Does an elderly female patient with hypertension, hyperlipidemia, hypothyroidism, and a history of osteoporosis need to continue taking raloxifene (Evista) 60 mg once daily after a recent Dual-Energy X-ray Absorptiometry (DEXA) scan showed normal bone density?

Discontinuation of Raloxifene After Normal DEXA Scan

This patient should continue raloxifene therapy despite the normal DEXA scan result, as she has a documented history of osteoporosis and current guidelines explicitly support extended use beyond 5 years when osteoporosis treatment is the primary indication. 1, 2

Rationale for Continuation

Guideline-based recommendations for extended therapy:

• The American Society of Clinical Oncology (ASCO) explicitly states that raloxifene "may be used longer than 5 years in women with osteoporosis, in whom breast cancer risk reduction is a secondary benefit." 1, 2
• Extended use beyond the standard 5-year duration for breast cancer risk reduction is specifically supported when osteoporosis is the primary treatment indication 1, 2
• The 2022 American College of Rheumatology guidelines conditionally recommend raloxifene as an option for osteoporosis treatment in postmenopausal women, acknowledging its role in fracture prevention 1

Understanding "Normal" DEXA Results in Context

A single normal DEXA scan does not negate a history of osteoporosis:

• Osteoporosis is a chronic condition requiring ongoing management, and improvement in bone density to the normal range represents treatment success, not disease resolution 3
• Raloxifene has been shown to increase bone mineral density by 2-3% at the spine and hip, and discontinuation would likely result in bone loss 3, 4
• The FDA label demonstrates that discontinuation due to excessive bone loss was significantly more frequent in placebo groups (3.7%) compared to raloxifene-treated patients (1.1%) 3

Clinical Evidence Supporting Continuation

Fracture risk reduction persists with ongoing therapy:

• Raloxifene reduces vertebral fracture risk by 30-50% in postmenopausal women with osteoporosis, with sustained benefit demonstrated over 3-4 years 5, 6, 7, 4
• The MORE trial showed raloxifene reduced new vertebral fractures from 10.1% (placebo) to 6.6% (60 mg daily) over 36 months 4
• Eight-year safety data demonstrate no increase in mortality and a favorable side-effect profile with extended use 2

Additional benefits beyond bone protection:

• Raloxifene reduces the risk of estrogen receptor-positive invasive breast cancer by approximately 70-80% 3, 5
• This breast cancer risk reduction benefit continues as a secondary advantage during osteoporosis treatment 1, 2

Safety Monitoring During Continued Therapy

Absolute contraindications to verify are absent:

• History of deep vein thrombosis, pulmonary embolism, stroke, or transient ischemic attack 1
• Prolonged immobilization periods 1
• The patient's current comorbidities (hypertension, hyperlipidemia, hypothyroidism) are not contraindications to raloxifene use 3

Ongoing monitoring recommendations:

• Monitor for signs and symptoms of venous thromboembolism, particularly during the first 4 months of any new treatment period 2
• Discontinue raloxifene at least 72 hours before and during any prolonged immobilization 2
• Timely workup of any abnormal vaginal bleeding 1
• Repeat DEXA scanning every 2-3 years to monitor bone density maintenance 1

Common Pitfall to Avoid

Do not discontinue osteoporosis therapy based solely on improved bone density: The achievement of normal bone density represents successful treatment response, not an indication to stop therapy. Discontinuation would likely result in renewed bone loss and increased fracture risk, as demonstrated by significantly higher discontinuation rates in placebo groups due to excessive bone loss 3. The patient's underlying osteoporosis diagnosis remains, and ongoing pharmacologic intervention is warranted to maintain bone health and prevent future fractures.