Treatment of Osteopenia
The first-line treatment for osteopenia should be oral bisphosphonates (alendronate 70 mg once weekly or risedronate 35 mg once weekly) for patients with high fracture risk, along with calcium and vitamin D supplementation and lifestyle modifications for all patients with osteopenia. 1
Risk Assessment and Treatment Decision
Treatment decisions for osteopenia should be based on comprehensive fracture risk assessment:
- Calculate 10-year fracture risk using the FRAX tool
- Consider pharmacologic treatment when:
- T-score is less than -1.5 with additional risk factors
- 10-year risk of major osteoporotic fracture ≥20%
- 10-year risk of hip fracture ≥3% 1
Risk Factors to Consider
- Previous fragility fractures (especially vertebral fractures increase risk 5-fold)
- Advanced age
- Family history of hip fracture
- Low body weight
- Smoking
- Excessive alcohol consumption
- Systemic steroid therapy 1
Non-Pharmacologic Management
For all patients with osteopenia:
Calcium and Vitamin D Supplementation:
- Calcium intake of 1000-1200 mg daily
- Vitamin D intake of 600-800 IU daily 1
Regular Exercise:
- Weight-bearing exercise at least 30 minutes, 3 days a week
- Muscle-strengthening exercises 1
Lifestyle Modifications:
- Smoking cessation
- Limit alcohol intake to 1-2 alcoholic beverages/day
- Maintain a balanced diet 1
Fall Prevention:
- Balance training
- Home hazard assessment
- Medication review
- Vision assessment
- Appropriate footwear 1
Pharmacologic Treatment
First-Line Therapy
Oral Bisphosphonates:
- Alendronate 70 mg once weekly OR
- Risedronate 35 mg once weekly 1
Administration instructions:
- Take in the morning immediately following breakfast
- Swallow whole while in an upright position with at least 4 ounces of plain water
- Avoid lying down for 30 minutes after taking the medication
- Do not take with calcium supplements, antacids, or iron preparations (take these at a different time of day) 2, 3
Alternative Options (for those who cannot tolerate oral bisphosphonates)
- Zoledronic acid: 5 mg IV every 2 years
- Denosumab: 60 mg subcutaneously every 6 months 1
Special Populations
- Patients on systemic steroid therapy: Should receive calcium and vitamin D supplementation for the duration of treatment 1
- Patients with inflammatory conditions: Treatment of underlying disease activity plus calcium/vitamin D supplementation can increase BMD by 0.76% annually 1
- Patients on aromatase inhibitors or androgen deprivation therapy: May benefit from bisphosphonates or denosumab 1
Monitoring
- Bone mineral density (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 a term defining bone density that is lower than normal but not as low as osteoporosis (T-score between -1.0 and -2.5) 4, 5
- Most fractures occur in individuals with osteopenia due to their greater number compared to those with osteoporosis 5
- Bisphosphonates work by inhibiting osteoclast activity, reducing bone resorption without directly inhibiting bone formation 2
- Evidence shows that oral and intravenous bisphosphonates cost-effectively reduce fractures in older osteopenic women 5
Common Pitfalls to Avoid
- Treating based solely on T-score: The diagnosis of osteopenia alone is not an indication for pharmacologic treatment; treatment decisions should be based on comprehensive fracture risk assessment 4, 5
- Neglecting underlying conditions: Evaluate and treat underlying conditions that may contribute to bone loss (vitamin D deficiency, hyperparathyroidism, hyperthyroidism, malabsorption disorders, chronic kidney disease) 1
- Overlooking medication effects: Review medications that may contribute to bone loss (e.g., glucocorticoids, anticonvulsants) 1
- Inadequate calcium and vitamin D supplementation: These are essential components of any osteopenia management plan 1, 6