What is the treatment for osteopenia?

Treatment of Osteopenia

For patients with osteopenia, treatment should include calcium (1000-1500 mg/day) and vitamin D (800-1000 IU/day) supplementation, weight-bearing exercise, smoking cessation, and limiting alcohol consumption, with bisphosphonate therapy considered when T-score is below -1.5 or when FRAX score indicates 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%. 1, 2

Risk Assessment and Diagnosis

Osteopenia is defined as bone mineral density (BMD) with a T-score between -1 and -2.5, representing a significant risk factor for progression to osteoporosis 3. When osteopenia is identified, a comprehensive fracture risk assessment should be performed:

• Calculate 10-year fracture risk using the FRAX tool
• Identify clinical risk factors: previous fragility fracture, glucocorticoid use, family history of hip fracture, low body weight/BMI, smoking, alcohol consumption 1
• Evaluate for secondary causes of bone loss (hypogonadism, vitamin D deficiency, glucocorticoid exposure, etc.)

Non-Pharmacological Management

1. Calcium and Vitamin D Supplementation:

   • Calcium: 1000-1500 mg daily 2, 1
   • Vitamin D: 800-1000 IU daily 2, 1
   • Supplemental calcium should only be given if dietary calcium is <800 mg/day 2

2. Exercise:

   • Weight-bearing and resistance exercises for at least 30 minutes, 3+ days per week 1
   • Regular physical activity helps maintain bone density 2

3. Lifestyle Modifications:

   • Smoking cessation 2, 1
   • Limit alcohol consumption 1
   • Fall prevention strategies 1

Pharmacological Management

Initiate bone-modifying agents when:

1. T-score criteria:

   • T-score less than -1.5 with additional risk factors 2
   • T-score ≤ -2.5 (osteoporosis range) 1

2. FRAX score thresholds:

   • 10-year risk of hip fracture ≥3% 2, 1
   • 10-year risk of major osteoporotic fracture ≥20% 2, 1

3. History of fragility fracture 1, 4

4. First-line pharmacological options:

   • Oral bisphosphonates (alendronate, risedronate) 1
   • IV bisphosphonates if oral not tolerated 1
   • Denosumab if bisphosphonates contraindicated 1
   • Raloxifene for postmenopausal women when above options inappropriate 1

Monitoring

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

Special Considerations

1. Patients on systemic steroid therapy:

   • Should receive calcium and vitamin D supplementation for the duration of treatment 2
   • Consider earlier initiation of bisphosphonates 2

2. Inflammatory conditions:

   • Treatment of underlying disease activity is important, particularly in younger patients 2
   • Tight control of disease activity plus calcium/vitamin D supplementation can increase BMD by 0.76% annually 2

3. Cancer survivors:

   • Be aware of treatment-related bone loss due to endocrine therapy, chemotherapy, or medications like glucocorticoids 2
   • Follow same thresholds for bone-modifying agent initiation 2

Common Pitfalls to Avoid

• Failing to assess for secondary causes of osteopenia
• Relying solely on T-score without considering FRAX score or clinical risk factors
• Inadequate calcium and vitamin D supplementation
• Not repeating BMD measurements at appropriate intervals
• Overlooking the importance of weight-bearing exercise and lifestyle modifications

By following this structured approach to osteopenia management, clinicians can effectively reduce the risk of progression to osteoporosis and prevent fragility fractures.