Try our Symptom Checker Got any other symptoms? Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. (type 1 or type 2). These risk factors appear to have a dose-dependent effect, i.e. There is, however, an increase in vertebral fractures.38 Osteonecrosis of the jaw and atypical femoral fractures are rare complications of bisphosphonate therapy that are associated with longer duration of use.39,40 Clinicians should consider discontinuing bisphosphonate therapy after five years in women without a personal history of vertebral fractures. by CJ Crandall 2019 Cited by 33 - Incident hip fractures and major . The Fracture Risk Assessment Tool, or FRAX, is a free online tool that estimates your risk of having a hip or other major fracture in the next 10 years, especially if you have osteoporosis. Enter yes or no depending on whether the patient currently smokes tobacco (see also notes on risk factors). Your FRAX score is your risk of having an osteoporosis-related fracture in the next 10 years. The other major fractures are your spine, forearm, and shoulder. While the FRAX tool can offer accuracy in assessing risk for bone fractures, critics say it underestimates the fracture risk in people who: National Osteoporosis Foundation: Bone Density Exam/Testing., National Osteoporosis Foundation: Risk Assessment (FRAX), What is Osteoporosis and What Causes It?, The North American Menopause Society: FRAX: a Tool for Estimating Your Fracture Risk., Osteoporosis International: Clinicians Guide to Prevention and Treatment of Osteoporosis. Preventing osteoporosis can help you prevent fractures and maintain strength as you age. The American Bone Health Fracture Risk Calculator (ABH FRC) Version 3.0, published 03/04/2021, estimates 10-year fracture risk for postmenopausal women and men age 45 and older who are not receiving treatment for osteoporosis. Your doctor will order a bone density test. MDCalc. Calcs that help predict probability of a disease, Subcategory of 'Diagnosis' designed to be very sensitive, Disease is diagnosed: prognosticate to guide treatment. For this reason reliance should not be placed on a patient's report of 'arthritis' unless there is clinical or laboratory evidence to support the diagnosis. Causes, symptoms, risk factors, and treatment. 1. Learn about infusion options for treating osteoporosis and how they compare to other treatment options. Have you ever had a bone density test on a table machine? [ 1, 2] Osteoporosis can result in devastating physical, psychosocial, and economic consequences. One study suggests that it is advisable to follow teriparatide therapy with bisphosphonate therapy to maintain BMD gains.43, Denosumab. For the FRAX score calculator, you'll have to answer several questions about habits such as alcohol intake and other disorders you may have that are linked to osteoporosis, such as type 1. Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Consuming more than 2.5 units of caffeine daily (1 unit = one cup of coffee or two cups of tea) may increase fracture risk.24 Diets with adequate protein intake are necessary for optimal bone health, but the proper amount or source (plant vs. animal) remains controversial. Multi-Factor Authentication (MFA) is required for all remote users Please install Symantec VIP on your mobile device to avoid any issues or delays with . The risk is expressed as a percentage: for example, 10% means 10 people out of a 100, with this level of risk, will develop osteoporosis in the next 10 years. Low risk - QRISK2 score of less than 10% This means that you have less than a one in ten chance of having a stroke or heart attack in the next 10 years. Moderate risk - QRISK2 of 10-20% Other drugs may be used, such as denosumab (Prolia) or zoledronic (Reclast), which are given by injection. If lifestyle changes are appropriate, your doctor may recommend: You will also be advised to reduce your fall risk in several ways. FRACTURE RISK CALCULATOR Fill out the following to estimate your fracture risk Full Name (optional) Sex? The FRAX tool has been developed to evaluate fracture risk of patients. The International Osteoporosis Foundation supports the maintenance and development of FRAX. Cadarette (2004) Osteoporos Int 15(5):361-366 [PubMed] This informationcan help your doctor decide whether further action needs to be taken. 1.3 Estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage). Denosumab is a human monoclonal antibody that inhibits the formation and activity of osteoclasts by blocking receptor activator of nuclear factor kappa B ligand. FRAX is short for Fracture Risk Assessment Tool. the higher the exposure, the greater the risk. However, your doctor may suggest one earlier if you have a personal history of fractures or a family history of bone problems. The current National Osteoporosis Foundation Guide recommends treating patients with FRAX 10-year risk scores of > or = 3% for hip fracture or > or = 20% for major osteoporotic fracture, to reduce their fracture risk. Personal details (such as height and weight, medication history, smoking history and family history) are entered to predict whether someone is at risk of developing osteoporosis in the next 10 years. