Treatment Options for Osteopenia
Pharmacologic treatment for osteopenia should be considered when T-score is less than -1.5 with additional risk factors, 10-year risk of major osteoporotic fracture ≥20%, or 10-year risk of hip fracture ≥3% based on the FRAX tool. 1
Lifestyle and Non-Pharmacologic Interventions
Calcium and Vitamin D
- Recommended calcium intake: 1000-1200 mg daily 1
- Recommended vitamin D intake: 600-800 IU daily with target serum level ≥20 ng/ml 1
- Caution: Calcium supplementation has been associated with kidney stones 1
Exercise
- Weight-bearing exercise: At least 30 minutes, 3 days per week 1
- Include a combination of:
- Weight-bearing exercises
- Resistance/strengthening exercises
- Balance training
- Flexibility/stretching exercises
Fall Prevention
- Home hazard assessment and modification
- Medication review to reduce medications causing drowsiness
- Balance and strength training
- Vision assessment
- Appropriate footwear 1
Other Lifestyle Modifications
- Maintain weight in recommended range
- Smoking cessation
- Limit alcohol intake to 1-2 drinks per day
- Follow a balanced diet 1
Pharmacologic Treatment
First-Line Treatment
- Oral bisphosphonates are recommended as first-line therapy due to safety, cost, and established efficacy 1:
- Alendronate 70 mg once weekly
- Risedronate 35 mg once weekly
- Alendronate inhibits osteoclast activity without directly affecting bone formation 2
Alternative Options
- Zoledronic acid 5 mg IV every 2 years 1
- May cause acute phase reactions within first week; acetaminophen or ibuprofen may help manage symptoms 1
- Denosumab 60 mg subcutaneously every 6 months for patients with contraindications to bisphosphonates 1
- Note: Discontinuation may increase risk of vertebral fractures 1
Special Considerations
- The American College of Physicians strongly recommends against using menopausal estrogen therapy or raloxifene for osteopenia treatment due to potential harms 1
- Risedronate treatment in women with advanced osteopenia (T-score near -2.5) may reduce fracture risk by 73% compared to placebo 1
Treatment for Special Populations
Cancer Patients
- Cancer survivors should follow the same thresholds for bone-modifying agent initiation 1
- Bisphosphonates or denosumab may be indicated to prevent bone loss in patients on aromatase inhibitors or androgen deprivation therapy 1
- Patients with vertebral fractures have a 5-fold increased risk of new vertebral fracture and 2-fold increased risk of hip fracture 3
Glucocorticoid Users
- Patients on systemic steroid therapy should receive calcium and vitamin D supplementation for the duration of treatment 1
- The risk versus benefit of alendronate for treatment at daily dosages of glucocorticoids less than 7.5 mg of prednisone has not been established 2
Monitoring
- Repeat BMD testing every 2-3 years 1
- More frequent monitoring for high-risk patients (e.g., those on high-dose glucocorticoids) 1
- Annual clinical fracture risk reassessment to adjust treatment plans as needed 1
Important Precautions with Bisphosphonate Use
- Hypocalcemia must be corrected before initiating therapy 2
- Risk of severe esophageal adverse experiences is greater in patients who lie down after taking oral bisphosphonates or fail to swallow with a full glass of water 2
- Rare but serious adverse effects include:
- Alendronate is not recommended for patients with creatinine clearance less than 35 mL/min 2
Fracture Risk Assessment
- Calculate 10-year fracture risk using the FRAX tool 1
- Vertebral fracture assessment (VFA) is useful for identifying undiagnosed vertebral fractures 1
- Evaluate and treat underlying conditions that may contribute to bone loss 1
Most fractures occur in individuals with BMD in the osteopenic range rather than those with osteoporosis, despite the lower individual risk, due to the larger number of people with osteopenia 4. Therefore, identifying high-risk individuals within the osteopenic range is crucial for targeted intervention.