What are the treatment options for osteopenia?

Treatment Options for Osteopenia

For patients with osteopenia, non-pharmacologic interventions including regular weight-bearing exercise, calcium and vitamin D supplementation, and fall prevention measures should be first-line therapy, with pharmacologic treatment reserved for those with high fracture risk based on FRAX scores or additional risk factors. 1

Assessment of Fracture Risk

• Osteopenia is defined as a bone mineral density (BMD) T-score between -1.0 and -2.5 2
• Comprehensive fracture risk assessment should include:
  • FRAX calculation (10-year fracture risk)
  • Consider pharmacologic treatment when:
    • T-score less than -1.5 with additional risk factors
    • 10-year risk of major osteoporotic fracture ≥20%
    • 10-year risk of hip fracture ≥3% 1

Non-Pharmacologic Interventions

Exercise and Lifestyle Modifications

• Regular weight-bearing exercise (at least 30 minutes, 3 days/week) 1
• Maintain healthy lifestyle:
  • Quit smoking
  • Limit alcohol to 1-2 drinks/day
  • Follow balanced diet 1

Calcium and Vitamin D

• Calcium intake: 1000-1200 mg daily
• Vitamin D intake: 600-800 IU daily 1
• Supplementation is often necessary as nutritional sources of vitamin D are limited 3

Fall Prevention

• Balance training
• Home hazard assessment
• Medication review
• Vision assessment
• Appropriate footwear 1

Pharmacologic Treatment

Indications for Pharmacologic Therapy

• High fracture risk based on FRAX score
• T-score less than -1.5 with additional risk factors
• Patients on systemic glucocorticoid therapy 1

First-Line Therapy

• Oral bisphosphonates:
  • Alendronate 70 mg once weekly
  • Risedronate 35 mg once weekly 1
  • Mechanism: Inhibits osteoclast activity without directly affecting bone formation 4
  • Low-quality evidence shows risedronate may reduce fracture risk by 73% compared to placebo in women with advanced osteopenia 1

Alternative Options

For patients who cannot tolerate oral bisphosphonates or have contraindications:

• Zoledronic acid 5 mg IV every 2 years
• Denosumab 60 mg subcutaneously every 6 months 1
• Teriparatide (anabolic agent) - increases lumbar spine BMD by 7.2% from baseline 5

Special Populations

• Cancer survivors: Same thresholds for bone-modifying agent initiation
• Patients on aromatase inhibitors or androgen deprivation therapy: Consider bisphosphonates or denosumab 1
• Patients on systemic steroid therapy: Calcium and vitamin D supplementation for duration of treatment 1

Monitoring and Follow-up

• 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 1

Important Considerations

• Osteopenia is not a disease but represents a wide range of fracture risks 2
• The label "osteopenia" alone should not trigger pharmacologic treatment 2
• Untreated bone loss can lead to a cycle of recurrent fractures, disability, and premature death 6
• Patients with existing vertebral fractures have a 5-fold increased risk of new vertebral fractures 1
• All antifracture therapeutics treat but do not cure the disease; skeletal deterioration resumes when medication is discontinued 6

Remember that early intervention with appropriate lifestyle modifications and, when indicated, pharmacologic therapy can significantly reduce fracture risk and improve long-term outcomes for patients with osteopenia.