What are the treatment options for osteopenia?

From the Guidelines

Treatment for osteopenia should be individualized, with a focus on lifestyle modifications and potentially pharmacologic treatment with bisphosphonates in females over 65 with low bone mass, as suggested by the American College of Physicians in 2023 1.

Key Considerations

• Lifestyle changes should be the first approach, including regular weight-bearing exercise, adequate calcium intake, vitamin D supplementation, smoking cessation, and limiting alcohol consumption.
• For medication, bisphosphonates such as alendronate, risedronate, or ibandronate may be considered, as they slow bone breakdown and allow bone-building cells to work more effectively.
• Other medication options include selective estrogen receptor modulators like raloxifene, hormone replacement therapy for postmenopausal women, or denosumab for those who cannot tolerate bisphosphonates.
• Treatment decisions should be based on fracture risk assessment using tools like FRAX, bone density measurements, age, gender, and other health conditions, as recommended by the American College of Physicians in 2017 1.

Benefits and Harms of Treatment

• Benefits of treatment include reduction in fracture risk, with bisphosphonates, denosumab, and teriparatide showing efficacy in reducing vertebral and nonvertebral fractures 1.
• Harms of treatment include mild upper GI symptoms, atypical subtrochanteric fracture, and osteonecrosis of the jaw with bisphosphonates, as well as cardiovascular and thromboembolic events with raloxifene 1.

Recent Guidelines

• The American College of Physicians suggests an individualized approach to pharmacologic treatment with bisphosphonates in females over 65 with low bone mass, balancing benefits and harms based on individual fracture risk assessment 1.
• The 2017 guideline from the American College of Physicians recommends offering pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women with known osteoporosis 1.

From the FDA Drug Label

Alendronate sodium 10 mg/day (for up to five years) reduced urinary excretion of markers of bone resorption, deoxypyridinoline and cross-linked N-telopeptides of type I collagen, by approximately 50% and 70%, respectively, to reach levels similar to those seen in healthy premenopausal women Teriparatide increased lumbar spine BMD compared with baseline at 3 months through 18 months of treatment. In patients treated with teriparatide, the mean percent change in BMD from baseline to endpoint was 7.2% at the lumbar spine, 3.6% at the total hip, and 3.7% at the femoral neck

The treatment options for osteopenia include:

• Alendronate: a bisphosphonate that reduces bone resorption and increases bone mass
• Teriparatide: an anabolic agent that increases bone formation and bone mass These medications can help to reduce the risk of fractures and improve bone density in patients with osteopenia. However, the specific treatment plan will depend on the individual patient's needs and medical history. 2, 2, 3

From the Research

Treatment Options for Osteopenia

• Correction of calcium and vitamin D deficiency can improve bone density in the hip and spine 4
• Regular weight-bearing exercise, such as walking 3 to 5 miles a week, can also improve bone density 4, 5
• A balanced diet with adequate calcium and vitamin D intake is essential for bone health 5
• Avoidance of smoking, excessive alcohol intake, and fall risks at home can decrease the risk of fracture 5
• Pharmaceutical agents, such as hormone replacement therapy, selective estrogen receptor modulator therapy, and anti-resorptive therapy, can be used to treat osteopenia and osteoporosis 4
• Anabolic therapy can be used to improve bone density in patients with osteoporosis who have failed anti-resorptive therapy 4

Pharmaceutical Treatment Options

• Denosumab, a fully human monoclonal antibody, has been shown to increase bone mineral density and reduce fracture risk in patients with osteoporosis 6, 7
• Bisphosphonates, such as alendronate, can also be used to treat osteoporosis, but denosumab may be more effective in increasing bone mineral density and reducing fracture risk 6
• Teriparatide, a recombinant form of parathyroid hormone, has been shown to be effective in preventing glucocorticoid-induced osteoporosis and may be superior to bisphosphonates in increasing bone mineral density and preventing vertebral fractures 8

Lifestyle Modifications

• Regular exercise, such as weight-bearing exercise, can help improve bone density and reduce the risk of fracture 5
• A balanced diet with adequate calcium and vitamin D intake is essential for bone health 5
• Avoidance of smoking, excessive alcohol intake, and fall risks at home can decrease the risk of fracture 5
• Emerging modifiable factors, such as B-vitamin, omega-3 fatty acid, soy isoflavone, and dehydroepiandrosterone supplementation, may also be important for bone health 5