ADT bone health management in prostate cancer

Authored by Fred Saad, published on 2026-05-06 19:52:02.0

  1. All men on ADT
    • BMD assessment with DXA
      Fracture clinical risk assessment (FRAX or CAROC) Non-pharmacological strategies* Calcium (1200 mg/day) Vitamin D (800-2000 units/day)
      • Castrate-resistant and bone metastases
        • Yes
          • Initiate Bone Targeted Therapy (cancer dosing)
            • Denosumab 120 mg SC q4weeks Zoledronic acid 4 mg IV q4weeks
        • No
          • High risk
            High risk, defined as any one of: 1) Osteoporosis (BMD T-score ≤ −2.5 at any site) 2) 10-year major osteoporotic fracture > 20% 3) Prior fragility fracture
            • Initiate Bone Targeted Therapy (osteoporosis dosing)
              • Alendronate 70 mg PO weekly Risedronate 35 mg PO weekly Risedronate 150 mg PO monthly Zoledronic acid 5 mg IV annually Denosumab 60 mg SC q6 months
                • Consider repeat DXA
          • Moderate risk
            (10-year major osteoporotic fracture 10-20%)
            • Initiate Bone Targeted Therapy (osteoporosis dosing)
              • Alendronate 70 mg PO weekly Risedronate 35 mg PO weekly Risedronate 150 mg PO monthly Zoledronic acid 5 mg IV annually Denosumab 60 mg SC q6 months
                • Consider repeat DXA
            • Observe
              • Repeat DXA every 1-2 years
          • Low risk
            (10-year major osteoporotic fracture <10%)
            • Observe
              • Repeat DXA every 2-3 years
  2. Fracture risk assessment tools:
    FRAX: www.sheffield.ac.uk/FRAX/tool.aspx?country=19 CAROC: www.osteoporosis.ca
tosprivacy