In the patient with no prior osteoporotic fracture, a preserved bone mineral density score (T > -1.0) with a low clinical risk factor score for fracture in 10 years (FRAX: <3% at hip and <20% any fracture), the risk of fracture is low.

Antiresorptive/anabolic osteoporosis therapy is not recommended

• The benefits to starting antiresorptive therapy in preventing a fracture are not thought to be in excess of their potential risks and cost in this population

However, there is always some risk of fracture. Here are some recommendations to lower the risk:

1. Consider a medication review and deprescribe if no longer indicated.
   
2. Prescribe a functionally appropriate exercise regimen, regardless of age
   • At least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity
   • Whole body strengthening activity at least twice per week
     
3. Discuss adequate calcium intake from all sources (diet preferred to supplements)
   • Women 50+ and Men 70+ = 1,200 mg daily; all else 1,000 mg daily
   • Calcium calculator OR Dietary calcium estimation: Number of dairy servings x 300 mg + 300 mg in general diet (unless restrictive diet like vegan, keto, etc.)
     
4. Discuss adequate Vitamin D from all sources (sunlight and diet preferred but difficult to get).  Serum goal of >30 ng/mL.
   • If low, supplement to goal of 30 ng/mL. Quick guide:  (30 – serum level) x 100 = # of international units daily
   • Supplementation guidelines:
     • Adults 19-70: ~600+ international units daily, but no more than 4000 IU
     • All adults 70+: ~800+ international units daily, but no more than 4000 IU
     • Pearl: Strongest evidence for vitamin D supplementation is in older adults living in residential care, likely because they are often deficient
       
5. If applicable:
   1. Smoking cessation
   2. Avoiding excess alcohol