Treatment Options for Osteopenia
For patients with osteopenia, first-line treatment should include calcium and vitamin D supplementation, weight-bearing exercise, smoking cessation, and limiting alcohol consumption, with pharmacologic 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
Non-Pharmacological Management
Calcium and Vitamin D Supplementation
- Recommended daily calcium intake 2, 1:
- Ages 9-18: 1,300 mg
- Ages 19-50: 1,000 mg
- Ages 51+: 1,200 mg
- Recommended daily vitamin D intake 2, 1:
- Ages 9-50: 600 IU
- Ages 51-70: 600 IU
- Ages 71+: 800 IU
- A serum vitamin D level of 20 ng/mL (50 nmol/L) is recommended for good bone health 2
- Supplemental calcium should only be given if dietary calcium is <800 mg/day 1
Exercise Recommendations
- Combination of exercise types is strongly recommended 2, 1:
- Weight-bearing exercises
- Resistance/strengthening exercises
- Balance training
- Flexibility/stretching exercises
- Endurance exercises
- Exercise should be performed at least 30 minutes, 3 days per week 1
- Exercise should be tailored to individual patient needs and abilities 2
Lifestyle Modifications
- Smoking cessation 2, 1
- Limit alcohol consumption 2, 1
- Fall prevention strategies including home hazard assessment 1
- Maintain adequate nutrition (low BMI is an independent risk factor) 1
Pharmacological Management
When to Consider Medication
Pharmacologic treatment should be considered when 2, 1:
- T-score is less than -1.5 with additional risk factors
- 10-year risk of major osteoporotic fracture ≥20%
- 10-year risk of hip fracture ≥3% (based on FRAX tool)
- History of low-trauma fracture
First-Line Treatment Options
Alternative Options
- IV bisphosphonates (if oral not tolerated) 1
- Denosumab (if bisphosphonates contraindicated) 1
- Raloxifene (for postmenopausal women when above options inappropriate) 2, 1
- Can be a good initial treatment in younger postmenopausal women 2
Special Populations
Patients on Glucocorticoid Therapy
- At high risk for developing osteoporosis 4, 5
- May sustain fractures at higher bone density than those not on glucocorticoids 4
- Should receive calcium and vitamin D supplementation for the duration of treatment 1, 5
- Consider pharmacologic therapy at higher T-scores than general population 2, 5
Cancer Survivors
- Be aware of treatment-related bone loss 2, 1
- Follow same thresholds for bone-modifying agent initiation 1
- Special consideration for:
- Premenopausal women receiving GnRH therapies or with chemotherapy-induced ovarian failure
- Postmenopausal women on aromatase inhibitors
- Men on androgen deprivation therapy
- Patients with history of bone marrow transplantation 2
Monitoring and Follow-up
- Repeat BMD testing every 2 years (or annually if clinically indicated) 1
- Reassess fracture risk annually in patients with continuing risk factors 1
- Monitor for treatment adherence and side effects 1
Important Considerations and Cautions
- Bisphosphonate side effects may include 3:
- Esophageal irritation (patients should remain upright for 30 minutes after taking)
- Musculoskeletal pain
- Rare but serious: osteonecrosis of the jaw, atypical femur fractures
- Hypocalcemia must be corrected before initiating bisphosphonate therapy 3
- Bisphosphonates are not recommended for patients with creatinine clearance less than 35 mL/min 3
- Osteopenia alone is not a disease and should not automatically trigger pharmacologic treatment 6, 7
- Most osteoporotic fractures occur in individuals with BMD T-scores in the osteopenic range, highlighting the importance of proper risk assessment 8, 7