PHARMACOTHERAPY SELF-ASSESSMENT PROGRAM

2025 ▪ BOOK 2

Geriatrics

SERIES EDITORS

Cynthia A. Sanoski, Pharm.D., FCCP, BCPS

Daniel M. Witt, Pharm.D., FCCP, BCPS
 PHARMACOTHERAPY SELF-ASSESSMENT PROGRAM

PSAP Series Editors

Cynthia A. Sanoski, Pharm.D., FCCP, BCPS, Associate Dean of Student Affairs and Professor
of Instruction, University of Iowa College of Pharmacy, Iowa City, Iowa

Daniel M. Witt, Pharm.D., FCCP, BCPS, Professor and Chair, Department of

Pharmacotherapy, Assistant Dean of Clinical Affairs, University of Utah College of Pharmacy,
Salt Lake City, Utah

The PSAP Series Editors design each year’s releases by drawing from the domains, tasks, and knowledge statements in the BPS
Pharmacotherapy Specialist Certification Content Outline/Classification System. Working with a Faculty Panel Chair (guest editor), the
Series Editors refine the list of chapters and features so that only the most relevant topics are updated in each release. Members of the
faculty panel collaborate on the content outline for each chapter and feature, ensuring a complete review of published evidence on
that clinical topic. Generalist BCPS reviewers join the editorial process to enhance the material’s appropriateness for the recertifying
audience. The result is an evidence-based update that can be used to self-assess clinical skills and improve patient outcomes.

New for 2025!

• Second-Chance Posttest Option Visit the ACCP Store at
• Complete single chapters/features for credit [Link]/store

Recertification ACPE Minimum

PSAP Release Content Planned Release Date
Deadline Deadline Hours
PSAP 2025 Book 1 Cardiology Jan. 15, 2025 Jul. 15, 2025 Jan. 15, 2028 12.0

PSAP 2025 Book 2 Geriatrics May 15, 2025 Nov. 14, 2025 May 15, 2028 12.0

Behavioral Health and

PSAP 2025 Book 3 Sep. 15, 2025 Mar. 13, 2026 Sep. 15, 2028 12.0
Pediatrics

Endocrinology and
PSAP 2026 Book 1 Jan. 15, 2026 Jul. 15, 2026 Jan. 15, 2029 12.0
Nephrology

Critical Care/
PSAP 2026 Book 2 May 15, 2026 Nov. 13, 2026 May 15, 2029 12.0
Emergency Medicine

Pulmonary and
PSAP 2026 Book 3 Sep. 15, 2026 Mar. 15, 2027 Sep. 15, 2029 12.0
Gastrointestinal

PSAP 2027 Book 1 Infectious Diseases Jan. 15, 2027 Jul. 15, 2027 Jan. 15, 2030 12.0

Hematology and
PSAP 2027 Book 2 May 17, 2027 Nov. 17, 2027 May 17, 2030 12.0
Oncology

Neurology and
PSAP 2027 Book 3 Sep. 15, 2027 Mar. 15, 2028 Sep. 15, 2030 12.0
Chronic Diseases

ACCP’s Self-Assessment Programs are home study series that provide clinical
pharmacists with pertinent therapeutic updates to enhance their practice skills
and improve patient outcomes.
The American College of Clinical Pharmacy is approved by BPS as a provider for the
recertification of BCPS. ®
IMPORTANT INFORMATION ON THE RELEASE
OF PSAP 2025 Book 2 (Geriatrics)

Book Formats and Content

Online book: All purchasers of this PSAP release have access to the online book (interactive PDFs). To access, go to [Link]
and sign into your My Account page using your e-mail address and password (technical assistance is available). Scroll down to
find your book and the required posttests under My Products. The online book can be saved to the desktop or printed. The latest
version of Adobe Acrobat Reader (available free) offers functionality such as highlighting or adding “sticky notes” to the text.

E-Media book: All purchasers also have access to the e-media version. Follow these instructions to load the text and
self-assessment questions in this book onto your e-reader, tablet, or Android phone.

PSAP Audio Companion: All purchasers also have access to the PSAP Audio Companion. Follow these instructions to load these
files onto an MP3 player.

Print books: If you have purchased a print version of this book, it will be delivered on or near the release date to the address of
record on your ACCP account. If you have not received the print book within 1 week of the release date, contact customer service
by e-mailing accp@[Link]. NOTE: The online book may be updated after the print book goes to press. Before submitting
a posttest, please check the online errata ([Link] for the presence of updates.

Hyperlinks: To facilitate further learning and research, this publication incorporates hyperlinks to websites administered by other
organizations. Internal and external hypertext links are visible as underlined text in the print book and are active in the Online and
e-Media versions of the book. NOTE: ACCP assumes no liability for material downloaded from or accessed on these websites.

Abbreviations, Laboratory Values: At the start of each chapter/feature are hyperlinks to tables with selected medical abbrevi-
ations and reference ranges for common laboratory tests. These tables can be used as a resource in reading the material and
completing the self-assessment questions.

NOTE: The editors and publisher of PSAP recognize that the development of this volume of material offers many opportunities for
error. Despite our best efforts, some errors may persist into publication. Drug dosage schedules are, we believe, accurate and in
accordance with current standards. Readers are advised, however, to check package inserts for the recommended dosages and
contraindications. This is especially important for new, infrequently used, and highly toxic drugs.
Director, Professional Development and Marketing: Joanna Gillette, B.A.
Director, ACCP Career Development Programs: Keri A. Sims, Pharm.D., BCPS
Senior Managing Editor: Edward Alderman, B.S., B.A.
Managing Editor: Peter Burns, B.A.
Senior Medical Editor: Kimma Sheldon-Old, Ph.D.
Director, Information Technology: Brent Paloutzian, A.A.S.

For ordering information or questions, e-mail: accp@[Link]

PSAP 2025 Book 2 (Geriatrics)

Library of Congress Control Number: 9781964074184
ISBN-13s: 978-1-964074-18-4 (print); 978-1-964074-19-1 (eBook)

Print versions are produced in the United States of America.

To cite PSAP properly:

Chapter authors. Chapter name. In: Sanoski CA, Witt DM, eds. Pharmacotherapy Self-Assessment Program, 2025 Book 2.
Geriatrics. Lenexa, KS: American College of Clinical Pharmacy, 2025:page range.

PSAP™ is a registered trademark of the American College of Clinical Pharmacy.

Pharmacotherapy
Self-Assessment
Program

Copyright ©2025 by the American College of Clinical Pharmacy. All rights reserved. This book is protected by copyright. No part of
this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic or mechan-
ical, including photocopy, without prior written permission of the American College of Clinical Pharmacy. NOTE: Purchasers of this
ACCP product may have one copy of the PDF printed for their personal educational use.
Continuing Pharmacy Education and
Recertification Instructions
TESTING

Book Release Date: May 15, 2025

BCPS test deadline: 11:59 p.m. (Central) on November 14, 2025
ACPE test deadline: 11:59 p.m. (Central) on May 15, 2028

Before submitting a posttest: Check the online errata for any changes or updates to this Pharmacotherapy Self-Assessment
Program release. You may complete one or all available elements for credit. Submitting a required posttest for BCPS recertifica-
tion attests that you have completed the test as an individual effort and not in collaboration with any other individual or group.
Failure to complete this test as an individual effort may jeopardize your ability to use PSAP for BCPS recertification.

PSAP Target Audience: The target audience for PSAP 2025 Book 2 (Geriatrics) includes geriatric pharmacotherapy specialists
and advanced-level clinical pharmacists providing care for older adults with common health conditions associated with aging,
especially as it relates to goals of care and end-of-life care considerations.

Available CPE credits: Purchasers who successfully complete all posttests for PSAP 2025 Book 2 (Geriatrics) can earn
16.0 contact hours of CPE credit. The universal activity numbers are as follows:

Learning Activity Learning Objectives ACPE Activity Number CPE (Hr)

Chapter: 1. Evaluate risk factors for osteoporosis and recommend 0217-0000-25-065-H01-P 2.5
Osteoporosis prevention strategies.
2. Distinguish differences among guideline recommendations for
screening and treatment of osteoporosis in men and women.
3. Assess pharmacotherapy options for osteoporosis prevention
and treatment in both men and women.
4. Develop a patient-specific osteoporosis treatment plan,
including appropriate monitoring to assess safety and efficacy.
Chapter: 1. Classify patient signs and symptoms consistent with 0217-0000-25-066-H01-P 2.0
Parkinson’s Parkinson disease (PD).
Disease 2. Design a therapeutic treatment plan for managing motor and
nonmotor symptoms of PD.
3. Assess the role of complementary and alternative medicine in
PD.
4. Evaluate the impact of care transitions on patients with PD.
5. Distinguish new treatment modalities for PD.
Chapter: Gout 1. Assess a patient profile for gout and gout-related 0217-0000-25-067-H01-P 1.5
complications.
2. Develop lifestyle modification plans to aid patients in
managing gout.
3. Design treatment plans for the acute management of a gout
flare.
4. Assess a patient profile to initiate or adjust urate-lowering
therapy for the chronic management of gout.
5. Create monitoring parameters to evaluate the efficacy of a
pharmacotherapy regimen for gout management.

(continued)
Learning Activity Learning Objectives ACPE Activity Number CPE (Hr)

Chapter: 1. Apply recommendations for the treatment of osteoarthritis 0217-0000-25-068-H01-P 2.0

Osteoarthritis (OA) current guidelines based on strength of evidence.
2. Devise an appropriate, patient-specific, nonpharmacologic
treatment plan for the management of OA.
3. Design a pharmacologic treatment plan in accordance with
current practice guidelines for an older adult with OA.
4. Develop recommendations to mitigate potential harm
associated with OA treatment in older adults.
5. Evaluate the potential place in OA treatment of complementary,
integrative, and emerging treatment options based on the
available evidence.
Recorded Webcast: 1. Apply the tenets and process for deprescribing a medication 0217-0000-25-069-H01-P 2.0
Deprescribing in to a case involving an older adult with multimorbidity.
the Older Adult 2. Distinguish myths associated with deprescribing that can affect
outcomes.
3. Given a clinical scenario, develop appropriate communication
strategies to address patient and caregiver concerns about
medication deprescribing.
4. Design a plan for deprescribing for an older adult with
multimorbidity.
Chapter: Palliative 1. Distinguish between the eligibility for and services offered by 0217-0000-25-070-H01-P 1.5
and End-of-Life palliative and hospice care.
Care 2. Develop person-centered care goals for an individual in
regard to end-of-life.
3. Analyze treatment considerations for management of
symptoms addressed in palliative and hospice care.
4. Devise a care plan for an individual receiving palliative or
hospice care that maximizes quality of life.
5. Recommend support mechanisms for all individuals involved
in end-of-life care, including the patient, family/caregivers and
health care professionals.
Chapter: 1. Evaluate older patients for the etiology, epidemiology, risk 0217-0000-25-071-H01-P 2.0
Immunizations in factors, and complications of common vaccine-preventable
Older Adults diseases.
2. Account for the impact of aging on vaccine response when
recommending immunizations for older adults.
3. Analyze the safety and effectiveness of vaccines indicated for
older adults to prevent influenza, respiratory syncytial virus,
pneumococcal disease, and shingles.
4. Design an immunization regimen for an older adult based on
age and comorbid conditions.
5. Resolve barriers to immunization for older adults.
Chapter: 1. Analyze an older adult’s care transition between different 0217-0000-25-072-H01-P 2.5
Transitions of care contexts on the basis of evidence-based principles of
Care safety and person-centered care.
2. Distinguish the different systems of care affecting care
transitions for older adults.
3. Evaluate community-based systems of care to support care
transitions for older adults.
4. Evaluate the type and impact of pharmacist-driven interventions
on care transition outcomes across practice settings.
5. Develop pharmacologic and nonpharmacologic therapy plans to
mitigate the risk of medication-related harm at care transition.
TO EARN CPE CREDITS FROM THIS PSAP BOOK

Posttest access: Go to [Link] and sign in with your e-mail address and password. Technical support is available from 8 a.m.
to 5 p.m. (Central) weekdays by calling (913) 492-3311. PSAP products are listed under My Products on your My Account page.

BCPS Recertification Credit: To receive BCPS recertification credit, a PSAP posttest must be submitted within the
6-month period after the book’s release (see above). Only completed tests are eligible for credit; no partial or incom-
plete tests will be processed. You may complete one or all available learning activities for credit.

The passing point to earn BCPS recertification credit is based on an expert analysis of the assessment items in each posttest module.
Any posttest submitted before the BCPS test deadline that meets this passing point will earn BCPS recertification credits. These
credits will be assigned as of the date of test submission and reported within 48 hours to BPS. For statements of recertification
credit, visit [Link].

Remediation: In accordance with BPS guidelines concerning remediation for products launched in 2024 and after, posttests that do
not reach the passing point for recertification credit will generate a second-chance test option. This test will automatically appear
in the learner’s My Account page and will have assessment items presented in a different order. To qualify for recertification credit,
the second-chance test must be submitted before the recertification posttest deadline stated above.

BCPS Recertification: The ACCP Recertification Dashboard is a free online tool that can track recertification credits as they are
earned through ACCP and schedule new opportunities for credits from upcoming ACCP professional development programs.
Questions regarding the number of hours required for BCPS recertification should be directed to BPS at [Link].

ACPE CPE Credit: To receive ACPE CPE credit for a PSAP module, a posttest must be submitted within 3 years after the book’s
release (see above). Only completed tests are eligible for credit; no partial or incomplete tests will be processed. You may complete
one or all available learning activities for credit. Any posttest submitted before the ACPE deadline that scores 50% or greater will be
awarded the appropriate CPE. These credits will be assigned as of the date of test submission and reported within 48 hours. For
statements of CPE credit, visit [Link].

Posttest answers: The explained answers for each learning activity – with rationale and supporting references – will be posted
2 weeks after the recertification posttest deadline and will be available on the My Account page to anyone who has either
(1) submitted a posttest or (2) waived the right to receive credit from a posttest. Go to [Link] and sign in with your
e-mail address and password. By completing the waiver form, you waive the opportunity to receive CPE credit for that module.

Continuing Pharmacy Education Credit: The American College of Clinical Pharmacy is accredited by the Accreditation
Council for Pharmacy Education as a provider of continuing pharmacy education.

The American College of Clinical Pharmacy is approved by the Board of Pharmacy Specialties as a
provider for the recertification of BCPS.

BPS is an autonomous division of the American Pharmacists Association. To maintain its strict, inde-
pendent standards for certification, BPS does NOT endorse or provide review information, preparatory
courses, or study guides for board certification examinations. BPS, through its specialty councils, is
responsible for specialty examination content, administration, scoring, and all other aspects of its
certification programs. BPS is totally separate and distinct from ACCP. For information about BPS
specialty recertification the BPS recertification process, go to: [Link]
PSAP 2025 Book 2 (Geriatrics) Faculty Panel
Series Editors: Disclosures: ACCP Staff/Series Leaders
Cynthia A. Sanoski, Pharm.D., FCCP, BCPS Consultancies: Mary Bridgeman (Pharmacy Times
Associate Dean of Student Affairs PTCE Advisory Board, ProCE, Clinical Care Options);
Professor of Instruction Daniel Witt (Roche Diagnostics)
University of Iowa College of Pharmacy Grants: Daniel Witt (Agency for Health Research
Iowa City, Iowa and Quality, Roche Diagnostics)
Daniel M. Witt, Pharm.D., FCCP, BCPS Other: Mary Bridgeman (Spouse or significant other
employed by Bristol Myers Squibb)
Professor and Chair
Department of Pharmacotherapy Nothing to disclose: Ed Alderman, Peter Burns,
Assistant Dean of Clinical Affairs Joanna Gillette, Brent Paloutzian, Cynthia Sanoski,
University of Utah College of Pharmacy Kimma Sheldon-Old, Keri Sims
Salt Lake City, Utah

Faculty Panel Chair:

Mary Barna Bridgeman, Pharm.D., FASCP,
FCCP, FNAP, BCPS, BCGP
Clinical Professor
Department of Pharmacy Practice and Administration
Ernest Mario School of Pharmacy
Rutgers, The State University of New Jersey
Piscataway, New Jersey
Internal Medicine Pharmacist
Pharmacy Department
Robert Wood Johnson University Hospital-New Brunswick
New Brunswick, New Jersey

Note: All relevant financial relationships listed for these individuals have been mitigated.

