Treatment of Osteopenia
For patients with osteopenia, the first-line treatment includes lifestyle modifications, calcium and vitamin D supplementation, with pharmacologic therapy reserved for those at higher risk of fracture based on additional risk factors. 1
Non-Pharmacologic Management
Calcium and Vitamin D
- Calcium intake of 1000-1200 mg daily 1
- Vitamin D intake of 600-800 IU daily (target serum level ≥20 ng/ml) 1
- For vitamin D deficiency, consider higher replacement doses (vitamin D3 2000 IU daily for 12 weeks, then 1000-2000 IU daily maintenance) 1
Exercise
- Weight-bearing exercise of at least 30 minutes, 3 days a week 1
- Combination of:
- Weight-bearing exercises
- Resistance/strengthening exercises
- Balance training
- Flexibility/stretching exercises
Lifestyle Modifications
- Maintain healthy weight
- Smoking cessation
- Limit alcohol to 1-2 drinks per day
- Follow a balanced diet 1, 2
Pharmacologic Treatment
When to Consider Medication
Pharmacologic treatment should be considered when:
- 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) 1
- Women 65 years or older with high fracture risk 3
First-Line Pharmacologic Options
- Bisphosphonates are the first-line treatment for osteopenia requiring pharmacologic intervention:
Low-quality evidence shows that risedronate treatment in women with advanced osteopenia (T-score near -2.5) may reduce fracture risk by 73% compared to placebo 3. This benefit is likely similar across all bisphosphonates.
Alternative Pharmacologic Options
Denosumab (60 mg subcutaneously every 6 months) for patients with contraindications to bisphosphonates 3, 1
- Note: When discontinuing denosumab, there may be increased risk of vertebral fractures; consider transitioning to a bisphosphonate 3
Teriparatide for high-risk patients who have failed anti-resorptive therapy 1, 4
The American College of Physicians strongly recommends against using menopausal estrogen therapy or raloxifene for osteopenia treatment due to potential harms 3.
Special Considerations
Cancer Survivors
- Cancer survivors should follow the same thresholds for bone-modifying agent initiation 1
- For patients on aromatase inhibitors or androgen deprivation therapy, bisphosphonates or denosumab may be indicated to prevent bone loss 3
Monitoring
- Repeat BMD testing every 2-3 years 1
- More frequent monitoring for high-risk patients (e.g., those on high-dose glucocorticoids)
- Annual clinical fracture risk reassessment 1
Fall Prevention
- Home hazard assessment
- Medication review to minimize drugs that increase fall risk
- Balance and strength training
- Vision assessment
- Appropriate footwear 1
Common Pitfalls and Caveats
- Bisphosphonates can cause GI adverse effects; ensure proper administration (taking with water, remaining upright for 30-60 minutes) 3, 5
- Zoledronic acid can cause acute phase reactions within the first week; acetaminophen or ibuprofen may help 3
- Long-term bisphosphonate use (>5 years) may be associated with atypical femur fractures and osteonecrosis of the jaw, requiring risk-benefit assessment for treatment continuation 5
- Calcium supplementation has been associated with kidney stones; careful dosing is important 3
- Treatment adherence is a significant challenge, with 30-50% of patients not taking osteoporosis medications correctly 2
Remember that osteopenia itself is not a disease but rather a risk factor for future fractures. Treatment decisions should be based on comprehensive fracture risk assessment rather than BMD alone 6.