What are the treatment recommendations for a 73-year-old female with osteopenia?

Treatment Recommendations for Osteopenia in a 73-Year-Old Female

For a 73-year-old female with osteopenia, treatment decisions should be based on fracture risk assessment rather than bone mineral density alone, with pharmacologic therapy recommended for those at high risk for fracture.

Assessment of Fracture Risk

• Calculate the 10-year fracture risk using the WHO Fracture Risk Assessment Tool (FRAX) 1, 2
• Consider pharmacologic treatment if:
  • 10-year risk of major osteoporotic fracture is ≥20% or
  • 10-year risk of hip fracture is ≥3% 1
• Advanced age (73 years) is itself a significant risk factor that increases fracture risk 1, 2

Non-Pharmacologic Interventions (For All Patients)

• Calcium supplementation: 1000-1200 mg daily 1, 2, 3
• Vitamin D supplementation: 800-1000 IU daily 1, 2, 3
• Weight-bearing exercise: 30 minutes at least 3 days per week 1, 2
• Smoking cessation and limiting alcohol intake 1, 2
• Fall prevention strategies 2

Pharmacologic Treatment Options

First-Line Treatment (If High Fracture Risk)

• Oral bisphosphonates are the first-line treatment 1, 2:
  • Alendronate: 70 mg weekly
  • Risedronate: 35 mg weekly or 150 mg monthly
  • Low-quality evidence showed that risedronate treatment in women with advanced osteopenia significantly reduced fragility fracture risk by 73% compared to placebo 1

Alternative Options (If Unable to Tolerate Bisphosphonates)

• Denosumab: 60 mg subcutaneous injection every 6 months 2, 4
  • Particularly useful in patients with renal impairment 2
  • Reduces risk of vertebral, nonvertebral, and hip fractures 2
  • Requires monitoring for hypocalcemia 4

Treatments to Avoid

• Menopausal estrogen therapy or estrogen plus progestogen therapy
• Raloxifene (associated with serious harms such as thromboembolism) 1

Duration of Treatment

• The American College of Physicians recommends treating for 5 years 1
• Bone density monitoring is not recommended during the 5-year treatment period 1

Special Considerations

• The balance of benefits and harms of treating osteopenic women is most favorable when fracture risk is high 1
• Women with severe osteopenia (T-score < -2.0) will benefit more than those with mild osteopenia (T-score between -1.0 and -1.5) 1
• Most osteoporotic fractures occur in individuals with BMD T-scores in the osteopenic range, despite lower individual risk 5, 6

Monitoring

• Check calcium levels before initiating treatment, particularly with denosumab 2, 4
• Ensure vitamin D deficiency is corrected before starting bisphosphonate therapy 2
• Maintain good oral hygiene and avoid invasive dental procedures while on denosumab to reduce risk of osteonecrosis of the jaw 2

Pitfalls to Avoid

1. Treating based on T-score alone without considering overall fracture risk
2. Failing to provide adequate calcium and vitamin D supplementation alongside pharmacologic therapy
3. Not considering drug-specific contraindications (e.g., renal function for bisphosphonates)
4. Overlooking the importance of non-pharmacologic interventions
5. Continuing treatment beyond recommended duration without reassessment

By following these evidence-based recommendations and considering the patient's specific fracture risk profile, appropriate treatment can be initiated to reduce fracture risk and improve outcomes in this 73-year-old female with osteopenia.