What are the treatment options for Osteopenia (bone density loss)?

From the Guidelines

Osteopenia treatment should focus on preventing progression to osteoporosis through lifestyle modifications and sometimes medication, with the primary goal of reducing fracture risk and maintaining bone density. The most recent and highest quality study on osteopenia treatment is from 2019, which provides recommendations on nutrition in chronic liver disease 1. However, for osteopenia treatment in general, the American College of Physicians guideline from 2017 is the most relevant, recommending pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis 1.

Key Recommendations:

• Increase calcium intake to 1000-1200mg daily and vitamin D to 800-1000 IU daily through diet and supplements.
• Regular weight-bearing exercise for 30 minutes most days of the week is essential, including activities like walking, jogging, or resistance training.
• Smoking cessation and limiting alcohol consumption to no more than one drink daily for women and two for men are important lifestyle changes.
• Medications are typically not prescribed for osteopenia alone unless there are additional risk factors for fracture.
• If medication is needed, bisphosphonates like alendronate (Fosamax) 70mg once weekly or risedronate (Actonel) 35mg once weekly are common first-line options. Some key points to consider when treating osteopenia include:
• Fall prevention strategies should be implemented, including home safety assessments, proper footwear, and vision checks.
• Regular bone density scans every 2-5 years are recommended to monitor bone health and treatment effectiveness.
• The decision to treat osteopenic women 65 years of age or older who are at a high risk for fracture should be based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications 1. The primary goal of osteopenia treatment is to reduce fracture risk and maintain bone density, and treatment should be individualized based on patient-specific factors and risk profiles.

From the FDA Drug Label

1.1 Treatment of Postmenopausal Women with Osteoporosis at High Risk for Fracture 1.2 Treatment to Increase Bone Mass in Men with Osteoporosis 1.3 Treatment of Glucocorticoid-Induced Osteoporosis 1.4 Treatment of Bone Loss in Men Receiving Androgen Deprivation Therapy for Prostate Cancer 1.5 Treatment of Bone Loss in Women Receiving Adjuvant Aromatase Inhibitor Therapy for Breast Cancer

The denosumab (SQ) is used to treat osteoporosis, but there is no direct information about treating osteopenia.

• The drug label mentions treatment of osteoporosis in postmenopausal women and men, as well as treatment of bone loss in certain conditions.
• However, osteopenia is not explicitly mentioned as an indication for denosumab (SQ) treatment 2.

From the Research

Osteopenia Treatment Options

• Osteopenia and osteoporosis are associated with increased fracture incidence, and various pharmacological agents can reduce the risk of fragility fractures 3
• Teriparatide, bisphosphonates, and denosumab are the most effective treatments in reducing the risk of fragility fractures, although differences in efficacy across drugs are small 3
• The selection of osteoporosis treatment should be individualized and based on factors such as underlying fracture risk, medical comorbidities, medication burden, and fracture risk reduction profiles 4

Pharmacological Therapies

• Antiresorptive therapies, including bisphosphonates, estrogens, selective estrogen receptor modulators (SERMs), calcitonin, and monoclonal antibodies like denosumab, can increase bone strength in individuals with osteoporosis 5
• Bisphosphonates are the most widely used first-line antiresorptive therapy and are recommended for patients with osteoporosis, a prior fragility fracture, or osteopenia, as well as individuals with a high risk of fracture 5
• Denosumab is another possible first-line therapy, although long-term safety data are lacking 5

Dietary Recommendations

• A Mediterranean-type diet and daily consumption of 2 to 3 dairy products are recommended to maintain a normal calcium-phosphorus balance and bone metabolism, and are associated with lower fracture risk 6
• Unbalanced Western diets, vegan diets, weight-loss diets in non-overweight individuals, alcohol consumption, and daily consumption of sodas are advised against due to their potential negative effects on bone health 6

Comparative Studies

• A comparison of three oral bisphosphonate therapies (alendronate, ibandronate, and risedronate) found differences in effect on the central skeleton but not on the peripheral skeleton 7
• Greater effects were observed for ibandronate (and alendronate) than risedronate at the spine but not the hip 7