Many common medications can deplete bone mineral other than ADT. Proton pump inhibitors , for example, are offenders. I was diagnosed with osteoporosis on a bone density DEXA scan nearly 2 years ago and have been on a bisphosphonate since. I take Caltrate/D once daily and Vitamin D2 2000 IU daily (as well as occasional Tums, calcium carbonate). I just started ADT, receiving my first Lupron injection 3 weeks ago. I will be due for a follow up DEXA in December marking 2 years since my first DEXA.

A bone density is the best measure of bone health although imperfect. In the absence of a fracture history, a low bone density fails to fully assess the quality of bone matrix.

Everyone deserves an evaluation of their bone health and fracture risk, but I am not sure that everyone on ADT requires bisphosphonate intervention.

Bisphosphonates are not without side effects, but the most notorious association (osteoporosis of the mandible) is infrequent. After treatment of >5 years on bisphosphonates there are reports of atypical stress fractures of the femur, so most providers would recommend limiting the use of bisphosphonates to a 5-year interval and then considering alternative pharmacologic approaches if the bone density remains low.