What is the diagnosis and treatment for osteopenia (reduced bone density)?

From the Guidelines

Osteopenia should be treated with a combination of lifestyle modifications, including regular weight-bearing exercise, and supplementation with calcium and vitamin D, with the goal of preventing further bone loss and reducing the risk of fractures, as recommended by the most recent guidelines 1.

Diagnosis and Treatment

Osteopenia is a condition where bone mineral density is lower than normal but not low enough to be classified as osteoporosis. It represents an early stage of bone loss that may progress to osteoporosis if not addressed.

• The diagnosis of osteopenia is typically made using dual energy X-ray absorptiometry (DEXA) scans, which measure bone mineral density at the femoral neck or the lowest value from either the lumbar spine or femoral neck 1.
• Treatment typically includes increasing calcium intake to 1000-1200mg daily and vitamin D to 800-1000 IU daily through diet or supplements, as well as regular weight-bearing exercise like walking, jogging, or resistance training for 30 minutes most days of the week to stimulate bone formation.
• Lifestyle modifications are crucial, including quitting smoking, limiting alcohol to no more than 1-2 drinks daily, and reducing caffeine intake.
• Prescription medications, such as bisphosphonates, may be considered if there are additional risk factors for fracture, but are not usually the first line of treatment for osteopenia alone 1.

Monitoring and Prevention

• Bone density testing should be repeated every 2-5 years to monitor progression, with more frequent testing recommended for individuals with a high risk of fracture or rapid bone loss 1.
• Osteopenia occurs because bone resorption exceeds bone formation, often due to aging, hormonal changes, or inadequate nutrition.
• Early intervention is important because once bone density is lost, it's difficult to fully restore, making prevention of further bone loss the primary goal of treatment.
• The risk of fractures should be assessed in every patient with osteopenia, using tools such as the FRAX calculator, to guide treatment decisions and prevent fragility fractures 1.

From the FDA Drug Label

Osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. The diagnosis can be confirmed by the finding of low bone mass, evidence of fracture on x-ray, a history of osteoporotic fracture, or height loss or kyphosis, indicative of vertebral (spinal) fracture Alendronate is a bisphosphonate that binds to bone hydroxyapatite and specifically inhibits the activity of osteoclasts, the bone-resorbing cells. Alendronate reduces bone resorption with no direct effect on bone formation, although the latter process is ultimately reduced because bone resorption and formation are coupled during bone turnover

The diagnosis of osteopenia (reduced bone density) is not directly addressed in the provided text, but osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. The treatment for osteoporosis with alendronate sodium includes:

• Daily oral doses of 5,20, and 40 mg for six weeks in postmenopausal women
• Long-term treatment of osteoporosis with alendronate sodium 10 mg/day (for up to five years)
• Once weekly alendronate sodium 70 mg for the treatment of osteoporosis and once weekly alendronate sodium 35 mg for the prevention of osteoporosis The key points of alendronate treatment are:
• Inhibition of bone resorption
• Reduction of bone turnover
• Increase in bone mass 2

From the Research

Diagnosis of Osteopenia

• Osteopenia is characterized by a bone mineral density (BMD) T-score between -1·0 and -2·5 3
• The diagnosis of osteopenia is not an indication for either intervention or reassurance, but BMD is a risk factor that should be incorporated into a quantitative fracture risk calculation 3

Treatment of Osteopenia

• Bisphosphonates have been shown to increase bone mineral density in patients with osteopenia 4
• Antiresorptive drugs, such as bisphosphonates, are currently the most widely used osteoporosis medications and can reduce the risk of vertebral, nonvertebral, and hip fractures in postmenopausal women with osteoporosis 5
• Oral and intravenous bisphosphonates can cost-effectively reduce fractures in older osteopenic women 3
• Major osteoporotic fracture risks of 10-15% could be acceptable indications for treatment with generic bisphosphonates in patients older than 65 years motivated to receive treatment 3

Treatment Options

• Alendronate and risedronate are first-line medications for the treatment of osteoporosis, given their efficacy in preventing both vertebral and nonvertebral fractures 4
• Risedronate may not be recommended in the scenario of treatment failure or adverse events following the use of alendronate 6
• Teriparatide, an anabolic therapy, has been demonstrated to be superior to the bisphosphonate risedronate in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture 5
• Romosozumab, a sclerostin antibody, increases BMD more profoundly and rapidly than alendronate and is also superior to alendronate in reducing the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis 5

Cost-Effectiveness of Treatment

• Bisphosphonate therapy is most cost-effective in populations aged 70 years and older, and is unlikely to be cost-effective in populations aged 50 years or younger 7
• Identifying risk factors for fractures through means such as spine radiographs to detect vertebral deformities improves the cost-effectiveness of treatment 7
• Screening for low BMD and treatment with alendronate or etidronate appears to be cost-effective in postmenopausal women in general and in women with rheumatoid arthritis initiating corticosteroid therapy 7