Note: Any views, thoughts, or opinions expressed by authors and reviewers in this publication do not necessarily reflect the
faculty member’s employer, organization, committee, or other group or individual.
Learning Activity Authors Reviewers Disclosures

Chapter: Osteoporosis Marissa C. Salvo, Pharm.D., FCCP, Mary L. Wagner, Pharm.D., MS, NBHWC Carol Heunisch: Nothing
BCACP Clinical Pharmacists to disclose
Associate Clinical Professor Department of Pharmacy Practice and Diane Gutgsell: Nothing
Department of Pharmacy Practice Administration to disclose
University of Connecticut School Ernest Mario School of Pharmacy Christina M. Polomoff:
of Pharmacy Rutgers, The State University of New Nothing to disclose
Storrs, Connecticut Jersey Marissa C. Salvo:
Piscataway, New Jersey Nothing to disclose
Christina M. Polomoff, Pharm.D., Mary L Wagner: Nothing
FASCP, BCACP, BCGP Carol Heunisch, Pharm.D., BCPS, BCCP to disclose
Associate Clinical Professor Pharmacy Director, Drug Policy and
University of Connecticut School Education
of Pharmacy Department of Pharmacy
Storrs, Connecticut Endeavor Health
Evanston, Illinois

Diane Gutgsell, Pharm.D., BCPS,

BC-ADM, CHC
Assistant Professor of Pharmacy
Practice
College of Pharmacy
Manchester University College of
Health Sciences, Nursing, & Pharmacy
Ambulatory Care Clinical Pharmacist
Neighborhood Health Clinics
Fort Wayne, Indiana
Chapter: Parkinson’s Jessica A. Bente, Pharm.D., MBA, Laura Meyer-Junco, Pharm.D., FASCP, Jessica A. Bente:
Disease BCPS, BCGP BCPS, CPE Honoraria (Bristol
Assistant Director of Pharmacy for Clinical Assistant Professor Myers Squibb)
Clinical Services Clinical Pharmacist, Hospice, Palliative Laura Meyer-Junco:
Department of Pharmacy Care, and Geriatrics Consultancies (Haleon
Cooperman Barnabas Medical Herbert M. and Carol H. Retzky College Consumer Health)
Center of Pharmacy Megan Farrell: Nothing
Livingston, New Jersey University of Illinois Chicago to disclose
Rockford, Illinois Michelle Maynard:
Ljubica Minova, Pharm.D., BCGP Honoraria (EMD
Geriatrics Clinical Pharmacist Michelle Maynard, Pharm.D., BCPS Serono, Amgen)
PGY2 Geriatric Pharmacy Ambulatory Neurology Pharmacist Ljubica Minova: Nothing
Residency Program Director Froedtert & the Medical College of to disclose
Cooperman Barnabas Medical Wisconsin Neurosciences Clinic
Center Milwaukee, Wisconsin
Livingston, New Jersey
Megan Farrell, Pharm.D., BCPS
Acute Care Clinical Pharmacist
Department of Pharmacy
Dignity Health – St. Rose Dominican
Health
Henderson, Nevada

(continued)
Learning Activity Authors Reviewers Disclosures

Chapter: Gout Jarred Prudencio, Pharm.D., Kristen Cook, Pharm.D., BCACP Kristen M. Cook:
BCACP, BC-ADM Clinical Associate Professor Nothing to disclose
Associate Professor Department of Pharmacy Practice and Alisa K. Escano: Nothing
Department of Pharmacy Practice Science to disclose
University of Hawaii at Hilo University of Nebraska Medical Center Jarred Prudencio:
Hilo, Hawaii College of Pharmacy Consultancies
Omaha, Nebraska (Board of Pharmacy
Specialties –
Alisa K. Escano, Pharm.D., BCPS Ambulatory Care
Assistant Professor Specialty Council)
VCU School of Pharmacy James Yau Hon Voo:
Falls Church, Virginia Nothing to disclose

James Yau Hon Voo, [Link]

(ClinPharm), BCPS
Lead Antimicrobial Stewardship
Pharmacist
Pharmacy Department
Sabah Women and Children Hospital
Kota Kinabalu, Sabah
Chapter: Osteoarthritis M. Thomas Bateman Jr., Pharm.D., Tasha Woodall, Pharm.D., BCGP M. Thomas Bateman Jr.:
BCACP Co-Director, MAHEC Center for Healthy Grants (Merck & Co.,
Clinical Assistant Professor Aging Inc)
Pharmacy Practice and Department of Pharmacy Sherrill Brown:
Administration Mountain Area Health Education Consultancies
Ernest Mario School of Pharmacy Center (Montana Medicaid
Rutgers, The State University of Asheville, North Carolina DUR Board, APhA
New Jersey Editorial Advisory
Piscataway, New Jersey Alifiya F. Hyderi, Pharm.D., MBA, BCPS Board);
Lead Clinical Pharmacist Clinical Pharmacy Specialist Jeffrey Gonzales: Stock
PGY2 Ambulatory Care Residency Inpatient Pharmacy ownership (Johnson
Program Director Rush University Medical Center and Johnson, Pfizer);
Pharmacy Department Chicago, Illinois Honoraria (Pharmacy
Henry J. Austin Health Center Times, Placebo, LLC,
Trenton, New Jersey Jeffrey Gonzales, Pharm.D., BCPS, APhA)
CDCES, PDE-C, DPLA Alifiya F Hyderi: Nothing
Caitlin McCarthy, Pharm.D., BCPP Ambulatory and Population Health to disclose
Clinical Associate Professor Clinical Pharmacy Specialist Caitlin E. McCarthy:
Pharmacy Practice and Trinity Health Consultancies (Henry
Administration Newtown Square, Pennsylvania J. Austin Health Center,
Ernest Mario School of Pharmacy APhA, AAPP); Grants
Rutgers, the State University of Sherrill Brown, DVM, Pharm.D., BCPS (Merck & Co., Inc.,
New Jersey Professor Health Resources
Piscataway, New Jersey Department of Pharmacy Practice and Services
University of Montana, Skaggs School Administration:
of Pharmacy Honoraria (ASHP, The
Missoula, Montana College of New Jersey)
Tasha Woodall: Nothing
to disclose

(continued)
Learning Activity Authors Reviewers Disclosures

Recorded Webcast: Ryan C. Costantino, Pharm.D., MS, Chanel F. Whittaker, Pharm.D., FASCP, Ahmad El Ouweini:
Deprescribing in the BCPS, BCGP BCGP Nothing to disclose
Older Adult Assistant Professor Professor Jennifer Szwak:
Department of Anesthesiology Associate Dean for Institutional Consultancies
Uniformed Services University Excellence and Engagement (Petauri);
Bethesda, Maryland Department of Practice, Sciences, and Ryan C. Costantino:
Health Outcomes Research Grants (Department
Director of Health Equity in Aging of Defense); Honoraria
The Peter Lamy Center on Drug (Oncology Nurses
Therapy and Aging Society (Oahu) Chapter)
University of Maryland School of Chanel F. Whittaker:
Pharmacy Consultancies
Baltimore, Maryland (American Geriatrics
Society); Grants
Ahmad El Ouweini, Pharm.D., BCPS, (University of Maryland
FCPR-CC System – Kirwin
Critical Care Clinical Pharmacist Center for Academic
Department of Pharmacy Practice Innovation)
Gulf Medical University
Clinical Lecturer
Thumbay University Hospital
Ajman, United Arab Emirates

Jennifer A. Szwak, Pharm.D., FCCP,

BCPS
Clinical Pharmacy Specialist, Internal
Medicine
Department of Pharmacy
The Johns Hopkins Hospital
Baltimore, Maryland
Chapter: Palliative and Rebecca J. Mahan, Pharm.D., Nicole Genovese, Pharm.D., BCGP Nicole Genovese:
End-of-Life Care FASCP, BCGP, BCACP Clinical Pharmacist Practitioner Nothing to disclose
Associate Professor Veterans Affairs New Jersey Kala Squires: Nothing to
Department of Pharmacy Practice- Healthcare System disclose
Geriatrics Division East Orange, New Jersey Jessica B. Emshoff:
Jerry H Hodge School of Pharmacy Consultancies
Vice Chair of Experiential Programs Kala Squires, Pharm.D., BCPS (Board of Pharmacy
Texas Tech University Health Clinical Pharmacist Specialties Geriatric
Sciences Center Department of Pharmacy Specialty Council)
Abilene, Texas Sierra Medical Center Rebecca Mahan:
Reno, Nevada Consultancies (ASCP/
APhA BCGP Content
Jessica Boss Emshoff, Pharm.D., Advisory Committee)
BCPS, BCGP
Professor of Pharmacy Practice
Department of Pharmacy Practice
College of Pharmacy
Northeast Ohio Medical University
Rootstown, Ohio

(continued)
Learning Activity Authors Reviewers Disclosures

Chapter: Immunizations Kaitlyn R. Rivard, Pharm.D., BCIDP Michael R. Brodeur, Pharm.D., FASCP, Michael R. Brodeur:
in Older Adults Infectious Diseases Clinical FNAP, BCGP Consultancies (Capital
Pharmacist Professor of Pharmacy District Physician
Department of Pharmacy Residency and Program Director PGY2 Health Plan)
Cleveland Clinic Geriatric Pharmacy A. Joshua Mosteller:
Cleveland, Ohio Department of Pharmacy Practice Nothing to disclose
Albany College of Pharmacy and Tom Achey Nothing to
Health Sciences disclose
Albany, New York Kaitlyn R. Rivard:
Consultancies (Pfizer
A. Joshua Mosteller, Pharm.D., BCPS Inc, Office Hours)
Pediatric Clinical Pharmacist
Department of Pharmacy
Atrium Health – Levine Children’s
Hospital
Charlotte, North Carolina

Thomas S. Achey, Pharm.D., MS, BCPS

Associate Professor
Department of Clinical Sciences
Fred Wilson School of Pharmacy
at High Point University
High Point, North Carolina
Chapter: Transitions of Julie B. Cooper, Pharm.D., BCPS, Maria Shin, Pharm.D., BCGP, BCPS Julie Bates Cooper:
Care BCCP Clinical Pharmacist Practitioner, Grants (American
Chair and Associate Professor Internal Medicine Association of Colleges
Department of Clinical Sciences Acute and Specialty Care Pharmacy of Pharmacy, American
Fred Wilson School of Pharmacy Robley Rex VA Medical Center Society of Health-
High Point, North Carolina Louisville, Kentucky System Pharmacists)
Ashley Heil: Nothing to
Hailey Soni, Pharm.D., BCPS disclose
Clinical Assistant Professor/Clinical Maria Shin:
Pharmacist Consultancies (ASHP):
Department of Pharmacy Practice Honoraria (Sullivan
University of Illinois Retzky College of University College of
Pharmacy Pharmacy)
Chicago, Illinois Hailey Soni: Stock
Ownership (Abbott
Ashley Heil, Pharm.D., BCPS, BCOP Laboratories)
Hematology/Oncology Clinical
Pharmacist Specialist
Avera McKennan Hospital & University
Health Center
Sioux Falls, South Dakota
TABLE OF CONTENTS
Chapter: Osteoporosis Chapter: Osteoarthritis
By Marissa C. Salvo, Pharm.D. , FCCP, BCACP; By M. Thomas Bateman Jr., Pharm.D., BCACP; and Caitlin McCarthy,
and Christina M. Polomoff, Pharm.D., FASCP, BCACP, BCGP Pharm.D., BCPP

Introduction ����������������������������������������������������������������������������������������� 1 Introduction����������������������������������������������������������������������������������������� 73

Risk Factors ����������������������������������������������������������������������������������������� 2 Diagnosis, Assessment, and Therapy Goals ��������������������������������� 73

Prevention �������������������������������������������������������������������������������������������� 3 Review of Practice Guidelines ��������������������������������������������������������� 74

Diagnostic Evaluation ������������������������������������������������������������������������� 5 Nonpharmacologic Therapy������������������������������������������������������������� 76

Guideline Recommendations ������������������������������������������������������������� 8 Pharmacologic Therapy ������������������������������������������������������������������� 80

Pharmacotherapy ����������������������������������������������������������������������������� 13 Safe Prescribing Practices��������������������������������������������������������������� 83

Conclusion ����������������������������������������������������������������������������������������� 22 Emerging Evidence����������������������������������������������������������������������������� 84

References ����������������������������������������������������������������������������������������� 22 Conclusion������������������������������������������������������������������������������������������ 86

Self-Assessment Questions������������������������������������������������������������� 27 References ����������������������������������������������������������������������������������������� 87

Self-Assessment Questions������������������������������������������������������������� 89
Chapter: Parkinson Disease
By Jessica A. Bente, Pharm.D., MBA, BCPS, BCGP; Recorded Webcast: Deprescribing in the
and Ljubica Minova, Pharm.D., BCGP Older Adult
Introduction ��������������������������������������������������������������������������������������� 31 By Ryan C. Costantino, Pharm.D., MS, BCPS, BCGP

Diagnosis and Disease Progression ����������������������������������������������� 31 Recorded Webcast: Deprescribing in the Older Adult������������������� 93
Treatment Strategies and Goals������������������������������������������������������� 34 References ����������������������������������������������������������������������������������������� 94
Complementary and Alternative Medicine in PD��������������������������� 42 Self-Assessment Questions������������������������������������������������������������� 97
Risks of Care Transitions for Patients with PD ����������������������������� 43
Chapter: Palliative and End-of-Life Care
New Treatments ������������������������������������������������������������������������������� 45
By Rebecca J. Mahan, Pharm.D., FASCP, BCGP, BCACP
Conclusion ����������������������������������������������������������������������������������������� 46
Introduction��������������������������������������������������������������������������������������� 101
References ����������������������������������������������������������������������������������������� 46
Establishing Goals and Expectations ������������������������������������������� 103
Self-Assessment Questions������������������������������������������������������������� 50
Symptom Management������������������������������������������������������������������� 105

Chapter: Gout Creating a Treatment Plan��������������������������������������������������������������� 108

By Jarred Prudencio, Pharm.D., BCACP, BC-ADM Support Plans����������������������������������������������������������������������������������� 110
Disease Overview ����������������������������������������������������������������������������� 55 Conclusion�����������������������������������������������������������������������������������������111
Diagnostics and Clinical Presentation ������������������������������������������� 56 References ����������������������������������������������������������������������������������������111
Nonpharmacologic Considerations ����������������������������������������������� 58 Self-Assessment Questions����������������������������������������������������������� 113
Acute Gout Attacks ��������������������������������������������������������������������������� 59
Chapter: Immunizations in Older Adults
Chronic Management of Gout ��������������������������������������������������������� 63
By Kaitlyn R. Rivard, Pharm.D., BCIDP
Role of the Pharmacist ��������������������������������������������������������������������� 66
Introduction��������������������������������������������������������������������������������������� 117
Conclusion ����������������������������������������������������������������������������������������� 67
Aging and the Immune System������������������������������������������������������� 120
References ����������������������������������������������������������������������������������������� 68
Centers for Disease Control and Prevention-
Self-Assessment Questions������������������������������������������������������������� 69 Recommended Vaccines����������������������������������������������������������������� 121

PSAP 2025 Book 2 • Geriatrics xi Table of Contents

 Overcoming Barriers to Immunization in Older Adults��������������� 133 Systems of Care Affecting Care Transitions ������������������������������� 149

Conclusion���������������������������������������������������������������������������������������� 135 Community Systems of Care Benefiting Older Adults���������������� 152

References ��������������������������������������������������������������������������������������� 135 Pharmacy-Led Interventions During Care Transitions

for Older Adults��������������������������������������������������������������������������������� 154
Self-Assessment Questions����������������������������������������������������������� 140
Pharmacotherapeutic Considerations for Safe
Care Transitions������������������������������������������������������������������������������� 156
Chapter: Transitions of Care
Conclusion���������������������������������������������������������������������������������������� 163
By Julie B. Cooper, Pharm.D., BCPS, BCCP
References ��������������������������������������������������������������������������������������� 163
Introduction��������������������������������������������������������������������������������������� 143
Self-Assessment Questions����������������������������������������������������������� 169
Epidemiology of Care Transitions for Older Adults��������������������� 144

Patient and Caregiver Perspectives at the Older

Adult Care Transition����������������������������������������������������������������������� 148

PSAP 2025 Book 2 • Geriatrics xii Table of Contents

Chapter: Osteoporosis
By Marissa C. Salvo, Pharm.D. , FCCP, BCACP; and Christina M. Polomoff,
Pharm.D., FASCP, BCACP, BCGP

Reviewed by Mary L Wagner, Pharm.D., MS, NBHWC; Carol Heunisch, Pharm.D., BCPS, BCCP;
and Diane Gutgsell, Pharm.D., BCPS, BC-ADM, CHC

LEARNING OBJECTIVES

1. Evaluate risk factors for osteoporosis and recommend prevention strategies.

2. Distinguish differences among guideline recommendations for screening and treatment of osteoporosis in men and
women.
3. Assess pharmacotherapy options for osteoporosis prevention and treatment in both men and women.
4. Develop a patient-specific osteoporosis treatment plan, including appropriate monitoring to assess safety and efficacy.

INTRODUCTION
ABBREVIATIONS IN THIS CHAPTER
Osteoporosis is a pervasive skeletal disorder characterized by
AACE American Association of Clinical
Endocrinologists decreased bone density and structural deterioration of bone tissue,
ACE American College of Endocrinology predisposing individuals to bone fragility and fractures. The disease
BMD Bone mineral density is a major public health concern because of its prevalence, affecting
DXA Dual-energy x-ray absorptiometry an estimated 500 million people globally, contributing to significant
morbidity, mortality, and health care costs (International Osteoporo-
FRAX Fracture Risk Assessment tool
sis Foundation [IOF] 2023). In the United States, an estimated 10 mil-
ISCD International Society for Clinical
Densitometry lion people older than 50 years have osteoporosis, about 2 million of
PTH Parathyroid hormone whom are men (Healthy People 2030 2025).
USPSTF U.S. Preventative Services Task
Force Epidemiology
The epidemiology of osteoporosis exposes notable differences
Table of other common abbreviations. between men and women, attributable to a combination of genetic,
hormonal, and lifestyle factors. The incidence of osteoporosis is sig-
nificantly higher in women, particularly those postmenopausal, and is
attributable to the decline in estrogen concentrations, which are cru-
cial for maintaining bone density (Vilaca 2022).

Differences Between Men and Women

More than 50% of postmenopausal White women experience an oste-
oporotic fracture in their lifetime, comparted with 20% of White men
(Porter 2023; Vilaca 2022). Although men generally have a higher peak
bone mass compared with females, the gradual decline in testoster-
one concentrations as they age contributes to bone loss and height-
ened fracture risk (Vilaca 2022). Compared with White individuals,
Black men and women have a lower incidence of osteoporosis (Porter
2023). A meta-analysis of White individuals within the United States
showed a higher fracture risk compared with those in other racial/
ethnic groups. The reduction in risk was most pronounced among

PSAP 2025 Book 2 • Geriatrics 1 Chapter: Osteoporosis

Black individuals, followed by a moderate decrease in Hispan- (DXA) in women leads to earlier diagnosis and intervention.
ics and Asian Americans, with the smallest reduction noted in Conversely, men are often under-screened and underdiag-
American Indians (Bao 2023). nosed, partly because of the misconception that osteoporo-
sis is predominantly a female disease (De Martinis 2021). In
Disparities in Screening and Treatment addition, although the overall prevalence of fragility fractures
Despite the high prevalence of osteoporosis in both sexes, is lower in men, they have higher rates of fracture-related
there are notable disparities in screening and treatment. mortality (IOF 2023). Of note, there can be variability in DXA
Female individuals are more likely to be screened for osteopo- screening because reporting T-scores from nondiagnostic
rosis because of the higher awareness of their risk, particularly sites can lead to confusion and inappropriate prescribing of
for postmenopausal women. Testing for bone mineral density treatment (Kim 2022). Furthermore, there are often barriers to
(BMD) more often using dual-energy x-ray absorptiometry osteoporosis screening, including patient nonadherence, cost
concerns among physicians and patients, limited time during
clinic visits, and low prioritization of screening (Choksi 2023).
Treatment disparities are also evident because women are
BASELINE KNOWLEDGE STATEMENTS
more likely to receive pharmacologic therapies, including bis-
Readers of this chapter are presumed to be familiar phosphonates, parathyroid hormone analogs, and selective
with the following: estrogen receptor modulators. In contrast, men are less often
• Pathophysiology of osteoporosis. prescribed these agents despite evidence supporting their
• Vitamin D physiology and metabolism efficacy in both sexes (Vilaca 2022).

