Management and Treatment of Osteopenia
Patients with osteopenia should receive lifestyle modifications as first-line treatment, with pharmacologic therapy reserved for those with high fracture risk (T-score 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 FRAX tool). 1
Risk Assessment and Diagnosis
- Osteopenia is defined as a bone mineral density (BMD) T-score between -1.0 and -2.5 2
- More than 60% of white women older than 64 years have osteopenia, and most fractures occur in this population 2
- Comprehensive fracture risk assessment is essential when osteopenia is identified:
- Calculate 10-year fracture risk using the FRAX tool
- Identify additional clinical risk factors (prior fractures, falls, low body weight, family history, etc.)
- Consider vertebral fracture assessment (VFA) to identify undiagnosed vertebral fractures 1
Non-Pharmacological Management
Calcium and Vitamin D
- Recommended calcium intake: 1000-1200 mg daily 1, 3
- Recommended vitamin D intake: 600-800 IU daily with a target serum level of ≥20 ng/ml 1, 3
- Caution: Calcium supplementation has been associated with kidney stones 1
Exercise Recommendations
- Weight-bearing exercise: at least 30 minutes, 3 days per week 1
- Include a combination of:
Lifestyle Modifications
- Maintain weight in the recommended range
- Smoking cessation
- Limit alcohol intake to 1-2 alcoholic beverages/day
- Follow a balanced diet 1
Fall Prevention
- Home hazard assessment
- Medication review to identify drugs that increase fall risk
- Balance and strength training
- Vision assessment
- Appropriate footwear 1
Pharmacological Treatment
Indications for Treatment
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
First-Line Treatment
- Oral bisphosphonates (alendronate 70 mg once weekly or risedronate 35 mg once weekly) are first-line due to safety, cost, and established efficacy 1
- Risedronate treatment in women with advanced osteopenia (T-score near -2.5) may reduce fracture risk by 73% compared to placebo 1
Alternative Treatments
- Zoledronic acid 5 mg IV every 2 years for those who cannot tolerate oral bisphosphonates 1
- Denosumab 60 mg subcutaneously every 6 months for patients with contraindications to bisphosphonates (caution: discontinuation may increase vertebral fracture risk) 1, 3
- Anabolic medications (teriparatide, abaloparatide, romosozumab) should be considered only for very high-risk individuals 3
Important Cautions
- The American College of Physicians strongly recommends against using menopausal estrogen therapy or raloxifene for osteopenia treatment due to potential harms 1
- Bisphosphonates can cause GI adverse effects; proper administration is essential 1
- Zoledronic acid can cause acute phase reactions within the first week; acetaminophen or ibuprofen may help 1
Special Populations
- Cancer survivors should follow the 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 1
- Patients on systemic steroid therapy should receive calcium and vitamin D supplementation for the duration of treatment 1
Monitoring
- Repeat BMD testing every 2-3 years
- More frequent monitoring for high-risk patients (e.g., those on high-dose glucocorticoids)
- Annual clinical fracture risk reassessment to adjust treatment plans as needed 1
Management of Underlying Conditions
- Evaluate and treat conditions that contribute to bone loss:
- Vitamin D deficiency
- Hyperparathyroidism
- Hyperthyroidism
- Malabsorption disorders
- Chronic kidney disease
- Medications (e.g., glucocorticoids, anticonvulsants) 1