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. by CJ Crandall 2019 Cited by 33 - Incident hip fractures and major osteoporotic fractures (MOF) during 10-year FRAX includes the following risk factors: age, sex, weight . In patients without a BMD test, the field should be left blank (see also notes on risk factors) (provided by Oregon Osteoporosis Center). The FRAXmodels have been developed from studying population-based cohorts from Europe, North America, Asia and Australia. A hip or vertebral (clinical or morphometric) fracture, T-score -2.5 at the femoral neck or spine after appropriate evaluation to exclude secondary causes, Low bone mass (T-score between -1.0 and -2.5 at the femoral neck or spine) and a 10-year probability of a hip fracture 3% or a 10-year probability of a major osteoporosis-related fracture 20% based on the US-adapted WHO algorithm, Clinicians judgment and/or patient preferences may indicate treatment for people with 10-year fracture probabilities above or below these levels. For details see our conditions. The optimal length of oral bisphosphonate therapy is unknown. Genetics is one of the most important factors that determine your risk of fractures. There is a direct relationship between tobacco and decreased bone density, whether its the smoking or the other risk factors of smokers, such as, being thinner, drinking more alcohol, being less physically active, and having a poor diet. Do not use dual energy x-ray absorptiometry (DEXA) to screen for osteoporosis in women younger than 65 years or in men younger than 70 years with no risk factors. Calculation assumes no other risk factors for Osteoporosis. MDCalc. Introduction Practical tips and precautions Absolute fracture risk calculators Too much alcohol interferes with calcium and vitamin D absorption, affects the liver, and decreases estrogen. Enter age in whole years, rounding to the nearest year. Copyright 2015 by the American Academy of Family Physicians. You can use this calculator to work out your risk of developing any osteoporotic (i.e. Weight must be between 70 and 300 pounds. What race and ethnicity do you most consider fits you? Privacy Policy. These factors include: BMI (weight to height ratio calculation) Otherwise enter no (see also notes on risk factors). The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. 7 mechanical forces that would not ordinarily result in fracture. Enter yes where the patient has a confirmed diagnosis of rheumatoid arthritis. About the bone fracture risk calculator. The most commonly recommended laboratory tests include serum 25-hydroxyvitamin D, calcium, creatinine, and thyroid-stimulating hormone levels.1,14, The National Osteoporosis Foundation recommends treatment of postmenopausal women and men with a personal history of hip or vertebral fracture, a T-score of 2.5 or less, or a combination of low bone mass (T-score between 1 and 2.5) and a 10-year probability of hip fracture of at least 3% or any major fracture of at least 20% as calculated by the FRAX Fracture Risk Assessment Tool.1 [corrected] The WHO recommendations are less specific, stating that persons with or at risk of osteoporosis should be considered for treatment.15 Randomized controlled trials of treatment have shown reduction of fractures for only two groups: those with a T-score of less than 2.5 and those who have already experienced a hip or vertebral fracture.16, Fall prevention is a priority for patients with osteoporosis because falls are more closely associated with fracture risk than is BMD.17 The USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older who are at increased risk of falls.18 A multicomponent exercise program that consists of weight-bearing resistance and balance training should be recommended. Parent Fractured Hip No Yes 7. Enter height in feet and inches. CALCIUM - Calcium Calculator | International Osteoporosis Foundation of 2 Are you getting ENOUGH CALCIUM ? A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Do you regularly have >2 alcoholic drinks a day? Each one, though, represents an important osteoporosis risk factor. MDCalc - Medical calculators, equations, scores, and guidelines Creatinine Clearance (Cockcroft-Gault Equation) Calculates CrCl according to the Cockcroft-Gault equation. PO Box 688, Wellington 6140, http://www.garvan.org.au/bone-fracture-risk/. The FRAXtool has been developed to evaluate fracture risk of patients. Learn more about how these and other nutrients can help you prevent osteoporosis, Bone