Would you start romosozumab in an active smoker?

This is not simple! But we are good at assessment of risk vs benefit (or benefit vs risk!)

First I would reassess fracture risk, prior treatments, reason to consider romo.

Then I would do a deep dive into risk assessment for cardiovascular disease: how much do they smoke, prior cardiovascular disease events, family hx of cardiovascular events, co-morbidities that increase CV risk, any testing like stress testing, etc.

Finally, I would have a good benefit/risk discussion with the patient and engag...