Risk Factors for Needing Oral Fosamax (Alendronate)

Primary Risk Factors

Individuals with established osteoporosis diagnosis based on bone mineral density (BMD) T-score ≤-2.5 or presence of fragility fractures are at high risk for needing oral alendronate, according to the American College of Physicians 1
Prior fragility fracture significantly increases the risk of subsequent fractures and is a strong indication for treatment, as stated by the National Osteoporosis Foundation 2
Very high fracture risk is defined as prior osteoporotic fracture(s), BMD T-score ≤−3.5, or FRAX 10-year risk of major osteoporotic fracture ≥30% or hip fracture ≥4.5%, as per the American College of Rheumatology 3
High fracture risk is defined as BMD T-score between −2.5 and −3.5, or FRAX 10-year risk of major osteoporotic fracture ≥20% but <30% or hip fracture ≥3% but <4.5%, according to the National Institute on Aging 3

Postmenopausal women with osteoporosis or low bone mass are at increased risk for needing oral alendronate, as recommended by the North American Menopause Society 1
Men over 50 years with osteoporosis or high fracture risk are also at increased risk, according to the Endocrine Society 2
Patients on glucocorticoid therapy (≥7.5 mg/day for ≥6 months) are at higher risk, particularly those with high doses or cumulative doses ≥5 g/year, as stated by the American College of Rheumatology 3
Patients with primary biliary cholangitis (PBC) have a higher risk of osteoporotic bone disease, as reported by the European Association for the Study of the Liver 4

The FRAX score (WHO Fracture Risk Assessment Tool) is recommended to estimate 10-year fracture risk and determine treatment thresholds, as suggested by the World Health Organization 1, 2
BMD measurement with DXA should be used to assess bone density, particularly in those whose fracture risk is near intervention thresholds, according to the International Osteoporosis Foundation 4
Vertebral fracture assessment or spinal x-ray should be performed to identify prevalent vertebral fractures, as recommended by the American College of Radiology 3, 1

Low body mass index is a secondary risk factor for needing oral alendronate, as reported by the National Institute on Aging 4
Older age, particularly in postmenopausal women, is a secondary risk factor, according to the American Geriatrics Society 4, 1
Family history of osteoporosis or fragility fractures is a secondary risk factor, as stated by the National Osteoporosis Foundation 1
History of falls or risk factors for falling is a secondary risk factor, according to the Centers for Disease Control and Prevention 4, 6
Secondary causes of osteoporosis, such as vitamin D deficiency, hyperparathyroidism, and malabsorption syndromes, should be considered, as reported by the Endocrine Society 4, 6

Assess fracture risk using FRAX and/or BMD measurement, as recommended by the American College of Physicians 1, 2
Identify high-risk individuals based on T-scores, FRAX scores, or presence of fragility fractures, according to the National Institute on Aging 3, 1
Consider alternative treatments (IV bisphosphonates, denosumab) for those who cannot tolerate oral medications, as suggested by the American College of Rheumatology 1, 5
Ensure adequate calcium and vitamin D intake before initiating therapy, as recommended by the National Osteoporosis Foundation 6

BMD testing with vertebral fracture assessment should be performed every 1-2 years during treatment, as recommended by the American College of Rheumatology 3
Reassessment after 3-5 years of therapy should be done to determine the need for continuation, according to the American College of Physicians 1
Patients should receive lifestyle advice, including adequate calcium and vitamin D intake, weight-bearing exercise, smoking cessation, and limiting alcohol consumption, as recommended by the National Institute on Aging 6