density screenings are used to determine your risk of osteoporosis or of fracturing a bone and may also be used to check whether treatment is, Typically, you don't stop treatment. Height must be between 4 feet 8 inches and 6 feet 4 inches. In a dosage of 20 mcg per day given subcutaneously for up to two years, teriparatide decreases vertebral and nonvertebral fractures.16,26 Teriparatide is approved for the treatment of postmenopausal women with severe bone loss, men with osteoporosis who have high risk of fracture, and individuals whose condition has not improved with bisphosphonate therapy. If the field is left blank, then a "no" response is assumed. More aggressive treatment usually includes a type of medication called bisphosphonates, such as alendronate (Fosamax) and ibandronate (Boniva). Copyright Medicalalgorithms.com Limited. 10-Year Fracture Risk Calculator The American Bone Health Fracture Risk Calculator Version 3.0 estimates fracture risk for women and men over age 45. The FRAX models have been developed from studying population-based cohorts from Europe, North America, Asia and Australia. What is osteoporosis and what causes it? Summary What it measures: The Fracture Risk Assessment Tool (FRAX) is a fracture risk calculator that estimates an individual's 10-year probability of incurring a hip or other major osteoporotic fracture. Oral bisphosphonates inhibit osteoclastic activity and are antiresorptive agents. Check all that apply.Check all that apply. the QRISK3-2018 calculator. The University of Sheffield launched the FRAX tool in 2008. Diseases (1991-2010), and the FRAX tool is based on data generated from that centre. Calculator Frequently Asked Questions (FAQs) page. Notes on FRAX - Fracture Risk Assessment Tool, https://patient.info/doctor/frax-fracture-risk-assessment-tool. Osteoporosis in men younger than 50 years cannot be diagnosed based on BMD assessment alone.7, Published osteoporosis screening guidelines vary greatly (eTable A). The Fracture Risk Assessment Tool (FRAX) (1) is a fracture risk calculator that estimates an individual's 10-year probability of incurring a hip or other major osteoporotic fracture, your FRAX score will be calculated, A risk score of >20 points indicates a very high risk of diabetes (50% chance of diabetes The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of Defense, the U.S. Army Medical Corps, or the U.S. Army at large. The need for follow-up bone mineral density testing in patients receiving treatment for osteoporosis is uncertain. If you want to add your bone density result, enter your femoral neck T-score (include the minus (-) sign if it is on the report). . A previous fracture denotes more accurately a previous fracture in adult life occurring spontaneously, or a fracture arising from trauma which, in a healthy individual, would not have resulted in a fracture. . Calculator About References. All women 65 years and older should be screened for osteoporosis with dual energy x-ray absorptiometry of the hip and lumbar spine. RA is a risk factor for fracture. The intravenous bisphosphonates approved by the U.S. Food and Drug Administration for the treatment of postmenopausal osteoporosis are zoledronic acid (Reclast), 5 mg yearly (shown to decrease vertebral and hip fractures),16,26,36 and ibandronate, 3 mg every three months.37 Although these medications are expensive, they are useful for high-risk patients who are unable to tolerate or adhere to oral therapy. By checking this box, you are confirming that you live in the US and you are opting in to receive your Fracture Risk Calculator results and information about managing bone health via email. Aerobic exercise programs that do not incorporate strength and balance training should be avoided because of the association with increased fracture risk.19 A thorough assessment of a patient's risks of falling and mitigation of those risk factors have strong evidence of effectiveness in fall prevention.20 A Cochrane review suggested that hip protectors decrease fracture risk.21, Patients should be counseled to quit smoking because it has been shown to decrease BMD at all skeletal sites.22 Heavy alcohol consumption (defined as more than four drinks per day for men or more than two drinks per day for women) is a major risk factor for fracture and should be discouraged.23, Dietary modifications may have a role in optimizing bone health. Explaining annual updates We release a new version of QRISK every spring, usually in April. The ABH FRC is a valuable tool for use in discussions between patients and their health care provider about the prevention and treatment of osteoporosis. Predicts fracture risk in the 6 months after radiotherapy, which may not be relevant for many patients (i.e., if no plans for radiotherapy and/or short life expectancy). The FRAX algorithms give