What is the recommendation for a patient with worsening osteopenia, as indicated by a declining Dual-Energy X-ray Absorptiometry (DEXA) scan?

From the Guidelines

If your bone density DEXA scan shows worsening results but you're still in the osteopenia range, I strongly recommend starting with lifestyle modifications and possibly medication depending on your fracture risk, as indicated by the most recent guidelines from the American College of Radiology 1. First, ensure adequate calcium intake of 1000-1200mg daily through diet or supplements, along with vitamin D supplementation of 800-1000 IU daily, as suggested by the EASL clinical practice guidelines on nutrition in chronic liver disease 1. Engage in regular weight-bearing exercise like walking, jogging, or resistance training for 30 minutes most days of the week. Avoid smoking and limit alcohol consumption to no more than 1-2 drinks daily. If you have additional risk factors for fracture (such as previous fractures, family history of hip fracture, or long-term steroid use), your doctor may recommend medication such as bisphosphonates (alendronate 70mg weekly or risedronate 35mg weekly), as recommended by the 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1. These interventions are important because declining bone density indicates active bone loss, which increases your risk of progressing to osteoporosis, and the goal is to stabilize bone density and prevent further deterioration, as bone loss accelerates fracture risk even before reaching osteoporosis thresholds. Key considerations include:

• Evaluating BMD in patients with risk factors for osteoporosis, such as long-term corticosteroid treatment, and before liver transplantation 1
• Utilizing lumbar and femoral densitometry (DXA) for diagnosing osteoporosis and osteopenia, and lateral X-rays of dorsal and lumbar spine for diagnosing vertebral fractures 1
• Repeating DEXA after 2-3 years in patients within normal BMD, and within 1 year when rapid bone loss is expected 1
• Including supplements of calcium and 25-hydroxy-vitamin D in patients with chronic liver disease and a T-score below −1.5 1
• Utilizing bisphosphonates in patients with osteoporosis and in those waiting for liver transplantation 1

From the FDA Drug Label

All patients in the trial had either a BMD T-score less than or equal to -2 at the femoral neck and less than or equal to -1 at the lumbar spine, or a baseline osteoporotic fracture and a BMD T-score less than or equal to -1 at the femoral neck At two years, the mean increases relative to placebo in BMD in men receiving alendronate sodium 10 mg/day were significant at the following sites: lumbar spine, 5.3%; femoral neck, 2.6%; trochanter, 3.1%; and total body, 1.6%.

The recommendation if bone density DEXA is getting worse but still with osteopenia is not directly addressed in the provided FDA drug label. Key points:

• The label discusses treatment of osteoporosis, glucocorticoid-induced osteoporosis, and Paget's disease of bone.
• It does not provide guidance on managing worsening osteopenia. 2

From the Research

Recommendation for Osteopenia with Worsening Bone Density

• The National Osteoporosis Foundation guidelines recommend treatment when bone loss is 2.0 SDs, or less when additional risk factors are present 3.
• For patients with osteopenia, correction of calcium and vitamin D deficiency and regular physical activity, such as walking 3 to 5 miles a week, can often improve bone density in the hip and spine 4.
• A daily intake of at least 1000 mg/day for calcium, 800 IU/day for vitamin D, and 1 g/kg body weight of protein is recommended for postmenopausal women to reduce the risk of osteoporosis 5.
• Antiresorptive drugs, such as bisphosphonates, and denosumab remain first-line treatment options for osteoporosis, but the ongoing need for these medications should be assessed after five years 6.
• Pharmaceutical agents, including hormone replacement therapy, selective estrogen receptor modulator therapy, and anti-resorptive therapy, may be recommended for the treatment of osteopenia and osteoporosis 4.

Lifestyle Changes and Monitoring

• Regular weight-bearing exercise and reduction in alcohol intake and smoking cessation can help reduce the risk of osteoporosis and/or fragility fractures 5.
• Ongoing monitoring is necessary for patients with osteopenia, and most will require some long-term therapy once started 6.
• Specialist referral should be considered for patients who sustain fractures while undergoing osteoporosis therapy 6.