Treatment Options for Osteopenia
The first-line treatment for osteopenia should include lifestyle modifications, adequate calcium and vitamin D intake, and regular weight-bearing exercise, with pharmacological therapy reserved for patients with significant fracture risk based on FRAX assessment or additional risk factors. 1
Assessment and Diagnosis
- Osteopenia is defined as a bone mineral density (BMD) T-score between -1.0 and -2.5, which represents lower bone density than normal but not as low as osteoporosis 2, 3
- Dual energy x-ray absorptiometry (DEXA) should be performed in all women 65 years and older, and in postmenopausal women younger than 65 with risk factors (history of fragility fracture, weight less than 127 lb, medications or diseases causing bone loss, parental history of hip fracture) 1
- Fracture risk assessment may include use of FRAX (www.sheffield.ac.uk/FRAX) or other tools to quantify fracture risk beyond BMD alone 1
Non-Pharmacological Interventions
Calcium and Vitamin D
- Recommended daily calcium intake: 1
- Ages 19-50: 1,000 mg
- Ages 51 and older: 1,200 mg
- Recommended daily vitamin D intake: 1
- Ages 19-70: 600 IU
- Ages 71 and older: 800 IU
- A serum vitamin D level of 20 ng/mL (50 nmol/L) is recommended for good bone health 1
Lifestyle Modifications
- Regular weight-bearing and muscle-strengthening exercises (aim for at least 30 minutes daily) 1
- Balance training exercises to reduce fall risk (tai chi, physical therapy, dancing) 1
- Smoking cessation 1
- Limiting alcohol consumption 1
- Fall prevention strategies (correcting vision/hearing problems, reviewing medications affecting balance, improving home safety) 1
Pharmacological Treatment
When to Consider Medication
- Pharmacological treatment should be considered when: 1
- FRAX calculation shows 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20%
- BMD shows significant osteopenia with additional risk factors
- History of prior osteoporotic fracture
- Clinical scenario indicates significant risk for fracture
Medication Options
- Bisphosphonates (oral or IV) are first-line therapy for most patients with significant fracture risk 1, 4, 5
- Denosumab is an alternative for patients at high risk of fracture or who cannot tolerate bisphosphonates 1
- Selective estrogen receptor modulators (SERMs) like raloxifene can be good initial treatment in younger postmenopausal women without hormonal-responsive cancers 1
- For patients with severe bone loss or who have failed other therapies, anabolic agents like teriparatide may be considered 1, 5
Special Populations
Cancer Survivors
- Cancer treatments can accelerate bone loss, particularly those causing hypogonadism (oophorectomy, GnRH agonists, chemotherapy-induced ovarian failure, aromatase inhibitors, anti-androgens) 1
- For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 1
- Hormonal therapies for osteoporosis management should generally be avoided in patients with hormonal-responsive cancers 1
Liver Transplant Patients
- Bone mineral density screening should be performed yearly for patients with pre-existing osteoporosis and osteopenia 1
- Liver transplant patients with osteopenia should perform regular weight-bearing exercise and receive calcium and vitamin D supplementation 1
Monitoring
- Repeat DEXA every 2 years or as clinically indicated to monitor treatment response 1
- Bone mineral density assessment should not be conducted more than annually 1
Important Considerations
- Osteopenia encompasses a wide range of fracture risks; treatment decisions should be based on comprehensive fracture risk assessment rather than BMD alone 2, 6
- Most fractures occur in people with osteopenia rather than osteoporosis due to the larger number of individuals in this category 6
- The goal of treatment is to prevent fractures, which significantly impact morbidity, mortality, and quality of life 5, 7