What are the recommended management and treatment options for patients with osteopenia?

Management and Treatment of Osteopenia

For patients with osteopenia, first-line management should include calcium (1000-1200 mg/day), vitamin D (600-800 IU/day), weight-bearing exercise, and lifestyle modifications, with pharmacologic therapy considered when T-score is below -1.5 with additional risk factors or when FRAX score indicates elevated fracture risk. 1

Non-Pharmacological Management

Calcium and Vitamin D

• Calcium intake: 1000-1200 mg daily 2, 1
  • Supplemental calcium should only be given if dietary calcium is <800 mg/day 1
• Vitamin D intake: 600-800 IU daily (target serum level ≥20 ng/ml) 2, 1
  • For vitamin D deficiency: Consider higher replacement doses (e.g., vitamin D3 2000 IU daily for 12 weeks then 1000-2000 IU daily maintenance) 2

Exercise and Lifestyle Modifications

• Weight-bearing exercise: 30 minutes at least 3 days per week 1
• Resistance/strength training: Focus on major muscle groups 1
• Balance training: To reduce fall risk 1
• Additional recommendations: 2, 1
  • Maintain weight in recommended range
  • Smoking cessation
  • Limit alcohol intake to 1-2 alcoholic beverages/day
  • Balanced diet

Risk Assessment and Monitoring

Fracture Risk Assessment

• Calculate 10-year fracture risk using FRAX tool 1
• Identify clinical risk factors for fracture:
  • Age >65 years
  • Previous fragility fracture
  • Family history of hip fracture
  • Low BMI
  • Glucocorticoid use
  • Smoking
  • Excessive alcohol consumption
  • Secondary causes of bone loss

Monitoring

• Repeat BMD testing every 2-3 years 2
• More frequent monitoring for high-risk patients (e.g., those on high-dose glucocorticoids) 2
• Annual clinical fracture risk reassessment 1

Pharmacological Treatment

Indications for Pharmacological Therapy

Consider pharmacologic treatment 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 fragility fracture

Treatment Options (in order of preference)

1. Oral bisphosphonates (first-line) 2, 1

   • Alendronate or risedronate
   • Preferred for safety, cost, and established efficacy

2. IV bisphosphonates 2, 1

   • Consider when oral bisphosphonates are not appropriate
   • Higher risk profile compared to oral therapy

3. Teriparatide 2, 1

   • Consider when bisphosphonates are contraindicated
   • Limitations: Cost and burden of daily injections

4. Denosumab 2, 1

   • Consider when bisphosphonates and teriparatide are not appropriate
   • Caution: Limited safety data in immunosuppressed patients

5. Raloxifene (for postmenopausal women only) 2, 1

   • Consider when other options are inappropriate
   • Limitations: Less data on hip fracture prevention, potential clotting risks

Special Considerations

Glucocorticoid-Induced Osteopenia

• More aggressive treatment approach needed 2
• For adults ≥40 years at moderate-to-high fracture risk on glucocorticoids:
  • Oral bisphosphonates strongly recommended
  • Consider pharmacologic therapy at higher T-scores than general population 1

Secondary Causes of Osteopenia

• Evaluate and treat underlying conditions 2
• Common secondary causes:
  • Vitamin D deficiency
  • Hyperparathyroidism
  • Hyperthyroidism
  • Malabsorption disorders
  • Chronic kidney disease
  • Medications (e.g., glucocorticoids, anticonvulsants)

HIV-Associated Osteopenia

• Higher calcium (1000-1500 mg) and vitamin D (800-1000 IU) intake recommended 2
• Consider earlier pharmacologic intervention 2

Fall Prevention Strategies

• Home hazard assessment
• Medication review (especially sedatives and antihypertensives)
• Balance and strength training
• Vision assessment
• Appropriate footwear

By implementing these evidence-based strategies, clinicians can effectively manage osteopenia and reduce the risk of progression to osteoporosis and fragility fractures, ultimately improving morbidity, mortality, and quality of life outcomes.