Osteopenia Management Recommendations
For patients with osteopenia, treatment should include calcium (1000-1500 mg/day), vitamin D (800-1000 IU/day), weight-bearing exercise, smoking cessation, and limiting alcohol consumption, with pharmacologic therapy considered when T-score is below -1.5 with additional risk factors or when FRAX score indicates 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%. 1
Non-Pharmacologic Management
Calcium and Vitamin D Supplementation
Calcium intake: 1000-1500 mg daily 1
- Only supplement if dietary calcium is <800 mg/day
- For adults 19-50 years: 1000 mg daily
- For adults 51+ years: 1200 mg daily
Vitamin D intake: 800-1000 IU daily 1
- Target serum vitamin D level: ≥20 ng/mL (50 nmol/L)
- Higher doses may be needed in patients with malabsorption 2
Exercise Recommendations
- Weight-bearing exercise: 30 minutes at least 3 days per week 1
- Include a combination of:
- Weight-bearing exercises (walking, jogging)
- Resistance/strengthening exercises
- Balance training
- Flexibility/stretching exercises
Lifestyle Modifications
- Smoking cessation
- Limit alcohol consumption
- Fall prevention strategies:
- Home hazard assessment
- Medication review
- Balance and strength training
Risk Assessment and Monitoring
Fracture Risk Assessment
- Calculate 10-year fracture risk using FRAX tool 1
- Identify additional clinical risk factors:
- Previous fracture
- Family history of hip fracture
- Glucocorticoid use
- Low BMI
- Secondary causes of osteoporosis
Monitoring
- Repeat BMD testing every 2 years for patients with osteopenia 1
- More frequent monitoring (annually) for patients with:
- Ongoing glucocorticoid therapy
- Significant risk factors
- Evidence of bone loss on previous DXA
Pharmacologic Treatment
Indications for Pharmacologic Therapy
- T-score less than -1.5 with additional risk factors 1
- 10-year risk of major osteoporotic fracture ≥20% 1
- 10-year risk of hip fracture ≥3% 1
- Special consideration for patients on:
- Systemic glucocorticoid therapy
- Aromatase inhibitors
- Androgen deprivation therapy
- GnRH therapies
First-Line Treatment Options
- Oral bisphosphonates (alendronate, risedronate) 1, 3
- IV bisphosphonates if oral not tolerated 1
- Denosumab if bisphosphonates contraindicated 1
- Raloxifene for younger postmenopausal women when above options inappropriate 1
Special Populations
Patients with Chronic Pancreatitis
- Basic preventive measures include adequate calcium/vitamin D intake, pancreatic enzyme supplementation if indicated, regular weight-bearing exercise, and smoking and alcohol avoidance 2
- For patients with osteopenia, repeat DXA every two years 2
HIV-Infected Patients
- Higher calcium (1000-1500 mg) and vitamin D (800-1000 IU) daily intake recommended due to high prevalence of low BMD 2
- FRAX tool may underestimate fracture risk in HIV-infected patients 2
Patients on Glucocorticoids
- Consider pharmacologic therapy at higher T-scores than the general population 1
- All patients on steroid treatment should receive calcium and vitamin D supplementation 2
Common Pitfalls and Caveats
Underdiagnosis: Most fractures occur in individuals with osteopenia rather than osteoporosis due to the larger number of people with osteopenia 3
Inadequate supplementation: Patients frequently do not take sufficient amounts of calcium and vitamin D, even when supplements are provided free of charge 4
FRAX limitations: The FRAX tool has not been validated in certain populations (e.g., HIV-infected persons) and may underestimate fracture risk 2
Secondary causes: Always evaluate for secondary causes of bone loss before initiating treatment 1
Cardiovascular risk: Current evidence is inconclusive regarding whether calcium supplements with vitamin D increase cardiovascular risk 5
By following these evidence-based recommendations, clinicians can effectively manage patients with osteopenia and reduce their risk of progression to osteoporosis and fragility fractures.