• Drug knowledge, including mechanisms of action,

HEDIS and CMS Indicators for Screening and
adverse effects, and major drug interactions of
medications used to treat osteoporosis Outcomes
Osteoporosis-related quality measures from Centers for Medi-
Table of common laboratory reference values care & Medicaid Services (CMS) and Healthcare Effectiveness
Data and Information Set (HEDIS) focus on women. The oste-
ADDITIONAL READINGS oporosis screening in older women measure is the percentage
of women 65-75 years who received osteoporosis screening
The following resources have additional background (National Committee for Quality Assurance [NCQA] 2025).
information of this topic: The osteoporosis management in women who had a fracture
• Camacho PM, Petak SM, Binkley N, et al. American measure is the percentage of women 67-85 years who have
Association of Clinical Endocrinologists and Ameri-
experienced a fracture and who had either a BMD test or
can College of Endocrinology clinical practice
drug prescription to treat osteoporosis in the 6 months after
guidelines for the diagnosis and treatment of post-
menopausal osteoporosis. Endocr Pract. 2020; the fracture (CMS 2024a; NCQA 2025). However, it should be
26(suppl 1):1-46. noted that CMS is working to advance health equity based on
• Eastell R, Rosen CJ, Black DM, et al. Pharmacologi- a Health Equity Index they have implemented to incentivize
cal management of osteoporosis in postmeno- health plans to improve care for the most vulnerable patients
pausal women: an Endocrine Society clinical (CMS 2024b).
practice guideline. J Clin Endocrinol Metab. Understanding the epidemiology, sex differences, and dis-
2019;104:1595-622. parities in screening and treatment of osteoporosis is essen-
• FRAX. Fracture Risk Assessment Tool. tial for developing a comprehensive prevention and treatment
• LeBoff MS, Greenspan SL, Insogna KL, et al. The care plan. By acknowledging and addressing these gaps,
clinician’s guide to prevention and treatment of health care providers can improve the quality of care and
osteoporosis [consensus statement]. Osteoporos
reduce the burden of this debilitating disease.
Int. 2022;33:2049-102.
• North American Menopause Society (NAMS). Man-
RISK FACTORS
agement of osteoporosis in postmenopausal
women: the 2021 position statement of The North Numerous risk factors, classified as nonmodifiable (ie, not able
American Menopause Society. Menopause. to be changed/addressed) and modifiable, put both female
2021;28(9):973-997. and male individuals at risk of developing osteoporosis and/or
• Shoback D, Rosen CJ, Black DM, et al. Pharmaco- contributing to an osteoporotic-related fracture. In both sexes,
logical management of osteoporosis in postmeno- BMD decreases with advancing age. The previous occurrence
pausal women: an Endocrine Society guideline of an adult-aged fracture is another nonmodifiable risk frac-
update. J Clin Endocrinol Metab. 2020;105:587-94.
ture. Fracture rates differ by sex, race, and skeletal site. In
women, those with the highest fracture risk—regardless of

PSAP 2025 Book 2 • Geriatrics 2 Chapter: Osteoporosis

 Table 1. Risk Factors Associated with Osteoporosis

Risk Factor Type Examples (non-inclusive)

Modifiable lifestyle • Low body weight

factors | Women: < 57.7 kg or BMI < 21 kg/m2

| Men: < 70 kg or BMI < 20-25

• Tobacco use (active or passive)

• Alcohol use
| Women: ≥ 2 drinks/day

| Men: ≥ 3 drinks/day

• Physical inactivity
• Low calcium intake
• Vitamin D insufficiency/deficiency

Health conditions • Autoimmune disease: rheumatoid arthritis, systemic lupus, multiple sclerosis
• Endocrine system disorders: diabetes, hyperparathyroidism, obesity, hyperthyroidism, hypogonadism
• GI and digestive disease: bariatric surgery, celiac disease, inflammatory bowel disease, malabsorption
syndromes
• Genetic conditions: cystic fibrosis, hemochromatosis, osteogenesis imperfecta
• Hematologic disorders: leukemia, lymphoma, hemophilia, multiple myeloma, sickle cell disease, thalassemia
• Neurologic disease: Parkinson’s disease, spinal cord injury, stroke
• Other health conditions: anorexia, chronic obstructive lung disease, chronic liver disease, congestive heart
failure, depression, HIV/AIDS, renal disease, weight loss

Medications • Aluminum-containing antacids

• Anticonvulsants: phenytoin, phenobarbital, valproate
• Androgen-deprivation therapy: bicalutamide, flutamide
• Aromatase inhibitors: anastrozole, letrozole
• Depot medroxyprogesterone acetate
• Gonadotropin-releasing hormone agonists and antagonists: goserelin, leuprolide, cetrorelix, elagolix
• Immunosuppressants: methotrexate, tacrolimus, cyclosporine
• Lithium
• Glucocorticoids: ≥ 5 mg/day prednisone or equivalent for ≥ 3 mo
• Proton pump inhibitors: lansoprazole, omeprazole, pantoprazole
• Selective serotonin reuptake inhibitors: citalopram, escitalopram, fluoxetine, paroxetine, sertraline
• Tamoxifen (premenopausal use)
• Thiazolidinediones: pioglitazone
• Unfractionated heparin

Information from Adler 2014; LeBoff 2022; NAMS 2021; Rao 2010.

skeletal site—are non-Hispanic White, Hispanic-American, PREVENTION

American Indian, African American, and Asian American, Calcium
listed in descending order of risk. In men, those with the high-
Calcium is a fundamental mineral for the maintenance of bone
est hip fracture risk are non-Hispanic White, with similar risk
health and is a vital component of the bone matrix. It has a role
among Hispanic-American and Black men and the lowest risk
in bone development, maintenance, and remodeling. Osteopo-
in Asian men. In addition, parental history of osteoporosis or
rosis, which is marked by reduced bone mass and structural
hip fracture, post-menopause, and premature menopause (eg,
deterioration of bone tissue, can be significantly mitigated
cessation of menses in women younger than 40 years) are
through adequate calcium intake. Adequate calcium intake is
nonmodifiable risk factors. Modifiable lifestyle risk factors
essential for achieving peak bone mass during youth and min-
and secondary causes related to medical conditions and med-
imizing bone loss in older adults (NIH 2024a). The National
ications also affect an individual’s osteoporosis risk (Table 1).
Academy of Medicine (formerly the Institute of Medicine, or
Postmenopausal women and men older than 50 years are rec-
IOM) recommends dietary reference intakes for calcium in
ommended for evaluation to assess and address their osteo-
adults (Table 2).
porosis risk factors (LeBoff 2022).

PSAP 2025 Book 2 • Geriatrics 3 Chapter: Osteoporosis

 suggested a potential link between high calcium supplement
Table 2. Recommended Dietary Reference Intake of intake and increased cardiovascular disease risk, although
Calcium this possibility remains controversial and is the subject of
ongoing research and debate (Reid 2017; Bolland 2013). An
Age (yr) Women (mg/day) Men (mg/day)
analysis of 1999-2010 National Health and Nutrition Examina-
19-50 1000 1000 tion Survey (NHANES) data from 14,408 adults with obesity
51-70 1200 1000 found calcium intake was 10% lower in those with hyperten-
sion than without (Chen 2015). A 13-year prospective cohort
> 70 1200 1200
study of 41,514 adults in Australia found a 25% lower rate of
stroke in those with the highest calcium intake (Khan 2015).
Information from IOM 2011.
In addition, a 10-year study found a 27% lower risk of athero-
sclerosis in those with the highest calcium intake (Anderson
2016). Subsequently, a large meta-analysis found no con-
Although calcium is essential for bone health, evidence sistent relationships between dietary, supplemental, or total
on the use of calcium supplementation to prevent fractures intake and cardiovascular disease mortality (Chung 2017).
is mixed. Some studies demonstrate the efficacy of calcium Based on the mixed evidence, a National Osteoporosis Foun-
supplementation in reducing fracture risk, whereas others do dation and American Society for Preventive Cardiology expert
not show significant effects. For example, a meta-analysis of panel concluded that there is lack of evidence linking calcium
8 randomized controlled trials in adults older than 50 years to cardiovascular disease and that calcium intake from food
found that 500-1200 mg/day calcium and 400-800 units of or supplements that does not exceed the upper limit (2000 to
vitamin D supplementation for 1-7 years reduced the total frac- 2500 mg/day as defined by the National Academy of Medicine)
tures by 15% and hip fractures by 30% (Weaver 2016). How- is safe “from a cardiovascular standpoint” (Kopecky 2016).
ever other systematic reviews showed no effect on fracture Furthermore, a recent meta-analysis of randomized trials
risk (Kahwati 2018; Zhao 2017). found no significant association between calcium supplemen-
The absorption of dietary calcium varies by type of foods, tation and increased risk of coronary heart disease, stroke, or
for example, ranging from 30% for dairy products compared all-cause mortality (Huo 2023).
with 5% for spinach (Weaver 2014). The amount of calcium Lastly, despite postulation that calcium might help reduce
in supplements vary; a multivitamin commonly has 200-300 the risk of some cancers, the evidence is inconsistent (Weaver
mg, whereas a calcium supplement commonly has 500 or 600 2020; IOM 2011). More trials are needed to determine whether
mg (NIH n.d.). Of note, calcium absorption is optimal at doses calcium intake decreases, increases, or has no effect on can-
of 500 mg or less (NIH 2024a). The most common forms are cer risk and mortality.
calcium carbonate, which should be taken with food because
it requires stomach acid for absorption, and calcium citrate, Vitamin D
which can be taken without food. In general, however, absorp- Vitamin D facilitates the absorption of calcium and phospho-
tion of calcium supplements is higher when taken with food rus, which are essential for bone mineralization. Therefore,
(Weaver 2014). vitamin D plays an important role in maintaining bone health.
Postmenopausal women are among those most likely to The dietary reference intake for vitamin D is 15 μg (600 inter-
need extra calcium because their decrease in estrogen pro- national units) per day in adults age 19-70 years, and 20 μg
duction reduces calcium absorption and increases calcium (800 international units) per day for adults older than 70 years
resorption from the bone (IOM 2011). However, many post- (NIH 2024b). These recommendations are designed to ade-
menopausal women do not meet the recommended daily cal- quately maintain total serum 25-hydroxyvitamin D concen-
cium intake. Studies indicate that the average daily calcium trations, which is generally considered above 30 ng/mL (IOM
intake for postmenopausal women is about 700-800 mg—well 2010). It is important to measure vitamin concentrations
below the target—with about one-third from dairy products because the intake requirements for supplementation vary
(North American Menopause Society [NAMS] 2021). This gap significantly among individuals. The American Association of
highlights the need for dietary modifications or supplementa- Clinical Endocrinologists (AACE)/American College of Endo-
tion to support bone health. crinology (ACE) guidelines state a goal total serum vitamin D
It should be noted that excessive intake of calcium can lead concentration of at least 30 ng/mL in patients with osteopo-
to hypercalcemia, which can cause nausea, vomiting, consti- rosis. However, because higher concentrations may promote
pation, and abnormal heart rhythms. Other adverse effects calcium excretion into the urine, an upper limit for the concen-
include kidney stones, usually in the form of calcium oxalate. tration may exist.
The role of calcium—which binds fatty acids and thus may Many endocrinologists measure vitamin D concentration
lower lipid absorption—in reducing cardiovascular disease with a goal of 30-50 ng/mL, and some may measure urinary cal-
has been mixed (Weaver 2020; IOM 2011). Some studies have cium excretion and suggest a dose modification for vitamin D

PSAP 2025 Book 2 • Geriatrics 4 Chapter: Osteoporosis

or calcium. Adults with vitamin D insufficiency or deficiency can be dosed once a day due to its longer half-life (Sato 2020).
(less than 20 ng/mL) may receive treatment doses of 125 μg However more studies are needed before incorporating vita-
(5000 international units) daily or 1250 μg (50,000 interna- min K as part of the osteoporosis prevention standard (Cama-
tional units) weekly of vitamin D2 or vitamin D3 to achieve a con- cho 2020).
centration of 30 ng/mL. Daily maintenance dosing with 25-100
μg) (1000-4000 international units) may be needed, depending
DIAGNOSTIC EVALUATION
on the vitamin D concentrations. Adding 25 μg (1000 interna-
tional units) of vitamin D to the patient’s current daily intake is The Bone Health & Osteoporosis Foundation (formerly
generally expected to raise their total serum vitamin D concen- National Osteoporosis Foundation) recommends a multimodal
tration by around 10 ng/mL over several weeks (Khan 2010). approach for evaluating and diagnosing osteoporosis. This
Of note, some medications, such as corticosteroids, anti- comprehensive approach consists of the following: assessing
convulsants, antacids, can cause vitamin D deficiency by individual osteoporosis risk factors, including potential sec-
increasing the rate at which the body metabolizes vitamin D. ondary causes, together with family and personal history; con-
The benefits of vitamin D supplementation for fall prevention ducting a physical examination, including assessing fall risk,
have been a topic of debate. A meta-analysis found that higher and evaluating symptoms, such as height loss, back pain and
daily doses of vitamin D (700 to 2000 international units) were fractures; and measuring BMD (LeBoff 2022).
associated with a lower fall risk among older adults, whereas
lower doses showed no significant effect. However, factors Dual-Energy X-ray Absorptiometry
such as calcium supplementation, baseline total serum vita- Dual-energy x-ray absorptiometry is the most common and
min D concentrations, and dosing frequency influenced fall validated imaging option for measuring BMD. This noninvasive
prevention outcomes (Wei 2022). Regardless, the consensus scan uses minimal radiation and takes less than 5 minutes to
supports the benefit of vitamin D supplementation in popula- complete in an outpatient setting. It evaluates BMD at central
tions at risk of deficiency. Future research should aim to refine skeletal sites, including lumbar spine and hip, as well as the
guidelines for optimal vitamin D in osteoporosis prevention. forearm and total body. In addition, DXA measures the amount
of bone mineral divided by the area of the bone scanned. To
Magnesium standardize BMD measurements from different sites, the
Magnesium is a vital mineral that contributes to bone health results are reported as a T-score or Z-score (NAMS 2021).
because it is a cofactor for enzymes involved in the synthe- The International Society for Clinical Densitometry (ISCD)
sis of bone matrix and stimulates osteoblast proliferation. recommends measuring BMD at the lumbar spine, total hip,
However, evidence is insufficient to determine its associa- or femoral neck site for osteoporosis diagnosis in postmeno-
tion with bone health in older adults. A systematic review of pausal women and in men 50 years and older; the 33% radius
cohort studies suggested a positive trend between higher (also called 1/3 radius) of the nondominant forearm can also
magnesium intake and higher hip and femoral BMD; however, be used in some cases (ISCD 2019). Adding a trabecular bone
a randomized controlled trial is needed to evaluate the effect score (TBS) to the DXA scan can assist in assessing bone
of magnesium intake on fracture risk (Groenendijk 2022). microarchitecture, which correlates to bone strength. Higher
However, those at risk of hypomagnesemia may benefit from TBS values indicate better microarchitecture, whereas lower
supplementation. Furthermore, magnesium may help offset TBS values indicate degraded microarchitecture. The use of
calcium-induced constipation, in those for whom magnesium TBS for evaluation of vertebral fracture risk assessment is
supplementation may be necessary (Camacho 2020). increasing in daily clinical practice (Shevroja 2021).
After DXA, a T-score for each site measured will be reported;
Other Vitamin Considerations the lowest reported T-score is used in evaluating and classify-
Other nutrients are potentially harmful or have mixed evi- ing the results. The T-score, expressed as a standard devia-
dence supporting efficacy. Excessive chronic intake of vita- tion (SD), compares an individual’s BMD with the mean BMD
min A (more than 10,000 units daily) has detrimental effects of a healthy young population. A score of 0 indicates that the
on the bone and should therefore be avoided (Camacho 2020). individual’s BMD is equal to the mean, whereas a score of +1.0
Although most multivitamin supplements should be signifi- indicates 1 SD above the mean, and a score of –1.0 indicates
cantly less than this dose, some individuals may be taking mul- 1 SD below the mean (Office of the Surgeon General 2004).
tiple supplements that contain vitamin A. In 1994, WHO developed diagnostic criteria for osteoporo-
Data are mixed suggesting vitamin K may decrease bone sis, comparing an individual’s BMD to the reference population
turnover and loss in postmenopausal women. Vitamin K— (using NHANES III data) of young (age 20-29 years), healthy,
which is classified as three known types: K1, K2, and K3— White women. An individual’s T-score of –2.5 or less is classi-
regulates the formation of osteoclasts and bone resorption. fied as osteoporosis, whereas classification as severe osteopo-
Vitamin K2 has both MK-4 and MK-7 homologs. MK-7 may be rosis includes the presence of one of more fragility fractures.
more effective and practical; it has a higher bioavailability and A fragility fracture is a low-trauma fracture sustained from

PSAP 2025 Book 2 • Geriatrics 5 Chapter: Osteoporosis

 Table 3. T-Score Interpretation Box 1. Patient-Specific Factors
Considered in the Fracture Risk
T-Score Interpretation Assessment (FRAX) Validated Tool
–1.0 and higher Normal bone mass • Patient demographic data: country, ethnicity, age, sex,
weight, height
Between –1.0 and –2.5 Low bone mass • History of a fracture, including clinical and subclinical
vertebral fractures
–2.5 or lower Osteoporosis
• History of parental fracture
–2.5 or lower with a fragility Severe osteoporosis • Lifestyle factors: current smoking status and alcohol use of
fracture ≥ 3 units/day
• Glucocorticoid use (prednisone ≥ 5 mg/day for ≥ 3 mo)

