What are the guidelines for treating osteopenia?

Guidelines for Osteopenia Treatment

The management of osteopenia should include lifestyle modifications as first-line therapy, with pharmacological treatment reserved for those with significant fracture risk as determined by FRAX assessment or additional risk factors. 1

Assessment of Fracture Risk

When osteopenia is identified (T-score between -1.0 and -2.5), a comprehensive fracture risk assessment should be performed:

• Calculate 10-year fracture risk using FRAX tool 2, 1
• Identify additional clinical risk factors:
  • Previous fragility fracture
  • Glucocorticoid use (≥2.5 mg/day for ≥3 months) 2
  • Family history of hip fracture
  • Low body weight/BMI (<19 kg/m²) 2
  • Smoking and alcohol consumption (≥3 units/day) 2
  • Secondary causes (hypogonadism, hyperparathyroidism, thyroid disease) 2

Treatment Algorithm

1. Low Fracture Risk (FRAX score: <3% for hip or <20% for major osteoporotic fracture)

• Non-pharmacological management only 2, 1:
  • Calcium intake (1000-1200 mg/day) 1
  • Vitamin D supplementation (600-800 IU/day) 1
  • Regular weight-bearing and resistance exercises 1
  • Smoking cessation and limiting alcohol consumption 2
  • Fall prevention strategies 1

2. Moderate to High Fracture Risk (FRAX score: ≥3% for hip or ≥20% for major osteoporotic fracture)

• Initiate pharmacological therapy in addition to lifestyle modifications 2, 1
• First-line treatment options (in order of preference) 2, 1:
  • Oral bisphosphonates (alendronate, risedronate)
  • IV bisphosphonates (if oral not tolerated)
  • Denosumab (if bisphosphonates contraindicated)
  • Raloxifene (for postmenopausal women when above options inappropriate)

3. Very High Risk (Previous vertebral fracture or multiple risk factors)

• Consider anabolic agents (teriparatide) followed by antiresorptive therapy 1, 3

Special Populations

Glucocorticoid-Induced Osteopenia

For patients on long-term glucocorticoids (≥2.5 mg/day for ≥3 months) 2:

• Low risk: Calcium and vitamin D supplementation only
• Moderate risk: Oral bisphosphonates preferred
• High risk: Consider more aggressive therapy

Cancer Survivors

• Assess bone health in all patients with nonmetastatic cancer, especially those on endocrine therapy or with treatment-induced hypogonadism 2
• Consider bone-modifying agents if FRAX score exceeds thresholds or if BMD shows significant osteopenia with additional risk factors 2

Chronic Liver Disease

• Ensure adequate nutrition (low BMI is an independent risk factor) 2
• Provide calcium (1 g/day) and vitamin D3 (800 IU/day) supplementation 2
• Consider bisphosphonate therapy if T-score <-2.5 or fragility fracture present 2

Monitoring

• Reassess fracture risk annually in patients continuing risk factors (e.g., glucocorticoid treatment) 2
• Repeat BMD testing every 2 years (or annually if clinically indicated) 2, 1
• Monitor for treatment adherence and side effects

Common Pitfalls to Avoid

1. Treating based on T-score alone: The decision to treat osteopenia should be based on overall fracture risk, not just BMD 1, 4

2. Overlooking secondary causes: Always evaluate for underlying conditions that may contribute to bone loss 1

3. Inadequate calcium and vitamin D: Ensure sufficient intake before initiating pharmacological therapy 5

4. Neglecting fall prevention: Reducing fall risk is essential in preventing fractures 1

5. Inappropriate bisphosphonate administration: Oral bisphosphonates must be taken with plain water on an empty stomach, at least 30 minutes before food, and the patient should remain upright 5

The number needed to treat (NNT) for preventing fractures in osteopenic patients without additional risk factors is much higher (>100) compared to patients with osteoporosis or previous fractures (NNT 10-20) 4. Therefore, pharmacological treatment should be reserved for those with significant fracture risk as determined by FRAX assessment or additional clinical risk factors.