What are the treatment options for osteopenia?

Treatment Options for Osteopenia

For patients with osteopenia, first-line management should include lifestyle modifications and calcium/vitamin D supplementation, with pharmacologic therapy reserved for those with high fracture risk (10-year risk of major osteoporotic fracture ≥20% or hip fracture ≥3% based on FRAX tool). 1

Non-Pharmacologic Interventions

Exercise and Lifestyle Modifications

• Perform regular weight-bearing and muscle-strengthening exercises (at least 30 minutes, 3 days per week) 1
• Avoid tobacco use and limit alcohol intake to 1-2 drinks per day 1
• Implement fall prevention strategies:
  • Balance training
  • Home hazard assessment
  • Medication review
  • Vision assessment
  • Appropriate footwear 1

Nutritional Support

• Calcium intake: 1000-1200 mg daily (from diet and supplements) 1
• Vitamin D intake: 600-800 IU daily 1
• Regular monitoring of vitamin D levels may be necessary, especially in high-risk individuals 1

Assessment of Fracture Risk

• Calculate 10-year fracture risk using the FRAX tool 1
• Identify clinical risk factors:
  • Age (increased risk with advancing age)
  • Previous fragility fractures (especially vertebral fractures, which increase risk of new vertebral fractures 5-fold) 2
  • Family history of hip fracture
  • Low body weight
  • Smoking and excessive alcohol consumption
  • Glucocorticoid use
  • Underlying conditions affecting bone health 1

Pharmacologic Treatment

Indications for Treatment

• T-score less than -1.5 with additional risk factors 1
• 10-year risk of major osteoporotic fracture ≥20% 1
• 10-year risk of hip fracture ≥3% 1

First-Line Therapy

• Oral bisphosphonates:
  • Alendronate 70 mg once weekly 1, 3
  • Risedronate 35 mg once weekly 1
  • These medications inhibit osteoclast activity, reducing bone resorption without directly inhibiting bone formation 3

Alternative Options

• For patients who cannot tolerate oral bisphosphonates:
  • Zoledronic acid 5 mg IV every 2 years 1
  • Denosumab 60 mg subcutaneously every 6 months 1

Special Considerations

• Cancer survivors should follow the same thresholds for bone-modifying agent initiation 1
• Patients on aromatase inhibitors or androgen deprivation therapy may benefit from bisphosphonates or denosumab 1
• The American College of Physicians recommends against menopausal estrogen therapy or raloxifene for osteopenia treatment due to potential harms 1

Monitoring and Follow-up

• Bone mineral density (BMD) testing:
  • Every 2-3 years for patients with osteopenia 1
  • More frequent monitoring for high-risk patients (e.g., those on high-dose glucocorticoids) 1
• Annual clinical fracture risk reassessment 1
• Monitor for medication side effects:
  • Bisphosphonates: esophageal irritation, musculoskeletal pain, rare cases of osteonecrosis of the jaw and atypical femoral fractures 3
  • Ensure proper administration of oral bisphosphonates (take with full glass of water, remain upright for 30 minutes) 3

Management of Underlying Conditions

• Evaluate and treat conditions that may contribute to bone loss:
  • Vitamin D deficiency
  • Hyperparathyroidism
  • Hyperthyroidism
  • Malabsorption disorders
  • Chronic kidney disease
  • Medications (e.g., glucocorticoids, anticonvulsants) 1
• Correct hypocalcemia before initiating bisphosphonate therapy 3
• For patients on systemic steroid therapy, calcium and vitamin D supplementation should be provided for the duration of treatment 1

Important Caveats

• Osteopenia is not a disease but a risk factor for fractures 4
• The label "osteopenia" encompasses a wide range of fracture risks; individual patient risk should be estimated from age, BMD, and clinical risk factors 4
• Most fractures occur in individuals with osteopenia rather than osteoporosis due to the larger number of people with osteopenia 5
• Pharmacologic treatment decisions should be based on overall fracture risk, not solely on BMD 4, 5

By following this comprehensive approach to osteopenia management, focusing on lifestyle modifications, nutritional support, and selective use of pharmacologic therapy based on fracture risk assessment, clinicians can effectively reduce fracture risk and improve outcomes for patients with osteopenia.