Information from Camacho 2020. • Rheumatoid arthritis

• Secondary osteoporosis: type 1 diabetes; osteogenesis
imperfecta in adults; untreated long-standing hyperthyroid-
ism; hypogonadism or premature menopause; osteoporosis
force similar to a fall from a standing position or lower and occurring at age < 40 years; chronic malnutrition or malab-
would not have otherwise occurred in healthy bone (Camacho sorption, chronic liver disease
2020). An individual with a T-score of –1 to –2.5 has low bone • Optional femoral neck bone mineral density

mass (Kanis 1994). Of note, the ISCD preferred terms are low Information from Fracture Risk Assessment Tool.
bone mass or low bone density rather than osteopenia (ISCD
2019). Table 3 provides an interpretation of T-scores. Although
the WHO T-score serves as the reference range for women and treatment can be initiated if risk factors and heel QUS frac-
men of all races, its appropriateness in male patients has been ture probability, using device- specific thresholds, is suffi-
debated (Binkley 2014). ciently high (ISCD 2019). However, DXA measurement remains
A Z-score, as reported as a standard deviation, compares the preferred method for diagnosing osteoporosis, predicting
an individual’s BMD to the average of matched patients with future fracture risk, and monitoring patients (LeBoff 2022).
the same age and sex. A Z-score is not used in diagnosis of
osteoporosis; rather, it used to assess bone health in chil- Fracture Risk Assessment
dren, premenopausal women, and men younger than 50 years. Despite evaluating BMD, patients without osteoporosis may
A Z-score of –2.0 or lower is considered below the expected still be at risk of a fracture. In a study of 8,065 women older
range for age (ISCD 2019). than 65 years followed for up to 5 years, at baseline 17% had
Although use of DXA for BMD evaluation is considered the osteoporosis as assessed with total hip BMD. Of the 243
gold standard for diagnosing osteoporosis, its rate of use is women who experienced a hip fracture, however, 54% did not
low. One notable concern is the significant decline in Medicare have a T-score indicative of osteoporosis or characteristics
reimbursement for office-based use of DXA for BMD assess- of fragility at baseline (Wainwright 2005). To further evaluate
ment, which has resulted in closure of facilities in some cases, fracture risk, other assessment and screening tools may be
thereby limiting patient accessibility (Lewiecki 2019b). Preven- warranted.
tion of osteoporotic fractures is possible; however, access to The Fracture Risk Assessment (FRAX) is a validated tool
diagnostic tools and effective treatments is necessary. for use in women and men age 40 to 90 years who have not
With limitations to access, high fracture probability previously been treated with osteoporosis medications. Given
assessed through use of a quantitative CT scan of the spine, that FRAX is a free, online-based calculator, it is the assess-
coupled with risk factors could also justify pharmacologic ment tool most often used. This tool assesses an individual’s
therapy (ISCD 2019). A quantitative CT (QCT) may be more 10-year probability of a major osteoporotic-related fracture
accurate than DXA because in individuals with degenerative (clinical spine, forearm, hip, or shoulder fracture) and hip
changes in the lumbar spine, a DXA can overestimate spinal fracture using patient-specific factors (Box 1). A score of 20%
BMD and underestimate fracture risk. For QCT, however, this or greater for major osteoporotic fracture or 3% or greater
degree of accuracy must be weighed against the high radiation for a hip fracture indicates increased risk. Although results
exposure (LeBoff 2022; ISCD 2019; Surgeon General 2004). of the FRAX cannot be used for osteoporosis diagnosis, it
Quantitative ultrasound (QUS) is an alternative noncentral can guide decisions for BMD screening. However, the FRAX
device to assess bone mass that provides a portable, low- has limitations necessitating clinical judgment. This tool is
er-cost option, and does not use radiation; instead, it uses most useful in patients with low femoral neck BMD, and it has
sound waves. Although QUS measures peripheral sites of not been validated using the lumbar spine BMD. Therefore,
bone, including the heel, leg, wrist and finger, the only validated in patients with a low lumbar spine BMD and relatively nor-
site of measurement is the heel (ISCD 2019; Surgeon General mal femoral neck BMD, the fracture risk is underestimated. In
2004). If a central DXA cannot be completed, pharmacologic addition, the relative weight of the risk factors incorporated

PSAP 2025 Book 2 • Geriatrics 6 Chapter: Osteoporosis

 Table 4. Select Risk Assessment Tools for Osteoporosis

Score for
Tool Population Patient Characteristics Increased Risk

ABONE (Age, Bulk, One or Never Women • Age > 45 yr ≥2

Estrogen) • Weight (kg)
• Current estrogen use

MORES (Male Osteoporosis Risk Men • Age ≥ 50 yr 6

Estimation Score) • Weight (kg)
• Chronic obstructive pulmonary disease

ORAI (Osteoporosis Risk Assessment Women • Age ≥ 45 yr ≥9

Instrument) • Weight (kg)

OSIRIS (Osteoporosis Index of Risk) Women • Agea <1

• Weight (kg)
• Current estrogen use
• Prior low-impact facture

OSTA (Osteoporosis Self-Assessment Men/Women • Age (40-94 yr) <2

Tool for Asians) • Weight (kg)

SCORE (Simple Calculated Osteoporosis Women • Age (postmenopausal and age ≥ 45 yr) ≥6
Risk Estimation) • Weight (lb)
• Race
• Rheumatoid arthritis
• Previous rib, wrist, hip fracture after age 45 yr
• Estrogen use

Information from Chavda 2022.

a
Age range for tool is not defined, but patients should be postmenopausal.

into the tool are not considered because selections are either patient-specific factors. These factors include sex, age (50-
“Yes” or “No” answers. Other risk factors, especially concern- 96 years), fractures since age 50 years, falls over the past
ing in older adults, such as fragility, the presence of multiple 12 months, and BMD, either as a T-score or actual BMD. The
comorbid conditions, use of multiple medications associ- results are reported as a GARVAN score for the 5- and 10-year
ated with fall/fractures, and life expectancy, are not included risk for both a hip fracture and an osteoporotic fracture/fragil-
(LeBoff 2022). ity fracture.
To modify a probability result from the conventional FRAX It is important to evaluate an individual’s fall risk because
estimate, the FRAXplus has been developed and is currently most fractures are associated with a fall. The risk of falls
in beta-testing. This newer tool accounts for the recency of increases with age, and falls occur in about 33% of individuals
an osteoporotic fracture, number of falls in the previous year, older than 65 years. Medical, neurologic, musculoskeletal, psy-
duration of type 2 diabetes, higher than average exposure to chological, and environmental factors all contribute to fall risk
oral glucocorticoids, hip axis length, trabecular bone score, (Table 5), specifically, a history of falls; gait, balance, or vision
and lumber spine BMD. Currently, use of FRAXplus online impairments; muscle weakness; and conditions and medica-
requires registration and payment, limiting its widespread use. tions associated with dizziness, sedation, weakness, and a
Of note, other risk assessment tools can also be used to aid in lack of coordination (LeBoff 2022; Camacho 2020). Some of
determining whom should undergo BMD screening (Table 4). these factors are modifiable, and with routine assessment and
modification an individual’s fall risk can be reduced.
Fall Risk Assessment The CDC’s Stopping Elderly Accidents, Deaths, & Injuries
Currently, the FRAX does not include recent fall(s). For individ- (STEADI) initiative aims to reduce falls and health care expen-
uals with a history of falls, the GARVAN fracture risk calcula- ditures while improving health outcomes. The core elements
tor can be used to estimate fracture risk. Similar to the FRAZ, of the STEADI initiative are screening, assessing, and interven-
the GARVAN calculator is available for free online, applies ing to reduce fall risk. A multitude of tools and resources are
to both men and women, has its limitations, and includes

PSAP 2025 Book 2 • Geriatrics 7 Chapter: Osteoporosis

 GUIDELINE RECOMMENDATIONS
Table 5. Factors That Increase Fall Risk
Screening

Type of Risk Risk Factor Multiple guidelines exist and vary on their recommenda-
tions for osteoporosis screening (Table 6). In January 2025,
Medical • Urinary urgency or incontinence
• Frailty the US Preventive Services Taskforce (USPSTF) released its
• Malnutrition final recommendation statement for osteoporosis screening
• Orthostatic hypotension to prevent fractures. For women, there are two “B grade” rec-
• Impaired vision ommendations: one recommends osteoporosis screening in
• Impaired hearing all women older than 65 years, and the other recommends
screening in postmenopausal women who are younger than
Neurologic • Dementia
• Parkinson disease 65 years and at an increased risk of an osteoporotic fracture
• Peripheral neuropathy (USPSTF 2025). For Medicare patients, it can be difficult to
• Seizure disorder obtain insurance coverage for a DXA at age 65 years; there-
• Stroke fore, it is very important to start assessing for risk factors
that may warrant a DXA scan at an earlier age. Several other
Musculoskeletal • Arthritis
• Poor balance organizations also provide recommendations for osteoporo-
• Weak muscles sis screening in women, including Bone Health & Osteoporo-
sis Foundation, AACE/ACE–Postmenopausal Osteoporosis,
Psychological • Anxiety
The Menopause Society management of osteoporosis in post-
• Depression
menopausal women position statement, and ISCD. All recom-
• Fear of falling
mend screening in women age 65 years and older; however,
• Diminished cognitive ability
their recommendations for screening younger women vary.
Environmental • Cords In men, the USPSTF provides an “I statement,” with the con-
• Obstacles in walking path
clusion that the current evidence is insufficient to recommend
• Loose or throw rugs
screening to prevent osteoporotic fractures in men (USPSTF
• Poor lighting
2025). Although other organizations—Endocrine Society:
• Stairs
Osteoporosis in Men, ISCD, and Bone Health & Osteoporosis
• Slippery floors
• Wet, icy, or uneven walkways Foundation—recommend osteoporosis screening in all men
• Lack of assistive devices (eg, stair 70 years and older, they vary regarding screening in younger
rail, holds in bathroom) men with risk factors.

Information from Camacho 2020; LeBoff 2022. Initiation of Pharmacotherapy for Treatment
Each guideline provides its own recommendations regard-
ing when to consider initiation of pharmacotherapy for pri-
available at no cost that can be used to incorporate this fall mary and secondary fracture prevention. The guidelines also
prevention program in clinical practice (CDC 2024). include the definition of and treatment for patients considered
Regular participation, throughout one’s life, in weight- to be very high risk of fractures (Table 7). Some guidelines
bearing, muscle-strengthening, and balance improving exer- provide recommendations for both men and postmenopausal
cises can minimize falls. Multiple guidelines endorse inclusion women, whereas others focus solely on postmenopausal
of such exercises, not only for individuals with osteoporosis women. In general, pharmacotherapy for primary fracture pre-
but for overall bone health (LeBoff 2022; Camacho 2020; Watts vention is recommended in patients with a T-score indicative
2012). Fall outcomes improve with high-intensity exercise pro- of osteoporosis as well as in those with a T-score indicative
grams that combine resistance, balance, and weight-bearing of low bone mass and a FRAX score indicative of increased
exercises in individuals with osteoporosis (Camacho 2020). fracture risk (LeBoff 2022; NAMS 2021; Camacho 2020; Watts
Incorporating physical activity is a lifestyle change. Show- 2012). Pharmacotherapy for secondary fracture prevention is
ing the value of physical activity as it relates to quality of warranted in individuals with a previous fracture (LeBoff 2022;
life and independence may be beneficial for patient engage- NAMS 2021; Camacho 2020; Shoback 2020; Eastell 2019;
ment. Furthermore, individuals may find physical therapy or Watts 2012).
group exercise with a certified fitness instructor beneficial for
safety, socialization, and motivation (Camacho 2020). Cou- AACE/ACE Clinical Practice Guidelines
pling risk factor modification and physical activity can bene- The AACE/ACE clinical practice guidelines for the diagnosis
fit individuals in decreasing their risk of a fall and potentially and treatment of postmenopausal osteoporosis were updated
a fracture. in 2020. The guidelines organize recommendations into 12

PSAP 2025 Book 2 • Geriatrics 8 Chapter: Osteoporosis

 Table 6. Guideline Recommendations for Osteoporosis Screening

Guideline (Year) Women Men Additional Considerations

AACE/ACE- • Age ≥ 65 yr — —
Postmenopausal • Younger postmenopausal women:
Osteoporosis (2020) | With history of fracture(s) without

major trauma
| Starting or taking long-term

glucocorticoid therapy
| With radiographic osteopenia

| With clinical risk factorsa if willing

to consider pharmacologic therapy

Bone Health & • Age ≥ 65 yr • Age ≥ 70 yr Adults with:
Osteoporosis • Younger postmenopausal women or • Ages 50-69 yr • Fracture at age ≥ 50 yr
Foundation (2022) b those in menopausal transition with with clinical • Condition associated with low bone mass or
clinical risk factors for fracture risk factors bone loss
for fracture • Using medication associated with low bone
mass or bone loss
Endocrine Society: — • Age ≥ 70 yr —
Osteoporosis in Men • Ages 50-69 with
(2012) risk factorsc
International • Age ≥ 65 yr • Age ≥ 70 yr Adults with:
Society for Clinical • Postmenopausal women age < 65 yr • Age < 70 yr with • Fragility fracture
Densitometry (2019) with a risk factord a risk factord • Disease or condition associated with low
• Women during menopausal transition bone mass or bone loss
with clinical risk factorsd • Taking medications associated with low
bone mass or bone loss
Anyone:
• Being considered for pharmacologic therapy
• Being treated, to monitor treatment effect
• Not receiving therapy but for whom evidence
of bone loss would lead to treatment
The Menopause • Age ≥ 65 yr — —
Society: Management • Age ≥ 50 yr with ≥ 1 risk factore
of Osteoporosis in • Postmenopausal with history of
Postmenopausal fracture since menopause
Women Position • Postmenopausal with known medical
Statement (2021) causes of bone loss or fracture
US Preventive • Age ≥ 65 yr — Adults over the age of 40 years
Services Task Force • Postmenopausal women • Without history of prior fractures
| Age < 65 yr • Or with health condition(s) associated with
| With ≥ 1 risk factorf bone loss
| At increased risk of osteoporotic • Or long-term use of medication(s)
fracture, as estimated by clinical associated with bone loss
risk assessment

Information from Camacho 2020; ISCD 2019; LeBoff 2022; NAMS 2021; USPSTF 2025; Watts 2012.
Abbreviations: AACE, American Association of Clinical Endocrinologists; ACE, American College of Endocrinology.
a
Low body weight; cigarette smoking; family history of spine or hip fractures; early menopause; secondary osteoporosis.
b
Previously known as the National Osteoporosis Foundation.
c
History of a fracture after age 50 yr; delayed puberty; hypogonadism; hyperparathyroidism; hyperthyroidism; chronic obstructive
pulmonary disease; use of medication linked to osteoporosis (ie, glucocorticoids); smoking; alcohol misuse; other causes of
secondary osteoporosis.
d
Low body weight; prior fracture; high risk medication use; disease or condition associated with bone loss.
e
Body weight < 57.7 kg (127 lb) or BMI < 21 kg/m2; parental history of hip fracture; current smoker; discontinuing estrogen with
additional risk factors for fracture.
f
Medical conditions and medications associated with secondary osteoporosis; menopausal status; low body weight; parental history
of hip fracture; cigarette smoking; and excess alcohol consumption.

PSAP 2025 Book 2 • Geriatrics 9 Chapter: Osteoporosis

 Table 7. Osteoporosis Treatment Guideline Recommendations

The Menopause
Society:
Management of
Bone Health & Endocrine Endocrine Osteoporosis in
AACE/ACE Post- American College Osteoporosis Society: Society: Postmenopausal
menopausal Osteo- of Physicians Foundation Osteoporosis in (2019; 2020 Women Position
porosis (2020) (2023) (2022)a Men (2012) update) Statement (2021)

Population • Postmenopausal • Postmeno- • Postmeno- • Men • Postmenopausal • Postmenopausal

women pausal women pausal women women women
• Men ≥ 50 yr • Men ≥ 50 yr

Primary • T-score ≤ –2.5 (by • T-score ≤ –2.5 • T-score ≤ –2.5 • T-scoreb ≤ –2.5 • At high risk of • T-score < –2.5 (by
fracture DXA) at spine, (by DXA) at (by DXA) at (by DXA) fractures DXA) at lumbar
prevention femoral neck, lumbar, spine, femoral neck, at spine, spine, femoral
total hip, or 1/3 total hip, or total hip, femoral neck, neck, or total hip
radius femoral neck lumbar spine, and/or total • T-score –1.0 to
• T-score–1.0 to (in certain cir- or 1/3 radius hip—AND— –2.5 (by DXA)
–2.5 (by DXA) at cumstances, • T-score –1.0 to no previous —AND—
femoral neck or can use 1/3 –2.5 (by DXA) spine or hip
| History of
total hip radius) at femoral fracture
fracture of
—AND— neck or total • T-score –1.0
proximal
hip to –2.5 (by
| 10-yr hip fracture humerus, pelvis,
—AND— DXA) at spine,
risk ≥ 3% or distal forearm
femoral neck
—OR—
| 10-yr hip —OR—
or total hip
fracture risk
| 10-yr major —AND— | History of
≥ 3%
osteoporotic- multiple
—OR—
| 10-yr hip
related fracture fractures at
fracture risk
risk ≥ 20% (per | 10-yr major other sites
≥ 3%
FRAX) osteoporotic- (excluding face,
related —OR— feet, hands)
fracture risk | 10-yr risk of —OR—
≥ 20% (per any fracture
| increased
FRAX) ≥ 20% (per
fracture risk
FRAX)
based on
country-specific
thresholds using
FRAXc

Secondary • Fragility fracture of — • Fracture • Hip or vertebral • Recent (≤ 2 yr) • Vertebral or hip
fracture hip or spine with of hip or fracture vertebral or fracture
prevention low bone mass lumbar spine without major nonvertebral
(regardless of trauma fracture
T-score)
• Fracture of
proximal
humerus,
pelvis, or distal
forearm with
low bone
mass (T-score
–1.0 to –2.5)

(continued)

PSAP 2025 Book 2 • Geriatrics 10 Chapter: Osteoporosis

 Table 7. Osteoporosis Treatment Guideline Recommendations (continued)

The Menopause
Society:
Management of
Bone Health & Endocrine Endocrine Osteoporosis in
AACE/ACE Post- American College Osteoporosis Society: Society: Postmenopausal
menopausal Osteo- of Physicians Foundation Osteoporosis in (2019; 2020 Women Position
porosis (2020) (2023) (2022)a Men (2012) update) Statement (2021)

Pharmaco- • Drugs with FDA • Both men and • Drugs with FDA • Drugs with FDA • Initial treatment • Bisphosphonates
therapy recom- approval to postmeno- approval to approval for with bisphos- (caution with
mendation(s) reduce risk of pausal women reduce risk of osteopo- phonates: renal function)
hip, nonvertebral, | Bisphospho- vertebral and rosis treat- alendronate, • Raloxifene in those
and spine nates are first- nonvertebral ment in men: risedronate, with a low risk
fractures: line option fractures: alendronate, zoledronic acid, of hip fracture,
alendronate, | Denosumab alendronate, risedronate, ibandronated elevated risk of
denosumab, is second-line risedronate, zoledronic • Denosumab is breast cancer,
risedronate, option zoledronic acid, teri- alternative and low risk of
zoledronic acid acid, paratide, or if initial therapy stroke and VTE
• Ibandronate or denosumab, receiving ADT, • Denosumab if high
raloxifene may teriparatide, denosumab fracture risk
be appropriate abaloparatide, • In men with
initial choice in romosozumab recent hip
those requiring fracture,
spine-specific zoledronic
efficacy acid

Very high • Recent fracture • Older age • Multiple spine — • Severe • Prior and recent
fracture (≤ 12 mo), • Recent fracture fractures/hip osteoporosis fractures
risk—definition fractures while (≤ 12 mo) fractures (T-score < −2.5 • Very low BMD
on approved • History of mul- —AND— and fractures) (T-score < –3.0)
osteoporosis tiple clinical • Severe or • Fracture sustained
• T-score ≤ –2.5 at
therapy osteoporotic multiple or BMD loss
lumbar spine
• Multiple fractures fractures vertebral while on
or hip
• Fractures while on • Multiple risk fractures antiresorptive
drugs causing factors for therapy
skeletal harm fracturee
• T-score ≤ –3.0 • Failure of other
• High risk of falls available
• History of injurious osteoporosis
falls therapy
—AND—
• Very high fracture
probability (10-yr
hip fracture
risk > 4.5% or
10-yr major
osteoporotic-
related fracture
risk > 30%) per
FRAX

