Fig. 2. Recommended algorithm for managing bone health in women receiving aromatase inhibitor therapy for breast cancer. ^a Includes AIs and ovarian suppression therapy/oophorectomy. ^b If patients experience an annual decrease in BMD of ≥ 10 % at any site (or ≥ 4–5 % in patients who were osteopenic at baseline) using the same DXA absorptiometry machine, secondary causes of bone loss such as vitamin D deficiency should be evaluated and antiresorptive therapy initiated. Use the lowest T-score from spine or hip. ^c Either denosumab (60 mg every 6 months) or six-monthly intravenous zoledronate (4 mg) as first-line treatment (for the duration of endocrine treatment/together typically for up to 5 years). Discontinuation of denosumab should be followed up by an appropriate antiresorptive. ^d Weekly oral alendronate (70 mg) or risedronate (35 mg) or monthly oral ibandronate (150 mg) for the duration of endocrine treatment/typically for up to 5 years. Abbreviations: AI, aromatase inhibitor; BMD, bone mineral density; BMI, body mass index.