the 10-year probability of fracture. Additional searches included Essential Evidence Plus, the U.S. Preventive Services Task Force, the Institute for Clinical Systems Improvement, the National Guideline Clearinghouse, the Cochrane Database of Systematic Reviews, and the National Osteoporosis Foundation website. Men are also more likely to fracture a bone as they age. A balanced diet consisting of vitamin D, calcium, protein, vegetables, and fruits is recommended; mononutrient dietary supplementation is unlikely to be helpful.24 Table 5 shows a comparison of nonpharmacologic therapies.1725, Table 6 summarizes pharmacologic treatments for osteoporosis, including bisphosphonates, raloxifene (Evista), teriparatide (Forteo), and denosumab (Prolia).16,2629, Mild upper gastrointestinal events, esophageal ulcerations, perforations, bleeding events, muscular and joint pains, Contraindications: abnormalities of the esophagus; inability to stand or sit upright for at least 30 minutes; hypersensitivity to any product component; increased risk of aspiration or dysphagia, 70 mg plus 2,800 IU or 5,600 IU per week, oral, 35 mg per week (day 1) plus 1,250 mg calcium per day (days 2 to 7 each week), oral, Contraindications: hypocalcemia creatinine clearance < 35 mL per minute per 1.73 m2 (0.58 mL per second per m2) and acute renal impairment; hypersensitivity to zoledronic acid or any components of this product, Pulmonary embolism, thromboembolic events, Contraindications: venous thromboembolism; pregnancy, women who may become pregnant, and breastfeeding mothers, 20 mcg per day for up to 2 years, subcutaneous, Arthralgia, pain, nausea, transient orthostatic hypotension, hypercalcemia, hyperuricemia, Contraindications: hypersensitivity to teriparatide or to any of its components; reactions have included angioedema and anaphylaxis. Learn strategies you can use today. Search dates: April and July 2014, and May 2015. Excess blood sugar affects collagen in the bones, making them brittle and more likely to break. Thus the current osteoporosis definition is a BMD that lies 2.5 standard deviations or more below the average value for . Raloxifene, a selective estrogen receptor modulator, is approved for treating postmenopausal osteoporosis, and is effective at reducing vertebral fractures only.16,26 Raloxifene is commonly associated with increased vasomotor symptoms. In their most sophisticated form, the FRAX tool is computer-driven and is available on this site. Usually these hormone-related therapies accompany other treatments and lifestyle improvements. English | Arabic | Bengali | Chinese Simplified | Chinese Traditional | Croatian | Czech | Danish | Dutch | Estonian | Farsi | Finnish | French | Georgian | German | Greek | Icelandic | Italian | Indonesian | Japanese | Korean | Lithuanian | Norwegian | Polish | Portuguese (Portugal) | Portuguese | Romanian | Russian | Serbia | Slovak | Spanish | Swedish | Thai | Turkish | Ukrainian, Individuals with fracture risk assessed since 1st June 2011, Age (between 40 and 90 years) or Date of Birth, Centre for Metabolic Bone Diseases, University of Sheffield, UK. Calcium is essential for building and maintaining healthy bones at all ages. Teriparatide is a recombinant human parathyroid hormone with bone anabolic activity. International Index of Erectile Function (IIEF-5) Assess erectile dysfunction. And if youve been taking glucocorticoids for a long time, talk with your doctor about whether you can cut back or stop taking those medications altogether. Gaucher disease is an inherited disorder that causes a buildup of GCase in your body. If no medical conditions, click next. Reduce bone loss and build stronger muscles. Enter Yes if you have ever taken a minimum of 5 milligram dose of Prednisone or steroids for 3 months or longer, or if you have taken very high doses of inhaled steroids regularly (> 400 micrograms/day budenoside or beclomethasone or > 200 micrograms/day fluticasone). Enter yes or no. Personal details (such as height and weight, medication history, smoking history and family history) are entered to predict whether someone is at risk of developing osteoporosis in the next 10 years. In patients who cannot tolerate or whose symptoms do not improve with bisphosphonate therapy, teriparatide (Forteo) and denosumab (Prolia) are effective alternative medications to prevent osteoporotic fractures. Copyright 2023 American Academy of Family Physicians. car accidents) Falls over last 12 months Do you have a Bone Mineral Density (BMD) measurement? You are also at an increased risk of falling and fracturing because of blood sugar levels, declining vision, associated peripheral neuropathy and nerve damage. The Women's Health Initiative study confirmed that estrogen, with or without progesterone, slightly reduced the risk of hip and vertebral fractures; however, this