Editing Hormonal Therapy (section)

=== Bone health ===

* '''Lifestyle changes'''
** '''Smoking and alcohol cessation'''
*** Smoking and alcohol use are associated with bone loss and fractures
** '''Exercise therapy''' using a combination of resistance and aerobic training, preferably in a supervised setting
*** Exercise may preserve BMD in men receiving ADT
* '''Calcium intake (1200 mg daily total from diet and supplements) and vitamin D supplementation (800–2000 IU daily)'''
** No evidence that shows this decreases risk of BMD loss or fractures in men receiving ADT but have been shown to prevent fractures in the general population age > 50
* '''Pharmacotherapy'''
** See Bone Health section in Castrate-Resistant Prostate Cancer Chapter Notes
** '''Bisphosphonates (zoledronic acid, alendronate, and pamidronate) can increase bone mineral density in men on ADT'''
** '''Indications for pharmacotherapy (4):'''
**# '''Osteoporosis'''
**# '''History of fragility fractures in the hip or spine'''
**# '''History of multiple fragility fractures'''
**# '''Moderate or high 10-year fracture risk'''
*** '''Other guideline-based indications for pharmacotherapy'''
**** '''2019 CUA CRPC Guidelines recommend denosumab or zoledronic acid every 4 weeks, along with daily calcium and vitamin D in men with CRPC and bone metastases'''
**** '''2020 CUA CSPC Guidelines recommend that all men treated with ADT require vitamin D supplementation (800-1200IU daily) and calcium supplementation (800mg-1000mg total intake daily). Those at high risk of fractures should be treated with bone targeted therapy (zoledronic acid 5mg once a year, alendronate 70mg weekly, denosumab 60mg every 6 months).'''
* '''Surveillance DXA (until treatment cessation)'''
** '''Every 2–3 years in low 10-year fracture risk'''
** '''Every 1-2 years in'''
*** '''Osteopenia'''
*** '''Moderate or high risk for fractures'''
** '''Patients started on pharmacological therapy should have followup DXA to assess for treatment response.'''