What is the management of osteopenia?

From the Guidelines

Management of osteopenia focuses on preventing progression to osteoporosis through lifestyle modifications and, in some cases, medication. The cornerstone of treatment includes regular weight-bearing exercise (30 minutes most days of the week) and resistance training (2-3 times weekly) to stimulate bone formation, as supported by the 2020 study on physical activity and osteoporosis prevention 1. Adequate calcium intake is essential, with recommended daily amounts of 1000-1200 mg for adults, preferably from dietary sources like dairy products, leafy greens, and fortified foods, with supplements if needed, as recommended by the 2017 American College of Physicians guideline update 1. Vitamin D supplementation of 800-1000 IU daily is important for calcium absorption and bone health, as suggested by the 2020 ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1. Smoking cessation and limiting alcohol consumption to no more than 1-2 drinks daily are strongly advised as both can accelerate bone loss. Fall prevention strategies should be implemented, including home safety modifications and balance training. For patients with higher fracture risk (T-scores closer to -2.5 or additional risk factors), medications may be considered, including bisphosphonates like alendronate (70 mg weekly) or risedronate (35 mg weekly), as recommended by the 2017 American College of Physicians guideline update 1. Regular bone density monitoring with DEXA scans every 2-5 years is recommended to track progression, as suggested by the 2016 EASL clinical practice guidelines on liver transplantation 1. These interventions work by either slowing bone resorption or enhancing bone formation, maintaining the delicate balance of bone remodeling to preserve bone mineral density and structural integrity. Key considerations in managing osteopenia include:

• Lifestyle modifications: weight-bearing exercise, resistance training, adequate calcium and vitamin D intake, smoking cessation, and limited alcohol consumption
• Medication: bisphosphonates, such as alendronate or risedronate, for patients with higher fracture risk
• Regular bone density monitoring with DEXA scans to track progression
• Fall prevention strategies to reduce the risk of fractures. The most recent and highest quality study, the 2020 study on physical activity and osteoporosis prevention 1, supports the importance of lifestyle modifications in preventing progression to osteoporosis. Additionally, the 2017 American College of Physicians guideline update 1 provides strong recommendations for the use of bisphosphonates in preventing fractures in patients with osteoporosis. Overall, a comprehensive approach to managing osteopenia, including lifestyle modifications, medication, and regular monitoring, is essential to preventing progression to osteoporosis and reducing the risk of fractures.

From the FDA Drug Label

Osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. The term osteopenia is not directly defined in the provided drug label, but it can be inferred that it refers to a condition of low bone mass that has not yet progressed to osteoporosis.

• Osteopenia is often considered a precursor to osteoporosis.
• The management of osteopenia is not explicitly stated in the label, but it can be inferred that treatment with alendronate may help to reduce bone resorption and increase bone mass.
• Alendronate has been shown to be effective in reducing the risk of fractures in patients with osteoporosis, and it may also be beneficial in managing osteopenia. 2

From the Research

Definition of Osteopenia

• Osteopenia is a term used to define bone density that is not normal but also not as low as osteoporosis 3.
• According to the World Health Organization, osteopenia is defined by bone densitometry as a T score -1 to -2.5 3.

Causes of Osteopenia

• There are many causes for osteopenia, including calcium and vitamin D deficiency and inactivity 3.
• Genetics plays an important role in a person's bone mineral density, and often Caucasian women with a thin body habitus who are premenopausal are found to have osteopenia 3.

Management of Osteopenia

• Correction of calcium and vitamin D deficiency and walking 3 to 5 miles a week can often improve bone density in the hip and spine 3.
• There are a variety of pharmaceutical agents that have been recommended for the treatment of osteopenia and osteoporosis, including hormone replacement therapy, selective estrogen receptor modulator therapy, and anti-resorptive therapy 3.
• Resistance exercise and supplementation with calcium and vitamin D can also promote bone health 4.
• Combination therapy of vitamin D and bisphosphonates may be effective in treating postmenopausal osteoporosis, with a more pronounced effect on increasing alkaline phosphatase, 25-hydroxyvitamin D, and serum calcium levels, as well as decreasing levels of serum bone-specific alkaline phosphatase, serum C-terminal telopeptide of type I collagen, and urinary N-telopeptide of type I collagen compared to monotherapy 5.

Treatment Options

• Hormone replacement therapy and potent bisphosphonates can produce greater effects on bone density 6.
• Anabolic therapy can also improve bone density in patients with osteoporosis who have failed anti-resorptive therapy 3.
• Fracture risk algorithms that combine clinical risk factors and bone mineral density can be used to target high-risk individuals for treatment 7.
• Long-term management is required for osteoporosis, and treatment with bisphosphonates or denosumab can be beneficial for up to 10 years 7.