benefit did not outweigh the increased risk of stroke, venous thromboembolism, coronary heart disease, and breast cancer, even for women at high risk of fracture.46 Lower doses of conjugated equine estrogens and estradiol have been shown to improve BMD, but a reduced risk of fracture has not been demonstrated and the safety is unknown.47. The primary test used to diagnose osteoporosis is dual X-ray absorptiometry (DEXA). The fun challenges, personalized instruction, and motivating rewards help students build their skills and understanding - all while exploring the galaxy with fractions! Data Sources: We reviewed all cited references from the original 2009 review article, then performed a PubMed search using the following key words: osteoporosis, osteopenia, screening, diagnosis, treatment, prevention, secondary, and vitamin D. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. They are written by UK doctors and based on research evidence, UK and European Guidelines, so you may find the language more technical than the condition leaflets. The FRAX tool helps toidentify people who may be atrisk of developing osteoporosis. The impact of fractures includes loss of function, significant costs, and increased mortality. the tool is based on individual patient models that integrate the risks associated with clinical risk factors as well as bone mineral density (BMD) at the femoral neck it gives the 10 year probability of a fracture - hip fracture and of a major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture) Enter "No" if you have other kinds of arthritis, such as osteoarthritis. Osteoporosis is a disease that weakens or thins your bones. nof.org/preventing-fractures/general-facts/bone-basics/are-you-at-risk/, nof.org/patients/diagnosis-information/bone-density-examtesting/, iofbonehealth.org/diagnosing-osteoporosis, menopause.org/for-women/menopauseflashes/bone-health-and-heart-health/frax-sup-sup-a-tool-for-estimating-your-fracture-risk, mayoclinic.org/diseases-conditions/osteoporosis/diagnosis-treatment/drc-20351974, 7 Things You Can Do Today to Prevent Osteoporosis. note: This review updates a previous article on this topic by Sweet, Sweet, Jeremiah, and Galazka.29. Several simplified paper versions, based on the number of risk factors are also available, and can be downloaded for . Find out more: The Effects of a FRAX Revision for the USA, The Potential Impact of New NOF Guidance on Treatment Patterns, Updated Fracture Incidence Rates for the US Version of FRAX, Copyright 2023 Bone Health & Osteoporosis Foundation. Previous Fracture No Yes 6. Registered in England and Wales. A diagnosis of osteoporosis isnt a guarantee that youll have a fracture. How Much Calcium and Vitamin D Do You Need to Prevent Osteoporosis? Any references to the WHO tool Fractions knowledge in grade 5 uniquely predicts student success in Algebra and . How to Interpret FRAX Score for Canada. Inflammation around the joints causes bone loss; pain leads to reduced activity.Enter "Yes" if you have Rheumatoid Arthritis. See Osteoporosis Risk Factors; Where other Osteoporosis risks exist, use FRAX Score or Osteoporosis SCORE Estimation; VI. This content is owned by the AAFP. First-line treatment to prevent fractures consists of fall prevention, smoking cessation, moderation of alcohol intake, and bisphosphonate therapy. The WHO criteria should not be applied to men younger than 50 years, children, or premenopausal women. Women younger than 65 years should be screened for osteoporosis if the estimated 10-year fracture risk equals or exceeds that of a 65-year-old white woman with no risk factors. It has been shown to decrease the occurrence of vertebral compression fractures only.16,26 Although calcitonin has modest analgesic properties in the setting of acute and chronic vertebral compression fracture, it is not considered first-line treatment for osteoporosis because more effective medications are available.16,41 There have also been reports of increased cancer rates associated with use of calcitonin.42, Teriparatide. It usually develops unnoticed over many years until you have a fracture. Osteoporosis, in which low bone mass and micro-structural deterioration of bone tissue lead to increased bone fragility, is the most common metabolic bone disease in the United States. Cortisol and parathyroid level is increased in alcoholics and leads to calcium malabsorption. Can only be used to predict fracture risk in long bones (i.e., not in vertebral mets). Low insulin levels in childhood or adolescence may lead to weaker bones and an increased risk of fractures in adulthood. 