Very high • Abaloparatide, • Romosozumab • Teriparatide or — • Teriparatide or • Anabolic therapy

fracture risk— denosumab, or teriparatide abaloparatide abaloparatide followed by
pharmaco- romosozumab, followed by for ≤ 2 for ≤ 2 yr—OR— antiresorptive
therapy recom- teriparatide, or bisphospho- yr—OR— • romosozumab treatment
medation(s) zoledronic acidf nate in post- romosozumab for ≤ 1 yr
menopausal for 1 yr • Followed by
women • Followed by antiresorptive
antiresorptive treatment
treatment

(continued)

PSAP 2025 Book 2 • Geriatrics 11 Chapter: Osteoporosis

 Table 7. Osteoporosis Treatment Guideline Recommendations (continued)

The Menopause
Society:
Management of
Bone Health & Endocrine Endocrine Osteoporosis in
AACE/ACE Post- American College Osteoporosis Society: Society: Postmenopausal
menopausal Osteo- of Physicians Foundation Osteoporosis in (2019; 2020 Women Position
porosis (2020) (2023) (2022)a Men (2012) update) Statement (2021)

Monitoring • DXA at spine and — • Annually review • DXA at spine • DXA at spine • DXA every 1-2 yr
response to hip every 1-2 yr response to and hip every and hip every after beginning
treatment after initiation and need for 1-2 yr 1-3 yr therapy
of therapy until continued
BMD is stable treatment
• Clinical
assessment
to identify new
fractures, falls,
and/or new
or worsening
comorbidities
• Repeat DXA
in those
exhibiting
signs of
vertebral
fractureg

Information from Camacho 2020; Eastell 2019; LeBoff 2022; NAMS 2021; Qaseem 2023; Shoback 2020; Watts 2012.
Abbreviations: AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; ADT = androgen-
deprivation therapy; BMD = bone mineral density; DXA = dual-energy x-ray absorptiometry; FRAX = Fracture Risk Assessment tool;
VTE = venous thromboembolism.
a
Previously known as the National Osteoporosis Foundation.
b
T-score below the mean for healthy young White men.
c
In the United States, 10-yr hip fracture risk ≥ 3%—OR—10-yr major osteoporotic-related fracture risk ≥ 20%.
d
Ibandronate is not recommended to reduce nonvertebral or hip fracture risk.
e
See Appendix in the ACP American College of Physicians guideline (Qaseem 2023, Table 3).
f
These drugs may be initial options in those unable to use oral therapy.
g
Height loss or back pain.

questions that span from fracture risk assessment and oste- For primary osteoporosis treatment, bisphosphonates are rec-
oporosis diagnosis, to pharmacologic treatment selection, ommended, followed by denosumab, if contraindications or
monitoring, and length of treatment, to need for referral to adverse effects occur from bisphosphonates, in both men and
an osteoporosis specialist. Detailed recommendations are postmenopausal women. This guideline also recommends
provided regarding when and what to initiate for pharmaco- taking an individualized approach regarding whether to start
therapy in primary and secondary fracture prevention. The a bisphosphonate for treatment of low bone mass, defined as
guidelines also provide a definition for very high fracture risk T-score between –1.0 and –2.5 at the femoral neck, lumbar
and suggest pharmacotherapy. In addition, they recommend a spine, or both, in women older than 65 years. The use of bis-
bisphosphonate or denosumab as sequential therapy after the phosphonates as initial treatment in postmenopausal women
use of an anabolic agents. Given the lack of known effect of is the only strong recommendation with high-certainty evi-
concomitant use of pharmacotherapy for prevention or treat- dence within this guideline. All other recommendations are
ment of postmenopausal osteoporosis, AACE/ACE does not conditional recommendations with low-­ certainty evidence
recommend this practice (Camacho 2020). (Qaseem 2023).

American College of Physicians Bone Health & Osteoporosis Foundation

The 2023 guideline, updated from 2017, provides recommenda- In 2022, Bone Health & Osteoporosis Foundation, previously
tions on pharmacologic treatment for the treatment of primary known as the National Osteoporosis Foundation, published
osteoporosis, defined as not secondary to a separate condi- its Clinician’s Guide focused on the prevention and treat-
tion or medication, in both men and postmenopausal women. ment of osteoporosis (previously published in 2014). The

PSAP 2025 Book 2 • Geriatrics 12 Chapter: Osteoporosis

guide provides recommendations for overall bone health, risk and be willing to take therapy. In women with a history of a hys-
assessment, diagnosis, pharmacologic treatment, and moni- terectomy, an estrogen-only option should be used. Nasal cal-
toring in the care of both men older than 50 years and post- citonin is a last-line option used when all other therapies are
menopausal women with osteoporosis. While specifying when not tolerated or not considered appropriate. Calcium and vita-
to initiate pharmacotherapy for primary and secondary frac- min D are recommended as adjunct to pharmacologic treat-
ture prevention, the 2022 guideline also highlights the needs ment and as monotherapy to prevent hip fractures in those
for individualized pharmacotherapy selection. Among the who cannot tolerate other therapies (Shoback 2020; Eastell
therapeutic options, consideration should be given to poten- 2019).
tial benefits and risks, onset and magnitude of effect, duration
of use, and site(s) of fracture reduction efficacy. The guide- North American Menopause Society
line supports using pharmacotherapy with FDA approval and The North American Menopause Society 2021 position state-
proven risk reduction for both vertebral and nonvertebral frac- ment, an update to the 2010 version, is inclusive of screen-
tures vs pharmacotherapies without these data. In addition, ing, prevention, diagnosis, and management of osteoporosis
the guideline states that antiresorptive therapy should be initi- in postmenopausal women. Like other guidelines, it highlights
ated after the discontinuation of denosumab, teriparatide, aba- the importance of combining nonpharmacologic measures
loparatide, or romosozumab (LeBoff 2022). with pharmacotherapy to increase bone density and improve
bone strength while incorporating strategies to reduce falls.
Endocrine Society Clinical Practice Guideline for This statement is the only guideline that suggests raloxifene
Men
as an initial treatment option if deemed appropriate. Bisphos-
The Osteoporosis in Men: An Endocrine Society Clinical Prac- phonates and denosumab, if deemed high fracture risk, are
tice Guideline provides recommendations for evaluating men also first-line treatment options. Anabolic therapies are sug-
older than 70 years and men age 50-69 years who may be at gested for those with very high fracture risk (NAMS 2021).
risk of osteoporosis, selecting and monitoring treatment, and
integrating lifestyle changes. Selection of pharmacotherapy
should be individualized and consider fracture history, T-score, PHARMACOTHERAPY
risk of hip fracture, BMD at different sites, comorbid medical Table 8 provides further details about the pharmacotherapy
conditions, cost, and other relevant factors. Specific to men, options for osteoporosis. Figure 1 provides a suggested ini-
this guideline includes a section on management of hypogo- tial treatment approach for postmenopausal women and men
nadism in men at high risk of fracture, including the role of older than 50 years with osteoporosis.
testosterone, and men with prostate cancer receiving andro-
gen-deprivation therapy. Because this guideline was last pub- Bisphosphonates
lished in 2012, recommendations do not include denosumab Current osteoporosis treatment guidelines recommend bis-
use without androgen-deprivation therapy or abaloparatide phosphonates (alendronate, ibandronate, risedronate, and
(Watts 2012). zoledronic acid) as a first-line class of antiresorptive agents
for the prevention or treatment of osteoporosis (Qaseem
Endocrine Society Clinical Practice Guideline for 2023; LeBoff 2022; NAMS 2021). Bisphosphonates inhibit
Postmenopausal Women osteoclast-mediated bone resorption. On osteoclast attach-
The Pharmacological Management of Osteoporosis in Post- ment to the bone surface, bisphosphonates are released and
menopausal Women was published in 2019, followed by an internalized by osteoclasts, leading to the disruption of osteo-
update in 2020 after the approval of romosozumab. The 2019 clast function. This mechanism reduces bone turnover, sta-
clinical practice guideline focuses on who to treat, the phar- bilizes bone mass, and increases BMD, ultimately lowering
macotherapeutic options, use of calcium and vitamin D, and fracture risk. Alendronate, risedronate, and zoledronic acid
monitoring. The selective estrogen receptor modulators ral- reduce the risk of vertebral fractures by 40%-70%, nonver-
oxifene and bazedoxifene are second-line options to reduce tebral fractures by 15%-39%, and hip fractures by 20%-50%
the risk of vertebral fractures in postmenopausal women with (Adler 2016).
low risk of deep vein thrombosis, in whom bisphosphonates Bisphosphonates are contraindicated in patients with cer-
or denosumab are not appropriate, or those with a high risk of tain conditions, including hypocalcemia and esophageal
breast cancer. For women younger than 60 years or fewer than abnormalities that delay esophageal emptying (eg, stric-
10 years post-menopause, in whom bisphosphonates or deno- ture or achalasia), and in patients who cannot remain upright
sumab are not appropriate, menopausal hormone therapy is for at least 30 minutes after oral administration. In addition,
another second-line option. Women should have a low risk of because bisphosphonates are predominantly excreted by the
deep vein thrombosis; experience bothersome vasomotor and kidneys, they are contraindicated in individuals with impaired
climacteric symptoms; have no contraindications, including a renal function; these agents should be avoided in patients with
history of prior myocardial infarction, stroke or breast cancer; CrCl less than 30-35 mL/min (LeBoff 2022; Camacho 2020).

PSAP 2025 Book 2 • Geriatrics 13 Chapter: Osteoporosis

 Table 8. Osteoporosis Pharmacotherapy

Skeletal Site
Fracture Risk
Agent Dosing FDA Approval Reduction Adverse Effects Key Points

Bisphosphonates

Alendronate • 10 mg/day or • Postmenopausal • Reduces risk • Transient • Take on awakening

(oral) 70 mg/wk osteoporosis, of hip, decreased total • Take ≥ 30 min before
• 70 mg effer- prophylaxis and vertebral, serum calcium first food, beverage
vescent treatment and non- • GI effects: N/V/D, (excluding water), or
tablet weekly • Osteoporosis, male vertebral constipation, medication of the day
• Prophylaxis: • Osteoporosis caused by fractures abdominal • Remain upright ≥ 30 min
5 mg/day or corticosteroid pain, flatulence, after administration and
35 mg/wk GERD, until after first food of
esophageal the day
irritation • Not recommended in CrCl
• Flu-like < 35 mL/min
symptoms
Ibandronate • 150 mg tab/mo • Postmenopausal • Reduces risk • Remain upright ≥ 60 min
• Hypocalcemia
(oral, IV) or 3 mg IV osteoporosis, of vertebral after oral administration
• ONJ (rare)
every 3 mo prophylaxis and fractures • Not recommended in CrCl
• AFF (rare)
• Prophylaxis: treatment < 30 mL/min
150 mg tab/ • Only approved for women
mo

Risedronate • 5 mg/day or • Postmenopausal • Reduces risk • Remain upright ≥ 30 min

(oral) 35 mg/wk or osteoporosis, of hip, after administration and
75 mg on 2 prophylaxis and vertebral, until after first food of
consecutive treatment and non- the day
days for total • Osteoporosis, male vertebral • Not recommended in CrCl
of 2 tabs/mo • Osteoporosis caused fractures < 30 mL/min
or 150 mg/wk by corticosteroid;
• Prophylaxis prophylaxis and
dose same treatment
as treatment
dose

Zoledronic • 5 mg/yr • Postmenopausal oste- • Reduces • Acetaminophen after

acid (IV) oporosis, prophylaxis risk of hip, administration may
and treatment vertebral, reduce incidence of flu-
• Osteoporosis, male and non- like reaction
• Osteoporosis caused by vertebral • Not recommended in CrCl
corticosteroid; prophy- fractures < 35 mL/min
laxis and treatment
• Osteoporosis, second-
ary prophylaxis for
recent low-trauma hip
fracture

RANKL Inhibitor

Denosumab • 60 mg every • Postmenopausal • Reduces risk • Fatigue • Must be administered by

(SQ) 6 mo osteoporosis, high risk of hip, • Dermatitis, health care professional
of fracture vertebral, eczema, rash • Bone loss can be
• Osteoporosis, men nonvertebral • Peripheral edema rapid after treatment
• Osteoporosis caused by fractures • Hypocalcemia discontinuation
corticosteroid • GI effects: N/V/D, • Boxed warning for
• Osteopenia, men at constipation greater risk of severe
high risk of fracture • Arthralgia hypocalcemia with
receiving androgen- • back pain eGFR < 30 mL/min/
deprivation therapy • URI 1.73 m2
• ONJ (rare)
• AFF (rare)

(continued)

PSAP 2025 Book 2 • Geriatrics 14 Chapter: Osteoporosis

 Table 8. Osteoporosis Pharmacotherapy (continued)

Skeletal Site
Fracture Risk
Agent Dosing FDA Approval Reduction Adverse Effects Key Points

Parathyroid Hormone and Parathyroid Hormone-Related Analogs

Teriparatide • 20 mcg once • Osteoporosis in men • Reduces risk • Hypercalcemia • Ensure adequate calcium
(SQ) daily and postmenopausal of vertebral (transient and vitamin D concen-
women at high risk of and non- increase 4-6 hr trations before initiation
fracturea or with failure vertebral after dose) and during therapy
of or intolerance fractures • Arthralgia, • After discontinuation, use
to other available • Rhinitis, antiresorptive therapy
osteoporosis therapies • Nausea, • Transient orthostatic hypo-
• Osteoporosis caused by • Dizziness, tension usually within
corticosteroids • Headache 4 hr of first few doses
• Store refrigerated and
protect from light
• Discard the pen 28 days
after first use
• Inject into thigh or
abdominal region

Abaloparatide • 80 mcg once • Osteoporosis in men • Reduces risk • Hypercalciuria • Ensure adequate calcium
(SQ) daily and postmenopausal of vertebral • Increased uric and vitamin D concen-
women at high risk of and non- acid trations before initiation
fracturea or with failure vertebral • Antibody and during therapy
of or intolerance fractures development • Duration ≤ 2 yr (in lifetime)
to other available • Erythema, and should be followed
osteoporosis therapies swelling, pain at with antiresorptive
injection site therapy
• Dizziness • No renal or hepatic dose
• Nausea adjustments
• Headache • Transient orthostatic
hypotension usually
occurs within 4 hr of
first few doses
• Inject into periumbilical
region of abdomen
• Rotate injection site daily
• Store refrigerated
• After first dose store at
68-77°F for 30 days

Sclerostin Inhibitor

Romosozumab • 210 mg/mo • Osteoporosis in • Reduces risk • Arthralgias • Administered as 2-105

(SQ) administered postmenopausal of vertebral • Headache mg injections
by health women at high risk of fractures • Hypersensitivity • Anabolic and antiresorp-
care provider fracturea or with failure reaction tive activity
of or intolerance • Injection site • Ensure adequate
to other available reaction calcium and vitamin D
osteoporosis therapies • ONJ (rare) concentrations before
• AFF (rare) initiation and during
therapy
• Duration ≤ 12 mo (doses)
and should be followed
with antiresorptive
therapy
• Boxed warning for CV
events; avoid if MI or
stroke within prior 12 mo
• Monitor for CV events and
discontinue therapy if
occur

(continued)

PSAP 2025 Book 2 • Geriatrics 15 Chapter: Osteoporosis

 Table 8. Osteoporosis Pharmacotherapy (continued)

Skeletal Site
Fracture Risk
Agent Dosing FDA Approval Reduction Adverse Effects Key Points

Estrogen Receptor Agonist/Antagonists

Raloxifene • 60 mg/day • Postmenopausal • Reduces risk • Hot flashes • Reduces breast cancer
(oral) osteoporosis; of vertebral • Peripheral edema risk
prophylaxis and fractures • Arthralgia • Avoid prolonged periods
treatment • Leg cramps of immobilization
• Invasive breast cancer, • Muscle spasms because of VTE risk
postmenopausal • Flu-like • Only approved for women
women at high risk; symptoms
prophylaxis • VTE (rare)

Conjugated • 1 tab/day: • Postmenopausal • Reduces risk • N/D • Intended only for

equine 0.45 mg osteoporosis; of vertebral • Indigestion postmenopausal
estrogens/ conjugated prophylaxis fractures • Dyspepsia women who still have a
bazedoxifene estrogens/ • Vasomotor symptoms • Upper abdominal uterus
(oral) 20 mg associated with pain • Use for shortest duration
bazedoxifene menopause • Muscle spasm possible, and only after
• VTE (rare) considering alternatives
• Avoid prolonged periods
of immobilization
because of VTE risk
• Only approved for women

Menopausal Hormone Therapy

Estrogen +/– • Formulation- • Postmenopausal • Reduces • Type/ • Bone loss can be

progestin dependent osteoporosis; risk of hip, formulation- rapid after treatment
(various prophylaxis vertebral, dependent discontinuation
formulations) • Menopause— and • Avoid prolonged periods
vulvovaginal atrophy nonvertebral of immobilization
and vasomotor fractures because of VTE risk
symptoms • Use of transdermal
formulation may
minimize systemic
adverse effects
• Only approved for women

Calcitonin Receptor Agonist

Calcitonin (IM, • 100 units IM/ • Postmenopausal • Reduces risk • Antibody • Last-line therapy reserved
SQ, intranasal SQ daily osteoporosis of vertebral development for women ≥ 5 yr post-
spray) • 1 spray (200 fractures • Rhinitis and menopause with no
units)/day epistaxis (nasal suitable alternative
intranasally, spray) treatments
alternating • Facial flushing
nostrils daily (injection)

Information from LeBoff 2022, UpToDate Lexidrug 2024, Merative Micromedex 2024.
Abbreviations: AFF, atypical femur fracture; CV, cardiovascular; eGFR, estimated glomerular filtration rate; GERD, gastroesophageal
reflux disease; IM, intramuscular; IV, intravenous; MI, myocardial infarction; N/V, nausea/vomiting; N/V/D, nausea/vomiting/diarrhea;
ONJ, osteonecrosis of the jaw; RANKL, receptor activator of nuclear factor kappa-B ligand; SQ, subcutaneous; URI, upper respiratory
infection; VTE, venous thromboembolism.
a
Defined as a history of osteoporotic fracture or multiple risk factors for fracture.

