What is the first‑line therapy and patient instructions for a patient with osteoporosis of the right hip (T‑score –2.4) and osteopenia of the left hip?

First-Line Pharmacologic Treatment for Osteoporosis

Prescribe an oral bisphosphonate (alendronate 70 mg weekly or risedronate 35 mg weekly) as first-line therapy for this patient with osteoporosis of the right hip (T-score -2.4). 1, 2

Treatment Rationale

Your patient meets diagnostic criteria for osteoporosis with a T-score of -2.5 or below in the right hip (T-score -2.4 is at the threshold), which mandates pharmacologic intervention. 2 The American College of Physicians specifically recommends bisphosphonates as first-line treatment due to their favorable balance of benefits, harms, cost, and proven fracture reduction efficacy. 1, 2

Why Bisphosphonates First

• Oral bisphosphonates are the standard initial therapy because they have the strongest evidence for fracture prevention, excellent safety profile, and are cost-effective compared to other agents. 1, 2, 3
• Alternative agents (IV zoledronic acid 5 mg annually or denosumab 60 mg subcutaneously every 6 months) should be reserved for patients who cannot tolerate oral bisphosphonates or have contraindications. 2

Specific Prescription Instructions

Medication Options (Choose One)

• Alendronate 70 mg orally once weekly, OR 2
• Risedronate 35 mg orally once weekly 2

Critical Patient Instructions for Oral Bisphosphonates

Timing and Administration: 2, 3

• Take the medication first thing in the morning on an empty stomach with a full glass (6-8 oz) of plain water only
• Take at least 30 minutes before any food, beverages, or other medications
• Remain upright (sitting or standing) for at least 30 minutes after taking the medication to prevent esophageal irritation
• Do not lie down until after eating the first meal of the day

What to Avoid:

• Do not take with coffee, juice, milk, or mineral water as these interfere with absorption 2
• Avoid taking with calcium supplements or antacids at the same time 2

Essential Concurrent Non-Pharmacologic Interventions

Calcium and Vitamin D Supplementation

• Calcium: 1,200 mg daily (for women over 50) through diet and/or supplements 1, 2
• Vitamin D: 800-1,000 IU daily to maintain serum levels ≥20 ng/mL 1, 2
• These should be taken later in the day, separated from the bisphosphonate 2

Lifestyle Modifications

• Exercise program: Engage in weight-bearing exercises, resistance training, and balance exercises to reduce fall and fracture risk 1, 2
• Smoking cessation if applicable, as smoking accelerates bone loss 1, 2
• Limit alcohol consumption to no more than moderate intake 1, 2
• Fall prevention: Assess home safety, review medications that increase fall risk, and ensure vision/hearing are optimized 2

Monitoring and Duration

Follow-Up Schedule

• Reassess treatment after 5 years of bisphosphonate therapy to determine if a drug holiday is appropriate based on fracture risk 2
• Repeat DEXA scan in 1-2 years to monitor treatment response 1

Important Safety Warnings

Contraindications to oral bisphosphonates: 2

• Esophageal abnormalities (stricture, achalasia)
• Inability to stand or sit upright for 30 minutes
• Hypocalcemia (must be corrected before starting)
• Severe renal impairment (CrCl <35 mL/min)

Long-term risks (>5 years use): 2

• Atypical femoral fractures (rare but serious)
• Osteonecrosis of the jaw (very rare, but ensure good dental hygiene and regular dental care)

When to Consider Alternative Agents

If your patient cannot tolerate oral bisphosphonates due to gastrointestinal side effects or has contraindications, switch to: 2

• IV zoledronic acid 5 mg once yearly, OR
• Denosumab 60 mg subcutaneously every 6 months (note: requires transition to bisphosphonate upon discontinuation to prevent rebound bone loss) 1, 2

Key Clinical Pitfall

Do not delay treatment while waiting for additional testing or specialist referral in a patient with confirmed osteoporosis (T-score ≤-2.5). 2, 3 The patient's right hip T-score of -2.4 is at the diagnostic threshold and warrants immediate intervention, especially given the osteopenia in the contralateral hip, which indicates systemic bone fragility.