What is the diagnosis and treatment plan for a 73-year-old female with osteopenia, presenting with a T score of -1.7 in the spine and -2.0 in the hip, indicating osteoporosis (bone mineral density loss)?

From the Guidelines

For a 73-year-old female with osteopenia (T-scores of -1.7 in spine and -2.0 in hip), I strongly recommend starting alendronate 70mg once weekly as first-line therapy, as supported by the American College of Physicians guideline update from 2017 1. This oral bisphosphonate helps prevent bone loss by inhibiting osteoclast activity. It is essential to take it first thing in the morning with a full glass of water, remaining upright for 30 minutes afterward without eating or drinking. Supplementing with calcium 1000-1200mg daily and vitamin D 800-1000 IU daily, divided into two doses for better absorption, is also crucial. Regular weight-bearing exercise, such as walking 30 minutes daily, and balance training are essential components of treatment. Fall prevention strategies should include home safety assessment, proper footwear, and vision checks. With T-scores between -1.0 and -2.5, you have osteopenia, which indicates lower bone density than normal but not as severe as osteoporosis. However, your age and T-scores approaching -2.5 warrant pharmacologic intervention to prevent fractures, as emphasized by the 2022 update on osteoporosis and bone mineral density from the American College of Radiology 1. Schedule a follow-up bone density scan in 1-2 years to monitor treatment effectiveness, and report any new back pain, height loss, or digestive issues promptly. It is also important to note that the accuracy and reproducibility of DXA have led to the establishment of standards for the diagnosis of osteoporosis, and fracture risk is determined when BMD as measured by DXA is compared with a gender-matched asymptomatic reference population 1. Given the high-quality evidence supporting the use of alendronate in preventing fractures in women with osteoporosis or osteopenia, starting alendronate 70mg once weekly is the most appropriate course of action to reduce the risk of hip and vertebral fractures in this patient.

From the FDA Drug Label

The efficacy and safety of Prolia in the treatment of postmenopausal osteoporosis was demonstrated in a 3-year, randomized, double-blind, placebo-controlled trial. Enrolled women had a baseline BMD T-score between -2.5 and -4. 0 at either the lumbar spine or total hip. The primary efficacy variable was the incidence of new morphometric (radiologically-diagnosed) vertebral fractures at 3 years. Prolia significantly reduced the incidence of new morphometric vertebral fractures at 1,2, and 3 years (p < 0.0001), as shown in Table 3. The incidence of new vertebral fractures at year 3 was 7.2% in the placebo-treated women compared to 2.3% for the Prolia-treated women. The absolute risk reduction was 4. 8% and relative risk reduction was 68% for new morphometric vertebral fractures at year 3.

The patient has osteopenia with a T score of -1.7 at the spine and -2.0 at the hip.

• The denosumab drug label does not directly address the treatment of osteopenia, but it does discuss the treatment of postmenopausal osteoporosis.
• The patient's T scores are higher than the range of -2.5 to -4.0 included in the clinical trial.
• However, denosumab has been shown to be effective in reducing the risk of vertebral fractures and increasing bone mineral density (BMD) in postmenopausal women with osteoporosis 2.
• Given the patient's osteopenia and the results of the clinical trial, denosumab may be considered as a treatment option to reduce the risk of fractures and increase BMD.
• However, the decision to use denosumab should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.

From the Research

Osteopenia Treatment Considerations

• The patient's T score of -1.7 for the spine and -2.0 for the hip indicates osteopenia, which is a condition characterized by low bone density that is not severe enough to be classified as osteoporosis 3.
• According to the study published in 2003, treatment of osteoporosis should be considered in women over 70 years old if the T-score is below -2.5, but the use of the Z-score is not appropriate in this age group 4.
• However, the study published in 2012 suggests that an osteopenic T-score does not in itself constitute a treatment imperative, and that treatment should be considered only if the patient has a history of low-energy fractures or a high risk of future fractures as assessed by risk calculators like FRAX 5.
• The study published in 2006 recommends the use of combination therapy with alendronic acid and colecalciferol (vitamin D3) for the treatment of osteoporosis, which may also be beneficial for patients with osteopenia 6.
• Another study published in 2005 found that alendronate, vitamin D, and calcium supplementation increased lumbar spine bone mineral density by 5.2% in patients with HIV infection and osteopenia/osteoporosis 7.

Treatment Options

• Alendronic acid and colecalciferol (vitamin D3) combination therapy may be a suitable treatment option for patients with osteopenia, especially those with low vitamin D levels 6.
• Calcium and vitamin D supplementation is also recommended to improve bone density in patients with osteopenia 3.
• Antiresorptive treatments, such as bisphosphonates or Denosumab, may be considered for patients with osteopenia who are at high risk of fractures or have a history of low-energy fractures 5.
• Anabolic therapy may be indicated in rare cases where patients have failed anti-resorptive therapy 5, 3.