After counseling about smoking cessation, this patient should continue her current alendronate therapy. She has documented osteoporosis and is at high risk for subsequent fractures due to multiple risk factors, including current smoking and a previous fracture. Her bone mineral density (BMD) has been well maintained on an oral bisphosphonate for the last several years. The best way to evaluate a dual-energy x-ray absorptiometry (DEXA) scan from measurement to measurement is to compare the bone mineral density readings from year to year, not the T-score. A change in BMD that is less than about 4% (or the percentage noted by the DEXA machine manufacturer) is not considered a statistically significant change. This regimen should be considered successful therapy since the goal of bisphosphonates is not to build bone mass but to stabilize bone loss. Since this patient has had stable BMD while on alendronate, there is no indication to convert to a more invasive, expensive option at this time. It will be important, however, to continue to follow her for atypical fractures of the long bone due to her prolonged bisphosphonate treatment. If leg pain or an atypical fracture is noted, bisphosphonate therapy should be discontinued.

Denosumab is a receptor activator of nuclear factor κB (RANK) ligand inhibitor FDA approved for the treatment of osteoporosis in postmenopausal women who are at high risk of fracture. Since this patient has not failed bisphosphonate therapy (shown a significant decrease in BMD while on bisphosphonate therapy) nor is she intolerant of the current therapy, there is no reason to change her therapy.

Teriparatide is appropriate as first-line therapy for patients at high risk for fracture (T-score < −3.0) or who have experienced progressive osteoporotic disease while on bisphosphonate therapy. This change would be unnecessary since the patient's BMD has been maintained for the past 5 years.

A drug holiday is indicated for patients who have been on bisphosphonate therapy for 3 to 5 years, have had no progression of the disease, and have minimal risk factors for additional fractures. This patient has multiple risk factors for fractures; therefore, a drug holiday would not be appropriate.