PSAP 2025 Book 2 • Geriatrics 16 Chapter: Osteoporosis

 Figure 1. Suggested Initial Approach for Osteoporosis Treatment

T-score ≤ −2.5 at femoral neck, total hip, lumbar spine (in some cases 1/3 radius)
OR
T-score between −1.0 and −2.5 in the spine, femoral neck or total hip
AND a 10-year hip fracture risk ≥ 3% OR a 10-year risk of any fracture (based on FRAX)

Assess calcium and vitamin D levels before Evaluate osteoporosis risk factors and modify as possible
initiation of therapy AND AND
Weight-bearing exercise and strength training as possible
Recommend adequate calcium and vitamin D AND
throughout therapy Conduct fall risk assessment and take measures to prevent falls

Postmenopausal Women Men ≥ 50 years old

Moderate to high fracture Very high fracture riska Moderate to high

Very high fracture riska
risk AND no prior fracture OR recent fracture fracture risk

First Line: Bisphosphonate

First Line: Bisphosphonate (alendronate,
(alendronate, risedronate,
risedronate, zoledronic acid) OR Denosumab Abaloparatideb, Teriparatideb, Abaloparatideb, Teriparatideb,
zoledronic acid)
Alternative (given patient specific OR Romosozumabb b Zoledronic acidd, or Denosumabb
Alternative: Denosumab ;
characteristics): Ibandronate or Raloxifene
testosteronec

Information from Qaseem 2023; LeBoff 2022; NAMS 2021; Camacho 2020; Kanis 2020; Shoback 2020; Eastell 2019;
Watts 2012.
Abbreviation: FRAX, Fracture Risk Assessment tool.
a
Very high-risk definitions vary but may include older age; fracture within the past 12 months; severe or multiple vertebral fractures;
T-score ≤ –3.0; fracture sustained or bone mineral density loss while receiving osteoporosis treatment; fracture while taking drugs
causing skeletal harm ((ie, oral glucocorticoids); high risk of falls; history of injurious falls; or a very high fracture probability (10-yr hip
fracture risk > 4.5% or 10-yr major osteoporotic-related fracture risk > 30%) based on FRAX.
b
Once therapy stopped/ends, follow with antiresorptive therapy.
c
Testosterone may be considered in men with hypogonadism at high risk of fracture with multiple testosterone levels < 200 ng/dL and
accompanied by clinical signs or symptoms of androgen deficiency.
d
Zoledronic acid is recommended in men with a recent hip fracture.

Bisphosphonates are generally well-tolerated but can be bisphosphonate “drug holiday,” which involves temporarily dis-
associated with GI issues, including esophagitis, dyspepsia, continuing bisphosphonate therapy after several years, with
and esophageal ulcers, which are more common with oral for- the intention of reducing the risk of adverse effects associ-
mulations. Therefore, patients should be counseled to remain ated with long-term use while also maintaining some degree
upright after administration, which should be after a pro- of fracture protection. The controversy regarding when to ini-
longed fast (overnight) to improve bioavailability and as a sep- tiate a drug holiday and the duration of the holiday stems from
arate administration from other medications (Camacho 2020). balancing between minimizing risks, such as osteonecrosis of
Osteonecrosis of the jaw and atypical femur fractures are rare the jaw and atypical femur fractures, and the potential for an
but serious complications, particularly with long-term use. increased risk of fractures while “off” the drug. Based on the
long half-life of bisphosphonates in bone tissues, these agents
Bisphosphonate Drug Holiday continue to exert anti-resorptive effects even after discontinu-
The ideal treatment duration with bisphosphonates in ation. For patients at high risk of fracture, however, the risk of
osteoporosis has sparked considerable debate in the med- fracture during a drug holiday might outweigh the benefits of
ical community. This reaction has led to the practice of a reducing adverse effects (LeBoff 2022).

PSAP 2025 Book 2 • Geriatrics 17 Chapter: Osteoporosis

 Clinical guidelines offer some guidance on the approach bone mass, whereas following it with teriparatide has been
to drug holidays, which vary based on the patient’s risk profile associated with bone loss at some skeletal sites (Leder 2015).
and require periodic reassessment to determine appropriate
duration and the need for resuming therapy. For patients with PTH and PTH-Related Analogs
low to moderate risk of fracture (T-score − 2.5 or greater, no Parathyroid hormone (PTH) has a role in regulating calcium
new fractures), a bisphosphonate drug holiday after 5 years homeostasis because typically it is secreted at a low level.
of oral therapy or 3 years of intravenous therapy can be con- With reduced total serum calcium concentrations, PTH secre-
sidered (LeBoff 2022; Camacho 2020). For high-risk patients tion is increased and contributes to bone resorption. How-
(T-score − 2.5 or less and/or recent fracture), continuation ever, intermittent administration of exogenous recombinant
with bisphosphonate or alternative therapy should be con- PTH stimulates bone formation. For postmenopausal women
sidered for up to 10 years with an oral bisphosphonate or with osteoporosis, both teriparatide and abaloparatide have
up to 6 years with annual intravenous zoledronic acid (LeB- been shown to increase BMD and reduce the risk of verte-
off 2022; Camacho 2020; Adler 2016). Other guidelines only bral and nonvertebral fractures (Camacho 2020; Miller 2016;
recommend the drug holiday in women with low-to-moder- Neer 2001).
ate fracture risk (NAMS 2021). Further research is needed Teriparatide and abaloparatide are derived from syn-
to assess the optimal duration of a bisphosphonate holiday. thetic analogs of PTH and are two anabolic agents with FDA
Some insurance companies cover bone markers, which may approval for the treatment of osteoporosis (LeBoff 2022; Sur-
be helpful in assessing when to restart treatment. These geon General 2004). Neither agent should be given to individ-
markers include serum C-terminal telopeptide of type I col- uals with hyperparathyroidism, and total serum calcium, PTH,
lagen (CTX-I) and N-terminal propeptide of type I procolla- total serum 25-hydroxyvitamin D, and alkaline phosphatase
gen (P1NP). concentrations should be evaluated before treatment initia-
tion. Adverse effects of both agents are mild; hypercalcemia is
RANKL Inhibitor less likely with abaloparatide. Transient orthostatic hypoten-
Denosumab sion may occur after the first few doses, which responds to
Denosumab is a monoclonal antibody that targets and binds to recumbent posture, and does not necessitate treatment dis-
receptor activator of nuclear factor kappa-B ligand (RANKL), continuation (Camacho 2020).
a protein necessary for the formation and function of osteo-
clasts, the cells responsible for bone resorption. By preventing Teriparatide
RANKL from activating its receptor on the surface of osteo- Teriparatide is a synthetic fragment of human PTH, with FDA
clasts, denosumab reduces bone resorption, increases bone approval for treatment of osteoporosis in men and post-
mass, and enhances bone strength. menopausal women at high risk of fracture and for glucocor-
Denosumab is recommended as a first-line agent for ticoid-induced osteoporosis. It is available as a prefilled pen
patients who are at high fracture risk and who are intolerant of for self-administration once daily as a subcutaneous injection
or have contraindications to bisphosphonates (Qaseem 2023; into the thigh or abdomen (LeBoff 2022).
LeBoff 2022; Camacho 2020). It is one of the most effective After an average of 18 months of therapy, teriparatide was
antiresorptive drugs available for osteoporosis, reducing inci- associated with a reduced risk of vertebral and nonverte-
dence of vertebral, nonvertebral, and hip fractures by 68%, bral fractures by 65%-77% and 35%-53%, respectively, com-
20%, and 40% respectively (Barrionuevo 2019; Zaheer 2015; pared with placebo (Neer 2001). The VERO trial compared
Cummings 2009). Long-term use of denosumab is also asso- teriparatide to risedronate for postmenopausal women with
ciated with a 48% reduction in upper limb fractures, and a severe osteoporosis. After 24 months of therapy, fewer new
reduction in forearm (43%), wrist (43%), and humerus (58%) vertebral fractures were reported in those receiving teri-
fractures at 7 years (LeBoff 2022). paratide (5.4% vs 12%; RR 0.44; 95% CI, 0.29-0.68) (Kendler
Because denosumab may cause hypocalcemia (2%–18%), 2018). In men, teriparatide use was found to increase BMD and
it is contraindicated in patients with baseline hypocalcemia, decrease the risk of vertebral fractures (Kaufman 2005).
based on data from Micromedex. Like bisphosphonates, deno- In the past, the duration of teriparatide use was limited to
sumab has been associated with rare cases of osteonecrosis 2 years because of the increased incidence of osteosarcoma
of the jaw and atypical femur fractures (LeBoff 2022). Discon- in rodent studies. In post-marketing human studies conducted
tinuation of denosumab treatment is associated with rapid over 15 years, an increased incidence of osteosarcoma was
bone loss that may result in vertebral fractures, especially in not observed; therefore, use of teriparatide for more than
those with prior vertebral fracture (Cummings 2018). For this 2 years in an individual’s lifetime may be considered if the indi-
reason, a drug holiday is not appropriate for this drug. During vidual remains at or returns to having a high risk of fracture
periods of suspended treatments, alternate resorptive ther- (Krege 2022; LeBoff 2022; Gilsenan 2021). After discontinua-
apy should be considered to maintain gains in BMD. Following tion of teriparatide, bone loss is rapid and antiresorptive ther-
denosumab therapy with alendronate has shown to preserve apy is warranted to maintain BMD gains.

PSAP 2025 Book 2 • Geriatrics 18 Chapter: Osteoporosis

Abaloparatide or continue to accrue BMD gains and reduce fracture risk
Abaloparatide is a synthetic peptide analog of human PTH- (LeBoff 2022; Camacho 2020; Shoback 2020).
related protein that has FDA approval for the treatment of In the FRAME trial, more than 7,100 postmenopausal women
osteoporosis in men and postmenopausal women at high risk were randomized to receive romosozumab or placebo for 1
of fracture. This agent is available as a prefilled pen for self- year. A 73% reduction in new vertebral fractures was observed
administration once daily as a subcutaneous injection into the in those receiving romosozumab (RR 0.27; 95% CI, 0.16-0.47).
periumbilical region of the abdomen. The treatment duration After 1 year of treatment with romosozumab, all women received
is limited to 24 months. After discontinuation, bone loss is denosumab treatment for the next 12 months. The women who
rapid and antiresorptive therapy is warranted to maintain BMD initially received romosozumab followed by denosumab contin-
gains (LeBoff 2022). ued to have a reduction in new vertebral fractures (RR 0.25; 95%
The ACTIVE study randomized postmenopausal women to CI, 0.16-0.40) (Cosman 2016). The FRAME follow-up extension
receive abaloparatide, teriparatide, or placebo. After an aver- study investigated an additional year of denosumab treatment
age of 18 months of therapy, abaloparatide was associated and found sustained significant reductions in relative risk and
with a reduced risk of new vertebral and nonvertebral frac- increases in spine and hip BMD (Lewiecki 2019a).
tures by 86% and 43%, respectively, compared with placebo. Slightly more than 4000 postmenopausal women with a
Increases in BMD at the hip and femoral neck were greater high fracture risk were included in the ARCH trial, evaluating
in those receiving abaloparatide vs teriparatide (Miller 2016). 1 year of treatment with romosozumab followed by 1 year of
In an extension study (ACTIVE-Extend), women received oral treatment with alendronate compared with 2 years of treat-
alendronate for an additional 6 months, totaling 24 months ment with alendronate. Results showed a RR reduction of 48%
of therapy. Results showed RR reductions of 87% for radio- for new vertebral fracture (RR, 0.52; 95% CI, 0.40-0.66), 38%
graphic spine fracture, 52% for nonvertebral fractures, and reduction for hip fracture, and 19% for nonvertebral fractures
58% for major osteoporotic fractures (Cosman 2017). The in the romosozumab/alendronate group compared with the
ATOM study randomized men 40-85 years with osteoporosis alendronate monotherapy group at 2 years (Saag 2017).
to receive either abaloparatide or placebo for 12 months. At Although romosozumab is not approved in the United States
study end, BMD gains were greater at the lumbar spine in the for use in men with osteoporosis, it does have this indication
abaloparatide group (least-square mean percentage change in other countries. A randomized study of 245 men receiving
[standard error] 8.48 [0.54] vs 1.17 [0.72]; P < 0.0001) (Czer- romosozumab or placebo for 12 months found BMD in the lum-
winski 2022). bar spine (12.1% vs 1.2%) and total hip (2.5% vs –0.5%) were
significantly improved (P < 0.001) in the romosozumab group.
Sclerostin Inhibitor Major adverse cardiovascular were higher with romosozumab
Sclerostin, a cytokine, binds with the Wnt receptor to inhibit treatment (4.9% vs 2.5%) (Lewiecki 2018).
precursor cells differentiation into mature bone-forming osteo-
blasts. By blocking the binding of sclerostin to osteoblasts, Estrogen Receptor Agonists/Antagonists
osteoblast activity (bone formation) increases and osteoclast Raloxifene
activity (bone resorption) decreases, having both anabolic and Raloxifene is a selective estrogen receptor modulator rec-
antiresorptive properties (LeBoff 2022; Camacho 2020). ommended to prevent vertebral fractures in postmenopausal
women who may benefit from the added breast cancer risk
Romosozumab
reduction and in whom first-line therapies such as bisphos-
Romosozumab is a fully human monoclonal antibody that phonates or denosumab are not appropriate. The dual action
increases bone formation and decreases resorption by inhib- of raloxifene allows it to act as an estrogen agonist on bone
iting sclerostin. It has FDA approval for the treatment of oste- metabolism while acting an estrogen antagonist on breast and
oporosis in postmenopausal women at high risk of fracture. uterine tissues.
Romosozumab is available as a prefilled syringe and admin- Raloxifene has shown to reduce the risk of vertebral frac-
istered subcutaneously as two injections, one immediately tures by 30%-50% in postmenopausal women (Dickler 2001).
after the other, by a health care provider monthly (LeBoff 2022; However, raloxifene has not been shown to reduce the risk
Camacho 2020; Shoback 2020). A boxed warning states that of nonvertebral or hip fractures, which limits its use primar-
romosozumab may increase the risk of myocardial infarction, ily to those at risk of vertebral fractures (LeBoff 2022). Also,
stroke, and cardiovascular death. For women who experienced because of the risk of venous thromboembolism (VTE), it
an myocardial infarction or stroke in the past 12 months, romo- should not be used in patients that have a baseline VTE risk.
sozumab should not be initiated. If an myocardial infarction or
stroke occurs during treatment, romosozumab should be dis- Conjugated Equine Estrogens/Bazedoxifene
continued. (LeBoff 2022). The treatment duration is limited to Conjugated estrogens/bazedoxifene is approved for preven-
12 months because of its waning anabolic effect. After dis- tion of osteoporosis after menopause and for moderate-to-
continuation, antiresorptive therapy is warranted to maintain severe hot flashes associate with menopause. This medication

PSAP 2025 Book 2 • Geriatrics 19 Chapter: Osteoporosis

combines conjugated estrogen with bazedoxifene, an estro- Testosterone promotes osteoblast activity and inhibits
gen agonist/antagonist. Bazedoxifene reduces the risk of osteoclast activity, leading to an increase in bone formation
endometrial hyperplasia, eliminating the need for progestins and decrease in bone resorption. Testosterone therapy in men
in women who have not undergone hysterectomy. Similar to with low testosterone levels has been shown to increase lum-
raloxifene, this drug has only been shown to reduce vertebral bar spine BMD (Snyder 2017). The benefits for fracture preven-
fractures and carries the risk of VTE (LeBoff 2022). It may be tion remain unclear, however, because the data on fracture risk
considered as an alternative to bisphosphonates or selective reduction is limited and mixed.
estrogen receptor modulators for women with contraindica-
tions to these treatments and may be preferable to raloxifene Calcitonin
in women with concomitant vasomotor symptoms (Camacho Salmon calcitonin is an endogenous hormone that prevents
2020). bone breakdown, thereby increasing bone density. This agent
is approved for the treatment of postmenopausal women who
Menopausal Hormone Therapy are at least 5 years post-menopause. Calcitonin reduces verte-
Menopausal hormone therapy (MHT), which includes estro- bral fractures by about 30% and may reduce pain and shorten
gen alone or in combination with progestin, is typically pre- time to mobilization post vertebral fractures (Chesnut 2000;
scribed for women after menopause or bilateral ovariectomy Lyritis 1999, 1997). However, calcitonin does not reduce the
with progestin to protect the uterus from unopposed estro- risk of nonvertebral and hip fractures (Chesnut 2000). Further-
gen. Postmenopausal women who have had a hysterectomy more, its safety profile has raised concerns, most notably the
may be treated with estrogen therapy alone. Treatment with potential increased risk of cancer. Because of its limited effi-
MHT may decrease vertebral and nonvertebral fractures by cacy and safety concerns, calcitonin should only be considered
25%-50% (LeBoff 2022). in rare cases as a last-line option for patients who cannot toler-
Despite its efficacy in reducing fracture risk, safety con- ate other therapies (LeBoff 2022; NAMS 2021; Camacho 2020).
cerns limit the use of MHT. The Women’s Health Initiative
(WHI) trial revealed an increased risk of cardiovascular dis- Medication Management Considerations
ease, VTE, and breast cancer with prolonged use of combined Approach to Treatment Initiation
estrogen-progestin therapy (Rossouw 2002). As a result,
Individualization of pharmacotherapy is necessary because
guidelines suggest limiting use to women younger than 60
the ideal initial medication is the one that incorporates
years who are within 10 years of the onset of menopause, as
patient-specific characteristics and preferences while reduc-
well as using the lowest effective dose for the shortest dura-
ing fracture risk. The speed of the medication’s onset, current
tion necessary (LeBoff 2022; NAMS 2021). However, because
fracture risk, site(s) of recent fracture(s), and individualized
of the many flaws in the WHI study, MHT can be considered
treatment outcomes should also guide therapy selection.
after an extensive evaluation of a person risk of breast can-
Figure 1 incorporates guideline recommendations to provide a
cer and cardiovascular disease. If estrogen (estradiol) is pre-
suggested initial osteoporosis treatment approach.
scribed, transdermal doses of 0.25 mg/day or 0.5 mg/day
orally should be considered. Lower doses of transdermal Routine Monitoring
estradiol (14 mcg) also have skeletal benefits. If a woman has Routine monitoring is critical to assess treatment effective-
a uterus, progesterone 100 mg daily or 200 mg for 14 days are ness, track disease progression, and adjust therapeutic strat-
suggested. When considering the risk-benefit ratio, if a woman egies accordingly. A DXA scan should be repeated every 1 to
is identified at menopause as having osteopenia/osteoporo- 3 years after initiation of therapy (LeBoff 2022; NAMS 2021;
sis, many life-years remain with drugs that have limited dosing Camacho 2020). Routine height measurement at every clinical
durations. Starting with MHT can delay the need for the oste- visit is also recommended. A loss of height greater than 2 cm
oporosis drugs for up to 10 years. This option is limited if DXA should prompt further evaluation, including imaging studies to
screening is postponed to age 65 years. assess for new or worsening vertebral fractures.

