What treatment is recommended for a patient with a normal Dual-Energy X-ray Absorptiometry (DEXA) scan but a 5% risk of hip fracture?

Pharmacologic Treatment is Recommended

A patient with a 5% 10-year hip fracture risk meets the threshold for pharmacologic osteoporosis treatment, even with a normal DEXA scan, and should be started on oral bisphosphonates as first-line therapy along with calcium and vitamin D supplementation. 1, 2

Treatment Threshold Justification

• The 5% hip fracture risk exceeds the established treatment threshold of ≥3% 10-year hip fracture probability, which is the criterion used by the National Osteoporosis Foundation and ACOG guidelines to initiate pharmacologic intervention 1, 2
• This threshold applies regardless of DEXA T-score results, as fracture risk assessment incorporates clinical factors beyond bone mineral density alone 1, 2
• The ACOG guidelines explicitly state that pharmacologic treatment should be considered in women with a 10-year hip fracture risk of at least 3%, even when T-scores are between -1.0 and -2.5 (or normal) 1

First-Line Pharmacologic Treatment

Oral bisphosphonates (alendronate or risedronate) should be prescribed as first-line therapy based on the following evidence:

• Bisphosphonates are recommended as first-line therapy for fracture prevention, with selection based on patient preference 1, 2
• Alendronate has demonstrated a 51% relative risk reduction in hip fractures in patients with baseline vertebral fractures and a 48% reduction in new vertebral fractures 3
• The FDA-approved dosing for alendronate is 10 mg daily or 70 mg weekly for treatment 1, 3

Mandatory Concurrent Non-Pharmacologic Treatment

All patients receiving osteoporosis treatment must receive:

• Calcium supplementation: 1,200 mg daily for patients 51-70 years and older 1, 2
• Vitamin D supplementation: 600-800 IU daily (800 IU for those ≥71 years), targeting serum 25(OH)D levels ≥20 ng/mL (some guidelines suggest 30-50 ng/mL) 1, 2
• Weight-bearing exercise to improve bone density 2
• Smoking cessation and alcohol limitation (≤2 servings daily) 1, 2
• Fall prevention strategies including balance training and home safety assessment 1, 2

Monitoring and Follow-Up

• Repeat DEXA scan after 2 years of therapy to assess treatment effectiveness and BMD changes 2, 4
• Annual monitoring is not recommended during the initial treatment period 2
• Reassess fracture risk every 1-2 years using clinical factors, BMD, and vertebral fracture assessment 1

Important Clinical Caveats

• A "normal" DEXA scan does not exclude significant fracture risk, as approximately 50% of patients who sustain osteoporotic fractures have T-scores above -2.5 5
• The FRAX tool incorporates clinical risk factors (age, prior fracture, parental hip fracture, glucocorticoid use, smoking, alcohol, rheumatoid arthritis) that independently predict fracture risk beyond BMD alone 1, 4
• Most patients (83-85%) designated as high fracture risk by FRAX actually have osteoporotic T-scores at one or more skeletal sites when all sites are measured, but conversely, <1% of high-risk patients have completely normal T-scores 5
• Bisphosphonate contraindications include esophageal abnormalities, inability to stand/sit upright for 30 minutes, and hypocalcemia—these must be screened before prescribing 1
• Alternative agents (raloxifene, denosumab, teriparatide) should be reserved for patients who cannot tolerate bisphosphonates or have contraindications 1

Treatment Duration Considerations

• Treatment should continue as long as fracture risk remains elevated 1
• The effect of bisphosphonates may diminish after discontinuation, requiring long-term therapy planning 6
• Reassessment at 1-2 year intervals allows for adjustment of therapy based on BMD response and ongoing fracture risk 1