PEARL: If the BMD is worsening (outside the margin of the least significant change), this should prompt a reevaluation of bisphosphonate therapy

Common causes to consider:

• Medication nonadherence – oral agents have adherence rates of only about 20-30%.  This may be due to side effects (GI, MSK, etc)
• Improper administration – absorption can be reduced when taken with other supplements (like calcium)

• There is an unaddressed/unrecognized/untreated secondary cause of osteoporosis.
  • Obtain labs: CBC, CMP, alkaline phosphatase, Phosphorus, magnesium, Parathyroid hormone, Thyroid function test,  25-hydroxy vitamin D, 24-hour urine calcium and creatinine (off calcium supplements, diuretics)
  • Perform a medication review and address culprit medications if possible

• Consider evaluating for secondary causes of osteoporosis as guided by labs, history and physical exam:
  • For example, anemia and hyperproteinemia suggests multiple myeloma, a low vitamin D may suggest a malabsorption state caused by celiac disease
  • Consider additional evaluation for secondary osteoporosis

• Consider alternative antiresorptive
  • The patient may have a poor response to bisphosphonate therapy and needs a stronger agent
  • Denosumab, Teriparatide or Abaloparatide, or Romosozumab

Consider endocrinology consultation if further guidance or diagnostic certainty is needed