What are the treatment options for osteopenia and osteoporosis?

Treatment Options for Osteopenia and Osteoporosis

Bisphosphonates are the first-line pharmacological treatment for osteoporosis, while lifestyle modifications including calcium and vitamin D supplementation are essential for both osteopenia and osteoporosis management. 1

Diagnosis and Assessment

• DEXA scan of lumbar spine and hip confirms diagnosis:
  • Osteoporosis: T-score ≤ -2.5
  • Osteopenia: T-score between -1.0 and -2.5 1, 2
• FRAX tool calculates 10-year fracture risk to guide treatment decisions 3, 1
• Laboratory workup to rule out secondary causes: calcium, phosphorus, 25-hydroxyvitamin D, parathyroid hormone, alkaline phosphatase, creatinine clearance, TSH, and blood count with CRP 1

Treatment Algorithm

First-Line Non-Pharmacological Management (For All Patients)

1. Calcium intake: 1000-1200 mg daily (diet + supplements) 3, 1
2. Vitamin D: 800-1000 IU daily (target serum level ≥30 ng/ml) 3, 1
3. Weight-bearing and resistance exercises 3, 1
4. Fall prevention strategies 3
5. Lifestyle modifications:
   • Tobacco cessation
   • Limiting alcohol consumption 3, 1

Pharmacological Treatment Indications

Initiate bone-modifying agents if any of the following:

• T-score ≤ -2.5 (osteoporosis)
• FRAX 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%
• Significant osteopenia with additional risk factors
• History of prior osteoporotic fracture 3, 1

Pharmacological Options

First-Line:

• Oral Bisphosphonates (alendronate, risedronate) 1, 2
  • Most cost-effective
  • Contraindicated in patients with esophageal disorders or inability to sit upright for 30-60 minutes

Second-Line:

• Intravenous Bisphosphonates (zoledronic acid)

  • For patients who cannot tolerate oral bisphosphonates
  • Administered yearly (osteoporosis) or every 2 years (osteopenia)
  • Use caution if eGFR <35 mL/min 1

• Denosumab (Prolia)

  • 60 mg subcutaneously every 6 months
  • Preferred for patients with renal impairment 1, 4
  • Warning: Requires continuous treatment or transition to bisphosphonate when stopping to prevent rebound bone loss 1

Third-Line (For Very High-Risk Patients):

• Anabolic Agents (teriparatide, abaloparatide, romosozumab)
  • Consider for patients with:
    • Recent vertebral fractures
    • Multiple fractures
    • Very low BMD (T-score < -3.0)
    • High fracture risk despite antiresorptive therapy 1, 2
  • Limited to 2 years of use, followed by antiresorptive therapy 1

Special Populations

Cancer Patients

• Higher risk due to cancer treatments (chemotherapy, endocrine therapy, glucocorticoids)
• Same treatment thresholds apply
• Consider more frequent monitoring 3

Patients on Glucocorticoids

• Higher fracture risk at any given BMD
• Lower treatment thresholds may be appropriate
• Consider bisphosphonate therapy if on long-term steroids 3, 1

Liver Transplant Patients

• Screen BMD yearly for pre-existing osteoporosis/osteopenia
• Screen every 2-3 years if normal baseline BMD
• Consider bisphosphonate therapy for osteoporosis or recurrent fractures 3

Monitoring

• Repeat DEXA scan every 1-2 years initially, then every 2 years if stable 3, 1
• Do not perform DEXA more frequently than annually 3
• Monitor for medication side effects:
  • Bisphosphonates: GI symptoms, osteonecrosis of jaw, atypical femoral fractures
  • Denosumab: Hypocalcemia, osteonecrosis of jaw, atypical femoral fractures 1, 4

Treatment Duration

• Bisphosphonates: Consider drug holiday after 3-5 years for moderate-risk patients
• Continue treatment in high-risk patients (T-score ≤ -2.5, ongoing fractures)
• Denosumab: Requires continuous treatment or transition to bisphosphonate when stopping 1

Common Pitfalls to Avoid

1. Failing to diagnose and treat osteoporosis after a fragility fracture
2. Not addressing calcium and vitamin D deficiency before starting pharmacotherapy
3. Abrupt discontinuation of denosumab without transitioning to a bisphosphonate
4. Overlooking secondary causes of bone loss
5. Inadequate monitoring of treatment response
6. Not considering drug interactions or contraindications when selecting therapy

The evidence clearly supports a proactive approach to osteoporosis management, with early intervention for high-risk patients to reduce the substantial morbidity and mortality associated with fragility fractures 2, 5.