-Ab) increases bone mass and decreases bone
resorptionand reduces fracture risk

61. Thanks