Testosterone Medication Adherence

Testosterone is not typically recommended as a treatment for Medication adherence with osteoporosis treatment is criti-
osteoporosis. However, in men with hypogonadism, a condi- cal to achieve the benefits for BMD and fracture risk reduc-
tion characterized by low testosterone levels, testosterone tion. Discussing medication adherence is important before
therapy may improve BMD. Therefore, testosterone replace- therapy initiation because there is an association between
ment therapy may be considered in men with confirmed hypo- optimal adherence during the first year of treatment and sub-
gonadism (testosterone concentration less than 300 ng/dL) sequent years in patients prescribed bisphosphonates. In
and clinical signs of testosterone deficiency, including low addition, 25%-30% of patients do not start taking their pre-
BMD or a history of fragility fractures, after excluding contra- scribed osteoporosis medication and 50% or more of patients
indications (Bhasin 2018). do not continue treatment after 1 year; therefore, regularly

PSAP 2025 Book 2 • Geriatrics 20 Chapter: Osteoporosis

revisiting medication adherence is also critical (LeBoff 2022). unintentional, such as limited knowledge of osteoporosis, con-
In a study evaluating bisphosphonate adherence, less than cern with adverse effects, distrust with the prescriber or the
35% of patients initiated on therapy continued past 6 months medication, lack of understanding of the need for the medica-
and about 18% continued therapy past 1 year (Fatoye 2019). tion or its effectiveness, complexity of treatment regimen, and
Osteoporosis treatment options are available in a variety of cost (LeBoff 2022). Focused support, monitoring, and regular
dosage forms and have variable frequencies of use. Engaging contact with a health care provider, such as a nurse or phar-
patients in shared clinical decision-making can better promote macist, after starting treatment may be an effective way to
medication adherence because the patient is part of deci- improve medication adherence and fracture outcomes (NAMS
sion-making process and incorporates patient preferences. 2021; Camacho 2020).
Patient-decision aids bring evidence-based information about
Markers of Bone Turnover
osteoporosis, treatment options, outcomes, and probabilities
forward for discussion. Use of PDAs also improves patient At this time, biochemical markers of bone turnover (BTM) do not
knowledge, encourages reflection, reduces decisional con- have FDA approval for diagnosing osteoporosis or are not rou-
flict, and provides an opportunity for the patient to provide tinely used in assessing fracture risk; however, BTM markers
their preferences, allowing a consensus to be reached with do provide a dynamic assessment of skeletal activity because
their prescriber (Nogués 2022). they respond quickly to pharmacotherapeutic intervention.
A variety of factors can contribute to patient nonadher- Biochemical markers of bone resorption include serum C-
ence with osteoporosis medication, whether intentional or telopeptide (CTX) and urinary N-telopeptide, and biochemical

Patient Care Scenario

A 67-year-old postmenopausal Asian woman (weight pulmonary disease, and osteoporosis. The patient’s home
68 kg [150 lb], height 165 cm [65 inches]) is evaluated at drugs include the following: budesonide/formoterol 160
follow-up for osteoporosis screening. She has a medical mcg/4.5 mcg 2 inhalations twice daily and 1 inhalation as
history that includes asthma, hypothyroidism, dyslip- needed every 4 hours; levothyroxine 75 mcg orally daily;
idemia, and gastroesophageal reflux disease. Her last atorvastatin 20 mg orally daily; omeprazole 20 mg orally
menstrual period was at age 50 years; she has no children. daily; and calcium/vitamin D 500 mg/400 units orally with
Her social history is notable for drinking 1-2 alcohol- dinner. Vital signs include blood pressure 128/82 mm Hg
containing beverages/day and 4 cups of coffee/day and and heart rate 70 beats/minute. Central DXA T-scores are
smoking tobacco cigarettes (5 cigarettes/day); she denies femoral neck –1.8, lumbar spine –1.6, and total hip –1.4.
use of other substances. She lives in an apartment with Pertinent laboratory values are LDL cholesterol 84 mg/dL,
her fiancé and is employed as a business executive. Her total SCr 0.8 mg/dL, thyrotropin 3.2 mIU/L, and estimated
father is alive and has a history of a stroke, hypertension, glomerular filtration rate 72 mL/minute/1.73 m2. What is
dyslipidemia, chronic obstructive pulmonary disease, best to recommend regarding the status of this patient’s
and prostate cancer; her mother died after a hip frac- bone health?
ture, and she also had breast cancer, chronic obstructive

ANSWER
This patient has multiple risk factors for osteoporosis, First-line treatment options for postmenopausal
including being older age, female, and postmenopausal, women include alendronate, risedronate, zoledronic
with current alcohol and tobacco use, parental history of acid, and denosumab (Camacho 2020; LeBoff 2022).
osteoporosis, parental history of hip fracture, and use of The patient’s renal function is appropriate, and has she
a proton pump inhibitor (LeBoff 2022). She was screened no contraindications for bisphosphonate use. An oral
for osteoporosis based on multiple guideline recommen- bisphosphonate is generally preferred to an injectable
dations for all women older than 65 years (Camacho 2020; medication because of convenient oral administration
International Society for Clinical Densitometry 2019; and lower cost. The patient should be included in the
LeBoff 2022; USPSTF 2025). Her central DXA T-scores decision-making process in selecting therapy, ensuring
do not indicate osteoporosis but rather low bone mass that patient preferences are incorporated. If a bisphos-
(T-score –1.0 to –2.5) (Camacho 2020; International phonate is selected, the patient should be educated about
Society for Clinical Densitometry 2019); however, her correct use, including separate bisphosphonate adminis-
FRAX scores are 3.7% for 10-year hip fracture risk and 19% tration from other medications, food, and drink by 30-60
for 10-year major osteoporotic-related fracture risk. Her minutes, drinking 8 ounces of water, and remaining
T-scores coupled with her FRAX scores warrant treatment upright for at least 30 minutes after administration. The
(Camacho 2020). Total serum calcium and 25-hydroxyvi- patient should continue oral bisphosphonate therapy for
tamin D concentrations should be assessed to ensure 5 years before considering a drug holiday, provided that
they are within normal range; otherwise, supplementation the T-score remains above –2.5 and has no recent frac-
should be started and continued during therapy. ture (Camacho 2020; LeBoff 2022). A repeat DXA scan to
assess BMD can be completed in 1-3 years.

PSAP 2025 Book 2 • Geriatrics 21 Chapter: Osteoporosis

markers of bone formation include serum amino-terminal pro-
Practice Points
peptide of type 1 procollagen (P1NP), bone-specific alkaline
phosphatase, and osteocalcin. The National Bone Health Alli- • Osteoporosis is a preventable and treatable medical
condition. Pharmacists can have a role in all aspects of
ance with the American Association for Clinical Chemistry
disease state management including prevention, screening,
established CTX and P1NP as the preferred markers of bone treatment, monitoring for adverse effects and treatment
resorption and formation, respectively (LeBoff 2022;Camacho response, promoting medication adherence, and engaging
2020; Bauer 2012). patients in their care throughout the care continuum.
Of note, BTM may predict rapidity of bone loss, magni- • Osteoporosis screening is routinely recommended for
tude of BMD increases with pharmacotherapy, extent of frac- postmenopausal women; however, some guidelines
recommend screening men older than 70 years as well.
ture risk reduction after 3-6 months of pharmacotherapy, and
• Modifiable and nonmodifiable risk factors as well as
assess medication adherence (LeBoff 2022). Several recom- medical conditions and medications are associated with
mendations, including those of Endocrine Society, AACE/ACE osteoporosis. Routine evaluation, and modification of risk
Clinical Practice Guideline, and Bone Health & Osteoporosis factors as possible, especially as a younger adult, can
Foundation, note that monitoring serum CTX for antiresorp- positively impact bone health.
• DXA is the gold standard for evaluating BMD. The re-
tive therapy and P1NP for anabolic therapy can assess patient
ported T-scores are used to classify low bone mass and
medication adherence or response to therapy. They also com-
osteoporosis.
ment on the potential usefulness of BTM markers in assess- • Evaluating and supplementing calcium and/or vitamin D is
ing bisphosphonate drug holiday; however, more research is critical to bone health as well as before and during treat-
needed to fully describe the usefulness of BTM (LeBoff 2022; ment. Some studies have suggested a potential link be-
Camacho 2020; Eastell 2019). Of importance, BTM markers tween high calcium supplementation intake and increased
cardiovascular disease; however, the National Osteoporosis
are impacted by diurnal variations and food, requiring samples
Foundation and American Society of Preventative Cardiol-
to be collected fasting in the morning. In addition, high cost, ogy note that there is a lack of evidence linking the two and
lack of standard reference ranges, and variable results depen- that calcium intakes not exceeding the upper limit are safe
dent on the laboratory and assay used limit the widespread from a cardiovascular standpoint.
use and usefulness of BTM for risk assessment (Camacho • For osteoporosis treatment in postmenopausal females
with moderate to high fracture risk, bisphosphonates (alen-
2020; Eastell 2019).
dronate, risedronate, and zoledronic acid) and denosumab
are considered first-line agents. For those with very high
fracture risk, anabolic agents (abaloparatide and teriparati-
CONCLUSION de) and romosozumab are recommended and should be
The role of the pharmacist in preventing and treating osteo- followed by antiresorptive therapy.
porosis is multifaceted. Pharmacists play a crucial role in • For osteoporosis treatment in men with moderate to high
fracture risk, bisphosphonates (alendronate, risedronate,
identifying patients at risk of osteoporosis, particularly those
and zoledronic acid) and denosumab are considered first-
who may be asymptomatic. By reviewing patient profiles and
line agents. For those with very high fracture risk, anabolic
medication histories, pharmacists can help identify potential agents (abaloparatide and teriparatide) are recommended
medication-related causes, and flag individuals for further and should be followed by antiresorptive therapy.
evaluation/testing. Counseling on vitamin D and calcium can • Multiple guidelines provide guidance on osteoporosis
also be provided by pharmacists, who are key educators. screening, treatment, and management. Shared deci-
sion-making for individualized therapy selection, and
Given their expertise in medication management, phar-
patient follow-up after therapy initiation can promote
macists are well positioned for immersion in the medication medication adherence.
management process. They can collaborate with prescrib-
ers to select guideline-recommended agents and incorpo-
rate patient-specific factors as well as cost. Pharmacists treatment. Continuous updates in guidelines and therapeutic
can monitor for drug interactions, mitigate adverse effects, advancements provide clinicians with the tools to effectively
and improve adherence. They can assess response and rec- manage osteoporosis. Pharmacists are uniquely positioned to
ommend adjustments to therapy. In addition, there may be contribute to improving patient outcomes and reducing bur-
an opportunity to engage treatment prescribing through den of osteoporosis-related fractures.
collaborative practice agreements, as well as improve
osteoporosis-related quality measures.
Osteoporosis is a prevalent condition, particularly in
REFERENCES
postmenopausal women and older adults. A comprehen- Adler RA. Osteoporosis in men: a review. Bone Res.
2014;2:14001. [Link]
sive approach, incorporating both prevention and treatment
strategies, is crucial for reducing the morbidity and mortal- Adler RA, El-Hajj Fuleihan G, Bauer DC, et al. Managing osteo-
ity associated with this condition. It is essential to recognize porosis in patients on long-term bisphosphonate treatment:
the sex differences and disparities that exist in screening and report of a task force of the American Society for Bone

PSAP 2025 Book 2 • Geriatrics 22 Chapter: Osteoporosis

 and Mineral Research. J Bone Miner Res. 2016;31(1):16-35. Chesnut CH 3rd, Silverman S, Andriano K, et al. A randomized
[Link] trial of nasal spray salmon calcitonin in postmenopausal
women with established osteoporosis: the prevent recur-
Anderson JJ, Kruszka B, Delaney JA, et al. Calcium intake rence of osteoporotic fractures study. PROOF Study Group.
from diet and supplements and the risk of coronary artery Am J Med. 2000;109(4):267-276. [Link]
calcification and its progression among older adults: s0002-9343(00)00490-3
10-year follow-up of the multi-ethnic study of atherosclero-
sis (MESA). J Am Heart Assoc. 2016;5(10):e003815. Choksi P, Gay BL, Haymart MR, Papaleontiou M. Physician-
[Link] reported barriers to osteoporosis screening: a nationwide
survey. Endocr Pract. 2023;29(8):606-611. [Link]
Barrionuevo P, Kapoor E, Asi N, et al. Efficacy of pharmaco- 10.1016/[Link].2023.05.001
logical therapies for the prevention of fractures in post-
menopausal women: a network meta-analysis. J Clin Chung M, Tang AM, Newberry SJ. Calcium intake and cardio-
Endocrinol Metab. 2019;104(5):1623-1630. [Link] vascular disease risk. Ann Intern Med. 2017;166(9):686-687.
10.1210/jc.2019-00192 [Link]

Bauer D, Krege J, Lane N, et al. National Bone Health Alliance Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab
Bone Turnover Marker Project: current practices and the treatment in postmenopausal women with osteoporosis.
need for US harmonization, standardization, and common N Engl J Med. 2016;375(16):1532-1543. [Link]
reference ranges. Osteoporos Int. 2012;23(10):2425-2433. 10.1056/nejmoa1607948
[Link]
Cosman F, Miller PD, Williams GC, et al. Eighteen months
Bhasin S, Brito JP, Cunningham GR, et al. Testosterone of treatment with subcutaneous abaloparatide followed
therapy in men with hypogonadism: an Endocrine Soci- by 6 months of treatment with alendronate in postmeno-
ety clinical practice guideline. J Clin Endocrinol Metab. pausal women with osteoporosis: results of the ACTIVEx-
2018;103(5):1715-1744. [Link] tend trial. Mayo Clin Proc. 2017;92(2):200-210. [Link]
2018-00229 org/10.1016/[Link].2016.10.009

Binkley N, Adler R, Bilezikian JP. Osteoporosis diagnosis in Cummings SR, Ferrari S, Eastell R, et al. Vertebral fractures
men: the T-score controversy revisited. Curr Osteoporos after discontinuation of denosumab: a post hoc analysis of
Rep. 2014;12(4):403-409. [Link] the randomized placebo-controlled FREEDOM trial and its
014-0242-z extension. J Bone Miner Res. 2018;33(2):190-198. https://
[Link]/10.1002/jbmr.3337
Bolland MJ, Grey A, Reid IR. Calcium supplements and cardio-
vascular risk: 5 years on. Ther Adv Drug Saf. 2013;4(5): Cummings SR, San Martin J, McClung MR, et al. Denosumab
199-210. [Link] for prevention of fractures in postmenopausal women with
osteoporosis. N Engl J Med. 2009;361(8):756-765. https://
Camacho PM, Petak SM, Binkley N, et al. American Asso- [Link]/10.1056/nejmoa0809493
ciation of Clinical Endocrinologists/American College of
Endocrinology clinical practice guidelines for the diagno- Czerwinski E, Cardona J, Plebanski R, et al. The efficacy and
sis and treatment of postmenopausal osteoporosis-2020 safety of abaloparatide-SC in men with osteoporosis:
update. Endocr Pract. 2020;26(Suppl 1):1-46. [Link] a randomized clinical trial. J Bone Miner Res. 2022;37(12):
org/10.4158/gl-2020-0524suppl 2435-2442. [Link]

Centers for Disease Control and Prevention (CDC). STEADI— De Martinis M, Sirufo MM, Polsinelli M, Placidi G, Di Silves-
older adult fall prevention. CDC, 2024. [Link]/ tre D, Ginaldi L. Gender differences in osteoporosis: a
steadi/about/[Link] single-center observational study. World J Mens Health.
2021;39(4):750-759. [Link]
Centers for Medicare & Medicaid Services (CMS). CMS
Medicare 2024 Part C & D Star Ratings technical notes. Dickler MN, Norton L. The MORE trial: multiple outcomes
CMS, 2024a. [Link]/files/document/2024-star- for raloxifene evaluation—breast cancer as a secondary
[Link] end point: implications for prevention. Ann N Y Acad Sci.
2001;949:134-142.
Centers for Medicare & Medicaid Services (CMS). CMS stra-
tegic plan: health equity. CMS, 2024b. [Link]/files/ Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH,
document/[Link] Shoback D. Pharmacological management of oste-
oporosis in postmenopausal women: an Endocrine
Chavda S, Chavda B, Dube R. Osteoporosis screening and Society* clinical practice guideline. J Clin Endocrinol
fracture risk assessment tool: its scope and role in general Metab. 2019;104(5):1595-1622. [Link]
clinical practice. Cureus. 2022;14(7):e26518. [Link] jc.2019-00221
org/10.7759/cureus.26518
Fatoye F, Smith P, Gebrye T, Yeowell G. Real-world persistence
Chen Y, Strasser S, Cao Y, Wang KS, Zheng S. Calcium intake and adherence with oral bisphosphonates for osteoporo-
and hypertension among obese adults in United States: sis: a systematic review. BMJ Open. 2019;9(4):e027049.
associations and implications explored. J Hum Hypertens. [Link]
2015;29(9):541-547. [Link]

PSAP 2025 Book 2 • Geriatrics 23 Chapter: Osteoporosis

Gilsenan A, Midkiff K, Harris D, Kellier-Steele N, McSorley D, Kendler DL, Marin F, Zerbini CAF, et al. Effects of teriparatide
Andrews EB. Teriparatide did not increase adult osteosar- and risedronate on new fractures in post-menopausal
coma incidence in a 15-year us postmarketing surveillance women with severe osteoporosis (VERO): a multicentre,
study. J Bone Miner Res. 2021;36(2):244-251. [Link] double-blind, double-dummy, randomised controlled trial.
org/10.1002/jbmr.4188 Lancet. 2018;391(10117):230-240. [Link]
s0140-6736(17)32137-2
Groenendijk I, van Delft M, Versloot P, van Loon LJC, de
Groot LCPGM. Impact of magnesium on bone health Khan B, Nowson CA, Daly RM, et al. Higher dietary cal-
in older adults: a systematic review and meta-analysis. cium intakes are associated with reduced risks of frac-
Bone. 2022;154:116233. [Link] tures, cardiovascular events, and mortality: a prospective
bone.2021.116233 cohort study of older men and women. J Bone Miner Res.
2015;30(10):1758-1766. [Link]
Healthy People 2030. Osteoporosis Workgroup. Office of
Disease Prevention and Health Promotion, 2025. https:// Khan QJ, Fabian CJ. How I treat vitamin D deficiency. J Oncol
[Link]/healthypeople/about/workgroups/osteo- Pract. 2010;6(2):97-101. [Link]
porosis-workgroup#:~:text=In%20the%20United%20
States%2C%20an,at%20increased%20risk%20for%20oste- Kim TY, Schafer AL. Variability in DXA reporting and other
oporosis . challenges in osteoporosis evaluation. JAMA Intern
Med. 2016;176(3):393-395. [Link]
Huo X, Clarke R, Halsey J, et al. Calcium supplements and jamainternmed.2015.7550
risk of CVD: a meta-analysis of randomized trials. Curr
Dev Nutr. 2023;7(3):100046. [Link] Kopecky SL, Bauer DC, Gulati M, et al. Lack of evidence link-
cdnut.2023.100046 ing calcium with or without vitamin d supplementation to
cardiovascular disease in generally healthy adults: a clin-
Institute of Medicine (IOM). Dietary Reference Intakes for ical guideline from the National Osteoporosis Foundation
Calcium and Vitamin D. National Academies Press; 2011. and the American Society for Preventive Cardiology. Ann
[Link]/books/NBK56070/ Intern Med. 2016;165(12):867-868. [Link]
m16-1743
Institute of Medicine (IOM), Food and Nutrition Board. Dietary
Reference Intakes for Calcium and Vitamin D. National Krege JH, Gilsenan AW, Komacko JL, Kellier-Steele N. Teri-
Academies Press, 2010. [Link] paratide and osteosarcoma risk: history, science, elimina-
books/NBK56070/ tion of boxed warning, and other label updates. JBMR Plus.
2022;6(9):e10665. [Link]
International Osteoporosis Foundation (IOF). Facts and
statistics about osteoporosis and its impact: epide- LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician’s
miology of osteoporosis and fragility fractures. IOF, guide to prevention and treatment of osteoporosis. Osteo-
2023. [Link]/facts-statistics/ poros Int. 2022;33(10):2049-2102. [Link]
epidemiology-of-osteoporosis-and-fragility-fractures s00198-021-05900-y

