What is the recommended treatment for osteopenia?

Treatment Recommendations for Osteopenia

For patients with osteopenia, the recommended treatment includes optimizing calcium intake (1,000-1,200 mg/day), vitamin D intake (600-800 IU/day), and lifestyle modifications, while pharmacological therapy should be reserved for those with higher fracture risk based on FRAX assessment or other risk factors.

Risk Assessment and Classification

Before initiating treatment, proper risk assessment is essential:

• For adults ≥40 years: Use FRAX tool to calculate 10-year fracture risk 1

  • Consider pharmacological therapy if 10-year risk of all osteoporotic fracture is ≥20% or hip fracture risk is ≥3% 1
  • Perform BMD testing with DXA and vertebral fracture assessment (VFA) 1

• For adults <40 years: BMD with VFA or spinal x-rays is advised as FRAX is not validated in this population 1

Non-Pharmacological Interventions (For All Patients)

1. Calcium and Vitamin D

   • Optimize calcium intake: 1,000-1,200 mg/day 1
   • Optimize vitamin D intake: 600-800 IU/day (target serum level ≥20 ng/ml) 1

2. Lifestyle Modifications

   • Regular weight-bearing or resistance training exercise (30 minutes at least 3 days/week) 1
   • Maintain weight in recommended range
   • Smoking cessation
   • Limit alcohol intake to 1-2 alcoholic beverages/day
   • Balanced diet 1

Pharmacological Treatment

Low Fracture Risk

• Optimize calcium and vitamin D intake and lifestyle modifications only 1
• Strong recommendation against IV bisphosphonates or raloxifene in this group 1

Moderate Fracture Risk

• Oral bisphosphonates are recommended over calcium and vitamin D alone 1
• Alternative options (if oral bisphosphonates not appropriate, in order of preference):
  1. IV bisphosphonates
  2. Teriparatide
  3. Denosumab
  4. Raloxifene (for postmenopausal women only) 1

High/Very High Fracture Risk

• Oral bisphosphonates strongly recommended over calcium and vitamin D alone 1
• For very high fracture risk, anabolic agents (PTH/PTHrP) are conditionally recommended over antiresorptive agents 1
• In adults ≥40 years at high risk, denosumab or PTH/PTHrP are conditionally recommended over bisphosphonates 1

Special Considerations

• Glucocorticoid Users: Patients on prednisone ≥2.5 mg/day for ≥3 months require special attention, as they have higher fracture risk 1

  • Adjust FRAX scores: increase major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 if prednisone dose >7.5 mg/day 1

• Sequential Treatment: After discontinuation of denosumab, romosozumab, or PTH/PTHrP, sequential treatment with another osteoporosis medication is recommended to prevent rebound bone loss 1

• Women of Childbearing Potential: Special considerations apply regarding medication safety 1

Common Pitfalls to Avoid

1. Misunderstanding Osteopenia: Osteopenia is not a disease but represents a wide range of fracture risks 2. Don't treat based solely on T-score without considering overall fracture risk.

2. Overtreatment: Not all patients with osteopenia require pharmacological therapy. Treatment decisions should be based on comprehensive fracture risk assessment, not just BMD 1.

3. Inadequate Follow-up: Regular monitoring of bone health is essential, with repeat DXA scans every 1-5 years depending on risk factors 1.

4. Ignoring Secondary Causes: Always evaluate for secondary causes of bone loss before initiating treatment 1.

5. Medication Discontinuation: Stopping certain medications (especially denosumab) without proper sequential therapy can lead to rebound bone loss and increased fracture risk 1.