24/7 Live Expert. The loss of bone minerals quicker than you can replace them is called bone demineralization, which can lead to other conditions like osteoporosis. You can learn more about how we ensure our content is accurate and current by reading our. To compare the power of FRAX without bone mineral density (BMD) and simpler screening tools (OST, ORAI, OSIRIS, SCORE and age alone) in predicting fractures. Predicts risk of pathologic fracture in patients with long bone metastasis. WebMD does not provide medical advice, diagnosis or treatment. The osteoporosis self-assessment tool (OST) 1 in women is a simple formula that predicts risk of osteoporosis for the patient based solely on current weight and age. Other perimenopausal or postmenopausal women with risk factors for osteoporosis if willing to consider pharmacologic interventions: Excessive consumption of alcohol (> 2 drinks per day for women), Low body weight (< 58 kg [128 lb] or body mass index < 20 kg per m, Any history of long-term systemic glucocorticoid therapy ( 3 months), American College of Obstetricians and Gynecologists, Bone density screening no more than once every two years beginning at 65 years of age, unless new health risks develop, Selective screening in women younger than 65 years if they are postmenopausal and have other osteoporosis risk factors or fracture, In the absence of new risk factors, DEXA monitoring of therapy should not be repeated after BMD is determined to be stable or improved, In women 65 years and older and in men 70 years and older, In postmenopausal women and men 50 to 69 years of age; recommended based on risk factor profile, With vertebral imaging in those who have had a fracture to determine degree of disease severity, At DEXA facilities using accepted quality assurance measures, In women 65 years and older and in men 70 years and older to diagnose vertebral fractures if T-score is 1.5, In women 70 years and older and in men 80 years and older to diagnose vertebral fractures, regardless of T-score, In postmenopausal women and men 50 years and older with a low-trauma fracture, In postmenopausal women and men 50 to 69 years of age to diagnose vertebral fractures if there is height loss 4 cm (1.5 in), or recent or ongoing long-term glucocorticoid therapy, To check for causes of secondary osteoporosis, BMD testing one to two years after initiating therapy to reduce fracture risk and every two years thereafter, More frequent testing in certain clinical situations, Longer interval between repeat BMD tests for patients without major risk factors and who have an initial T-score in the normal or upper lowbone mass range, Risk factors: glucocorticoid use (> 3 months cumulative therapy in past year), high-risk medication use, hypogonadism or premature menopause (age < 45 years), malabsorption syndrome, hyperparathyroidism, other associated disorders, Low body weight (< 60 kg [132 lb]) or weight loss (> 10% of weight at 25 years of age), Vertebral fracture or osteopenia on radiography, Repeat BMD testing in one to three years and reassess risk in moderate- and high-risk groups, United Kingdom National Osteoporosis Guideline Group, Case finding for BMD assessment is based on risk factor assessment and comparison of risk to age- and sex-specific fracture probabilities, Screen for osteoporosis in women 65 years and older, and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors, Current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men, Central nervous system disorders (e.g., epilepsy, multiple sclerosis, Parkinson disease, spinal cord injury, stroke), Endocrine/metabolic disorders (adrenal insufficiency, athletic amenorrhea, Cushing syndrome, hemochromatosis, homocystinuria, primary hyperparathyroidism, hyperprolactinemia, hyperthyroidism, primary or secondary hypogonadism, premature menopause, thyrotoxicosis, type 1 diabetes mellitus), Gastrointestinal disorders (celiac disease, gastric bypass, inflammatory bowel disease, malabsorption, pancreatic insufficiency, primary biliary cirrhosis), Hematologic disorders (hemophilia, leukemia and lymphomas, monoclonal gammopathies, multiple myeloma, sickle cell disease, thalassemia), Human immunodeficiency virus infection or AIDS, Nutrition disorders (alcoholism, anorexia nervosa/bulimia, malnutrition, vitamin A excess, vitamin D deficiency), Anticonvulsants (e.g., phenobarbital, phenytoin [Dilantin]), Gonadotropin-releasing hormone agonists and antagonists, Thiazolidinediones (e.g., pioglitazone [Actos]), 4 drinks per day for men or 2 drinks per day for women, 2.5 cups of coffee or 5 cups of tea per day, Multicomponent exercise with strength and balance training, Consider drug discontinuation after 5 years in low-risk patients, Small risk of atypical femoral shaft fractures; osteonecrosis of the jaw, Alendronate/cholecalciferol (Fosamax Plus D), Muscular and joint pains; small risk of osteonecrosis of the jaw (especially older women with poor dental hygiene or cancer) Contraindications: hypocalcemia; pregnancy.
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