International Society for Clinical Densitometry (ISCD). Indi- Leder BZ, Tsai JN, Uihlein AV, et al. Denosumab and teri-
cations for bone mineral density (BMD) testing [Adult Offi- paratide transitions in postmenopausal osteoporosis
cial Positions of ISCD]. ISCD, 2019. [Link] (the DATA-Switch study): extension of a randomised con-
official-positions/adult-positions/ trolled trial. Lancet. 2015;386(9999):1147-1155. [Link]
org/10.1016/s0140-6736(15)61120-5
Kahwati LC, Weber RP, Pan H, et al. Vitamin D, calcium, or
combined supplementation for the primary prevention of Lewiecki EM, Blicharski T, Goemaere S, et al. A phase III ran-
fractures in community-dwelling adults: evidence report domized placebo-controlled trial to evaluate efficacy and
and systematic review for the US Preventive Services safety of romosozumab in men with osteoporosis. J Clin
Task Force. JAMA. 2018;319(15):1600-1612. [Link] Endocrinol Metab. 2018;103(9):3183-3193. [Link]
org/10.1001/jama.2017.21640 org/10.1210/jc.2017-02163

Kanis JA, Harvey NC, McCloskey E, et al. Algorithm for the Lewiecki EM, Dinavahi RV, Lazaretti-Castro M, et al. One year
management of patients at low, high and very high risk of of romosozumab followed by two years of denosumab
osteoporotic fractures. Osteoporos Int. 2020;31(1):1-12. maintains fracture risk reductions: results of the FRAME
[Link] Extension Study. J Bone Miner Res. 2019a;34(3):419-428.
[Link]
Kanis JA, Melton LJ 3rd, Christiansen C, Johnston CC,
Khaltaev N. The diagnosis of osteoporosis. J Bone Lewiecki EM, Ortendahl JD, Vanderpuye-Orgle J, et al. Health-
Miner Res. 1994;9(8):1137-1141. [Link] care policy changes in osteoporosis can improve out-
jbmr.5650090802 comes and reduce costs in the United States. JBMR Plus.
2019b;3(9):e10192. [Link]
Kaufman JM, Orwoll E, Goemaere S, et al. Teriparatide
effects on vertebral fractures and bone mineral density in Lyritis GP, Ioannidis GV, Karachalios T, et al. Analgesic effect
men with osteoporosis: treatment and discontinuation of of salmon calcitonin suppositories in patients with acute
therapy. Osteoporos Int. 2005;16(5):510-516. [Link] pain due to recent osteoporotic vertebral crush fractures: a
org/10.1007/s00198-004-1713-3 prospective double-blind, randomized, placebo-controlled

PSAP 2025 Book 2 • Geriatrics 24 Chapter: Osteoporosis

 clinical study. Clin J Pain. 1999;15(4):284-289. [Link] from the American College of Physicians. Ann Intern Med.
org/10.1097/00002508-199912000-00004 2023;176(2):224-238. [Link]

Lyritis GP, Paspati I, Karachalios T, Ioakimidis D, Skarantavos Rao SS, Budhwar N, Ashfaque A. Osteoporosis in men. Am
G, Lyritis PG. Pain relief from nasal salmon calcitonin in Fam Physician. 2010;82(5):503-508.
osteoporotic vertebral crush fractures. A double blind, pla-
cebo-controlled clinical study. Acta Orthop Scand Suppl. Reid IR, Birstow SM, Bolland MJ. Calcium and cardiovascu-
1997;275:112-114. [Link] lar disease. Endocrinol Metab (Seoul). 2017;32(3):339-349.
11744761 [Link]

Miller PD, Hattersley G, Riis BJ, et al. Effect of abalopa- Rossouw JE, Anderson GL, Prentice RL, et al. Risks and bene-
ratide vs placebo on new vertebral fractures in postmeno- fits of estrogen plus progestin in healthy postmenopausal
pausal women with osteoporosis: a randomized clinical women: principal results from the Women’s Health Initia-
trial. JAMA. 2016;316(7):722-733. [Link] tive randomized controlled trial. JAMA. 2002;288(3):321-
jama.2016.11136 333. [Link]

National Committee for Quality Assurance (NCQA). HEDIS Saag KG, Petersen J, Brandi ML, et al. Romosozumab or alen-
measures and technical resources. NCQ, 2025. [Link]. dronate for fracture prevention in women with osteopo-
org/hedis/measures/ rosis. N Engl J Med. 2017;377(15):1417-1427. [Link]
org/10.1056/nejmoa1708322
National Institutes of Health (NIH), Office of Dietary Supple-
ments. Calcium: fact sheet for health professionals. NIH, Sato T, Inaba N, Yamashita T. MK-7 and its effects on bone
2024a. Updated July 24, 2024. [Link] quality and strength. Nutrients. 2020;12(4):965. [Link]
factsheets/Calcium-HealthProfessional/ org/10.3390/nu12040965

National Institutes of Health (NIH), Office of Dietary Sup- Shevroja E, Cafarelli FP, Guglielmi G, Hans D. DXA parame-
plements. Dietary Supplement Label Database (DSLD). ters, trabecular bone score (TBS) and bone mineral density
Updated periodically. [Link] (BMD), in fracture risk prediction in endocrine-mediated
Dietary_Supplement_Label_Database.aspx secondary osteoporosis. Endocrine. 2021;74(1):20-28.
[Link]
National Institutes of Health (NIH), Office of Dietary Supple-
ments. Vitamin D: fact sheet for health professionals. NIH, Shoback D, Rosen CJ, Black DM, Cheung AM, Murad MH,
2024b. Updated July 26, 2024. [Link] Eastell R. Pharmacological management of osteoporosis
factsheets/VitaminD-HealthProfessional/ in postmenopausal women: an Endocrine Society guide-
line update. J Clin Endocrinol Metab. 2020;105(3):dgaa048.
Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathy- [Link]
roid hormone (1-34) on fractures and bone mineral den-
sity in postmenopausal women with osteoporosis. N Engl Snyder PJ, Kopperdahl DL, Stephens-Shields AJ, et al. Effect
J Med. 2001;344(19):1434-1441. [Link] of testosterone treatment on volumetric bone density
nejm200105103441904 and strength in older men with low testosterone: a con-
trolled clinical trial. JAMA Intern Med. 2017;177(4):471-479.
Nogués X, Carbonell MC, Canals L, Lizán L, Palacios S. Cur- [Link]
rent situation of shared decision making in osteoporo-
sis: A comprehensive literature review of patient decision U.S. Preventive Services Task Force (USPSTF). Osteoporosis
aids and decision drivers. Health Sci Rep. 2022;5(6):e849. to prevent fractures: screening. Updated January 14, 2025.
[Link] [Link]
recommendation/osteoporosis-screening.
North American Menopause Society (NAMS). Management
of osteoporosis in postmenopausal women: the 2021 Vilaca T, Eastell R, Schini M. Osteoporosis in men. Lan-
position statement of The North American Menopause cet Diabetes Endocrinol. 2022;10(4):273-283. [Link]
Society. Menopause. 2021;28(9):973-997. [Link] org/10.1016/s2213-8587(22)00012-2
[Link]/menopausejournal/abstract/2021/09000/ Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in
management_of_osteoporosis_in_postmenopausal.[Link] men: an Endocrine Society clinical practice guideline.
Office of the Surgeon General (US). Bone Health and Osteo- J Clin Endocrinol Metab. 2012;97:1802-22. [Link]
porosis: A Report of the Surgeon General. Office of the Sur- org/10.1210/jc.2011-3045
geon General (US); 2004. [Link] Weaver CM. Calcium. In: Marriott BP, Birt DF, Stallings VA,
gov/20945569/ Yates AA, eds. Present Knowledge in Nutrition. 11th ed.
Porter JL, Varacallo M. Osteoporosis. Updated August 4, Wiley-Blackwell; 2020:321-48.
2023. In: StatPearls [internet]. StatPearls Publishing; Janu- Weaver CM, Alexander DD, Boushey CJ, et al. Calcium plus
ary 2024. [Link]/books/NBK441901/ vitamin D supplementation and risk of fractures: an
Qaseem A, Hicks LA, Etxeandia-Ikobaltzeta I, et al. Pharmaco- updated meta-analysis from the National Osteoporosis
logic treatment of primary osteoporosis or low bone mass Foundation. Osteoporos Int. 2016;27(1):367-376. https://
to prevent fractures in adults: a living clinical guideline [Link]/10.1007/s00198-015-3386-5

PSAP 2025 Book 2 • Geriatrics 25 Chapter: Osteoporosis

Weaver CM, Heaney RP. Calcium. In: Ross AC, Caballero B, Zaheer S, LeBoff M, Lewiecki EM. Denosumab for the treat-
Cousins RJ, Tucker KL, Ziegler TR, eds. Modern nutrition in ment of osteoporosis. Expert Opin Drug Metab Toxicol.
health and disease. 11th ed. Lippincott Williams & Wilkins; 2015;11(3):461-470. [Link]
2014:133-49. 5.1000860

Wei FL, Li T, Gao QY, et al. Association between vitamin D Zhao JG, Zeng XT, Wang J, Liu L. Association between cal-
supplementation and fall prevention. Front Endocrinol cium or vitamin D supplementation and fracture inci-
(Lausanne). 2022;13:919839. [Link] dence in community-dwelling older adults: a systematic
fendo.2022.919839 review and meta-analysis. JAMA. 2017;318(24):2466-2482.
[Link]
Wainwright SA, Marshall LM, Ensrud KE, et al. Hip fracture
in women without osteoporosis. J Clin Endocrinol Metab
2005;90:2787-9. [Link]

PSAP 2025 Book 2 • Geriatrics 26 Chapter: Osteoporosis

Self-Assessment Questions
The next three questions pertain to the following C. Calculating a GARVAN score and removing obstacles
case. at home
S.A., a 66-year-old White woman (weight 59 kg [130 lb], height D. Incorporating physical activity and assessing home
170.2 cm [67 inches], BMI 20.4 kg/m2), comes to the primary environmental factors
care clinic for her annual wellness visit. Her last menstrual
5. Two 65-year-old patients, a man and a woman, are at risk
period was at age 52 years. S.A.’s medical history includes
for osteoporosis. They both have a history of diabetes,
hypertension, hypothyroidism, and generalized anxiety dis-
hypertension, and asthma. They each smoke cigarettes
order. Her home drugs include losartan 100 mg orally daily,
(½ pack daily) and enjoy two glasses of wine with dinner
levothyroxine 100 mcg orally daily (thyrotropin within normal
each evening. On the basis of current population-based
limits), and escitalopram 10 mg orally daily. Her family history
evidence, which one of the following best evaluates the
is significant for myocardial infarction, type 2 diabetes, and
difference in likely outcomes for these two patients?
osteoporosis in her mother and hypertension, hyperlipidemia,
and for chronic obstructive pulmonary disease in her father. A. The woman is more likely to be under-screened and
S.A. denies tobacco use, consumes four alcoholic beverages underdiagnosed and has a greater risk of fracture-
per week, and walks 60 minutes daily. related mortality.
B. The woman is more likely to be under-screened and
1. Which one of the following would be best to obtain in eval-
underdiagnosed and has a lower risk of fracture-
uating S.A.’s bone health?
related mortality.
A. Blood pressure C. The man is more likely to be under-screened and
B. Calcium and vitamin D intake underdiagnosed and has a greater risk of fracture-
C. MORES risk score related mortality.
D. GARVAN risk score D. The man is more likely to be under-screened and
2. According to US Preventive Services Task Force (USPSTF), underdiagnosed and has a lower risk of fracture-
which one of the following best evaluates S.A.’s osteopo- related mortality.
rosis risk and need for further evaluation? 6. A 51-year-old woman (BMI 23 kg/m2) comes in for her
A. Her age warrants a central dual-energy x-ray annual physical examination. Her medical history includes
absorptiometry (DXA) scan. hypertension, which is well-controlled with lisinopril, and
B. Her 10-year risk of a hip fracture is 2.4%; no further seasonal allergies, for which she takes cetirizine. The
evaluation is warranted. patient plays pickleball three times per week. She asks
C. Her 10-year risk of a hip fracture is 2.4%; a central whether taking a calcium supplement may reduce her risk
DXA scan should be ordered. of fractures as well as reduce her risk of cardiovascular
D. Her 10-year risk of a major osteoporotic fracture is disease. Which one of the following educational points is
10%; no further evaluation is warranted. best to share with this patient?

3. S.A. receives a DXA scan; T-scores are –2.0 at the femoral A. Currently there is lack of strong evidence linking
neck, –1.5 at the lumbar spine, and –2.5 for the total hip. calcium supplementation to cardiovascular disease.
Which one of the following is best to recommend for S.A.? B. There is strong evidence that calcium supplementa-
tion increases the risk of cardiovascular disease.
A. Ibandronate 150 mg orally monthly
C. A 10-year study found the risk of atherosclerosis was
B. Raloxifene 60 mg orally daily
higher in those taking the highest amount of calcium
C. Risedronate 150 mg orally monthly
intake.
D. Alendronate 5 mg orally daily
D. A 13-year prospective cohort study found a higher
4. The pharmacist member of an interprofessional care team rate of stroke in those taking the highest calcium
is preparing to discharge to home a 92-year-old man who intake.
recently sustained a vertebral fracture. Which one of the
following is best for the pharmacist to discuss with a home
physical therapist to minimize this patient’s fall risk?
A. Evaluating the patient’s memory and balance
B. Assessing medication adherence and nutrition at
home

PSAP 2025 Book 2 • Geriatrics 27 Chapter: Osteoporosis

7. According to the Bone Health & Osteoporosis Foundation, 11. Which one of the following is best to recommend regard-
which one of the following patients is most likely to bene- ing J.P.’s magnesium intake?
fit from osteoporosis screening with a DXA scan?
A. Initiate supplementation due to hypomagnesemia.
A. A 69-year-old-man with a 33% radius (1/3 radius) B. Initiate supplementation to offset the potential
fracture at age 48 years diarrhea side effect from metformin.
B. A 60-year-old-postmenopausal woman with Crohn C. Avoid foods rich in magnesium.
disease D. Avoid magnesium supplementation.
C. A 65-year-old-man who had a myocardial infarction
2 months ago The next three questions pertain to the following case.
D. A 52-year-old woman in the menopausal transition S.J., a 68-year-old man (weight 97.7 kg [215.4 lb], height 183 cm
with atopic dermatitis [72 inches]), comes to a primary care clinic visit after having a
8. A 66-year-old man with osteoporosis is taking zoledronic DXA scan that showed a T-score score –2.2 at the hip, –1.9 at
acid 5 mg intravenously yearly. His recent T-score is –2.3 the femoral neck, and –2.1 at the spine. He currently takes losar-
and he has had no new fractures. Which one of the follow- tan, phenytoin, and sertraline. S.J.’s pertinent laboratory values
ing is the best time to recommend a bisphosphonate drug include albumin 4.5 g/dL, total serum calcium 10.0 mg/dL, SCr
holiday for this patient? 0.9 mg/dL, and testosterone concentration 557 ng/dL.

A. After 1 year of zoledronic acid 12. Which one of the following is best to recommend for S.J.?
B. After 3 years of zoledronic acid A. Alendronate 70 mg orally weekly
C. After 5 years of zoledronic acid B. Ibandronate 150 mg orally monthly
D. After 6 years of zoledronic acid C. Romosozumab 210 mg subcutaneously monthly
D. Teriparatide 20 mcg subcutaneously daily
The next three questions pertain to the following case.
13. Which one of the following best assesses the number of
J.P., a 56-year-old woman (weight 54.5 kg [120.2 lb], height
medications that may be contributing to secondary oste-
162.5 cm [64 inches]), comes to the primary care clinic for her
oporosis in S.J.?
annual physical examination. Her medical history includes
diabetes, hypertension, and osteoporosis. J.P.’s home drugs A. None
include metformin 1000 mg twice daily, empagliflozin 25 mg B. One
once daily, lisinopril 20 mg daily, and alendronate 10 mg daily. C. Two
She takes in about 600 mg calcium per day through her diet. D. Three
Pertinent laboratory values include albumin 4.0 g/dL, total 14. Which one of the following is best to recommend regard-
serum calcium 8.9 mg/dL, magnesium 2.2 mg/dL, SCr 0.9 mg/ ing testosterone replacement therapy for S.J.?
dL, and total serum 25-hydroxyvitamin D 19 ng/mL. J.P. denies
A. Do not recommend; he does not have hypogonadism
tobacco use and consumes one alcoholic beverage per week.
or clinical signs of testosterone deficiency.
9. Which one of the following is best to recommend regard- B. Do not recommend; testosterone is not
ing J.P.’s calcium intake? recommended as an option in any patients with
A. Supplement with 300 mg of calcium per day. osteoporosis.
B. Supplement with 600 mg of calcium per day. C. Recommend; he has hypogonadism and clinical
C. Supplement with 1200 mg of calcium per day. signs of testosterone deficiency.
D. Do not supplement with calcium. D. Recommend; testosterone should be added to his
osteoporosis treatment plan.
10. Which one of the following is best to recommend regard-
ing J.P.’s vitamin D intake? 15. A 71-year-old woman with osteoporosis is taking iband-
ronate 150 mg orally monthly. Her recent T-score is –2.7
A. Vitamin D3 1000 international units daily
at the hip, –2.5 at the femoral neck, and –2.6 at the spine.
B. Vitamin D3 5000 international units weekly
She recently sustained a fracture. At which one of the fol-
C. Vitamin D2 50,000 international units weekly
lowing times would it be best to consider a bisphospho-
D. No vitamin D supplementation
nate drug holiday for this patient?
A. After 3 years of ibandronate
B. After 6 years of ibandronate
C. After 10 years of ibandronate
D. No drug holiday

PSAP 2025 Book 2 • Geriatrics 28 Chapter: Osteoporosis