What are the recommended treatments for osteopenia?

Recommended Treatments for Osteopenia

For patients with osteopenia, treatment should include lifestyle modifications, calcium and vitamin D supplementation, and in higher-risk individuals, pharmacological therapy with bisphosphonates or other bone-modifying agents based on fracture risk assessment. 1

Assessment and Risk Stratification

• Dual energy x-ray absorptiometry (DEXA) is recommended for all women 65 years and older, and in younger postmenopausal women with risk factors 1
• Fracture risk should be calculated using the FRAX tool, which should be adjusted by 1.15 for major osteoporotic fracture risk and 1.2 for hip fracture risk if prednisone dose is >7.5 mg/day 2
• Pharmacological treatment should be considered when FRAX calculation shows a 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% 1
• For patients on glucocorticoids, clinical fracture risk reassessment should be performed every 12 months 2

Non-Pharmacological Interventions

• Calcium intake should be optimized to 1,000-1,200 mg/day for all adults 2, 1
• Vitamin D intake should be 600-800 IU/day (with a target serum level ≥20 ng/ml) 2, 1
• Regular weight-bearing and resistance training exercises are recommended to improve bone density 2, 1
• Balance training exercises (tai chi, physical therapy, dancing) help reduce fall risk 1
• Lifestyle modifications include maintaining weight in recommended range, smoking cessation, and limiting alcohol intake to 1-2 alcoholic beverages per day 2, 1

Pharmacological Treatment

For Adults ≥40 Years at Moderate-to-High Fracture Risk:

• Oral bisphosphonates (such as alendronate) are first-line therapy due to safety, cost, and efficacy 2, 3
• Alendronate inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 3
• Alternative therapies if oral bisphosphonates are not appropriate (in order of preference) 2:
  • IV bisphosphonates
  • Teriparatide (for high-risk patients)
  • Denosumab
  • Raloxifene (for postmenopausal women if no other therapy is available)

For Adults <40 Years:

• Pharmacological therapy should be considered for those with a history of osteoporotic fracture, or those on long-term glucocorticoids (≥6 months at ≥7.5 mg/day) with hip or spine BMD Z-score <-3 or bone loss ≥10%/year 2
• Oral bisphosphonates are the preferred first-line therapy 2

For Special Populations:

• For patients on glucocorticoids at high doses (≥30 mg/day and cumulative dose >5 gm in 1 year), oral bisphosphonates are recommended over calcium and vitamin D alone 2
• For women of childbearing potential at moderate-to-high fracture risk who are using effective birth control, oral bisphosphonates are preferred 2
• For patients with HIV infection, low BMD has been linked to low body weight, hormonal deficiencies, glucocorticoid use, and lifestyle factors 2

Monitoring

• Repeat DEXA should be performed 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 and Pitfalls

• Osteopenia is not a disease but rather a term defining bone density that is not normal but not as low as osteoporosis (T-score between -1.0 and -2.5) 4, 5
• The label "osteopenia" can cause unnecessary anxiety and encompasses a wide range of fracture risks 4
• Osteopenia by itself is not an indication for pharmacological treatment; decisions should be based on overall fracture risk 4
• Even with appropriate recommendations, adherence to preventive therapies for bone health is often poor, with only 5-62% of patients on glucocorticoid therapy receiving appropriate preventive therapies 2
• Secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) should be identified and treated 2, 5