What is the recommended care guideline for an older adult patient with a DEXA (Dual-Energy X-ray Absorptiometry) scan score indicating osteoporosis?

Management of DEXA T-Score of -2.5

A T-score of -2.5 meets the World Health Organization diagnostic threshold for osteoporosis and requires initiation of pharmacologic treatment with bisphosphonates as first-line therapy, along with calcium and vitamin D supplementation. 1, 2

Diagnostic Confirmation

• A T-score of -2.5 represents bone mineral density that is 2.5 standard deviations below the young adult mean, which is the precise diagnostic cutoff for osteoporosis according to WHO criteria 1
• This diagnosis applies when the T-score of -2.5 is measured at the lumbar spine, femoral neck, total hip, or one-third radius 1
• The lowest T-score from any of these measurement sites should be used for diagnostic classification 1

Immediate Treatment Recommendations

Pharmacologic Therapy

Oral bisphosphonates are the first-line treatment for patients with a T-score of -2.5. 3, 4

• Bisphosphonates reduce vertebral fractures by 52 per 1000 person-years (95% CI: -95 to -18) and hip fractures by 6 per 1000 person-years (95% CI: -11 to -1) 2
• Alendronate is a commonly used oral bisphosphonate, with dosing of 5 mg daily or 10 mg daily depending on patient weight and specific indication 5
• If oral bisphosphonates are contraindicated or not tolerated, parenteral therapy with denosumab 60 mg subcutaneously every 6 months should be considered 6, 3

Universal Supplementation

All patients with osteoporosis require calcium and vitamin D supplementation regardless of pharmacologic treatment choice. 1, 2

• Calcium: 1000-1200 mg daily 1, 2
• Vitamin D: 800-1000 IU daily (some guidelines recommend 600-800 IU) 1, 2

Risk Stratification and Additional Assessment

Fracture Risk Assessment

• Patients with T-scores of -2.5 have high risk for hip and vertebral fractures 1
• Consider calculating FRAX score to quantify 10-year absolute fracture risk, which incorporates BMD along with clinical risk factors including age, gender, prior fractures, family history, smoking, glucocorticoid use, and rheumatoid arthritis 2, 4

Vertebral Fracture Assessment

Consider vertebral fracture assessment (VFA) imaging, as vertebral fractures are often asymptomatic and represent the strongest predictor of future fractures. 7

• VFA is indicated for patients with T-score < -1.0 who are women aged ≥70 years or men aged ≥80 years 8
• VFA is also indicated for patients with historical height loss >4 cm, self-reported prior vertebral fracture, or glucocorticoid use ≥5 mg prednisone equivalent daily for ≥3 months 8
• The presence of a vertebral fracture establishes osteoporosis diagnosis and treatment indication regardless of T-score 7

Monitoring Strategy

• Repeat DEXA scanning should occur in 1-2 years on the same machine using identical protocols 1, 9
• Compare absolute BMD values (g/cm²) rather than T-scores between scans to assess treatment response 9
• More frequent monitoring (every 1-2 years) is recommended for patients with T-scores ≤-2.5 1

Lifestyle Modifications

All patients should be counseled on non-pharmacologic interventions that reduce fracture risk. 2, 4

• Weight-bearing and muscle resistance exercises (squats, push-ups) 2
• Balance exercises (heel raises, standing on one foot) 2
• Smoking cessation 2, 4
• Moderation of alcohol intake 4

Special Considerations

Age-Specific Guidance

• For premenopausal women and men under age 50, Z-scores (not T-scores) should be used for interpretation, and osteoporosis diagnosis cannot be made on BMD alone in these populations 1
• For patients aged ≥65 years, the vast majority will have T-scores of -1.5 or below, making DEXA confirmation useful but not absolutely necessary before initiating treatment 3

Glucocorticoid-Induced Osteoporosis

• Fractures occur at higher BMD levels in glucocorticoid-induced osteoporosis compared to postmenopausal osteoporosis 3
• Bone protective therapy should be considered in glucocorticoid-treated patients with T-score <-1.5 3
• For patients on ≥7.5 mg/day prednisone equivalent for ≥3 months, treatment with denosumab 60 mg subcutaneously every 6 months or oral bisphosphonates is indicated 6

Common Pitfalls to Avoid

• Do not delay treatment while waiting for additional testing—a T-score of -2.5 alone warrants immediate pharmacologic intervention 1, 2
• Do not rely solely on T-scores without considering clinical risk factors such as prior fractures, which may indicate need for more aggressive therapy 1
• Do not use T-scores for diagnosis in premenopausal women or men <50 years old; Z-scores are appropriate for these populations 1
• Do not skip vertebral fracture assessment, as many vertebral fractures are asymptomatic and would upgrade treatment urgency 7
• Ensure adequate renal function before prescribing bisphosphonates; alendronate is not recommended for patients with creatinine clearance <35 mL/min 5

Very High-Risk Patients

• Anabolic medications (teriparatide, abaloparatide, romosozumab) should be considered for very high-risk individuals with recent vertebral fractures, hip fracture with T-score ≤-2.5, or multiple fractures, followed by transition to an antiresorptive agent 2, 4