What is the treatment for osteopenia?

Treatment of Osteopenia

The treatment of osteopenia should include lifestyle modifications, calcium and vitamin D supplementation, and in cases with significant risk factors, pharmacological therapy with bisphosphonates or other bone-modifying agents. 1, 2

Assessment and Risk Stratification

• Fracture risk should be calculated using the FRAX tool to determine the need for pharmacological intervention 2
• Pharmacological treatment should be considered when the FRAX calculation shows a 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% 1, 2
• Bone mineral density (BMD) measurement using dual-energy x-ray absorptiometry (DXA) of the spine, hip, and femoral neck is the preferred assessment method to quantify fracture risk 1
• Repeat DXA should be performed every 2 years or as clinically indicated, but not more frequently than annually 1, 2

Non-Pharmacological Interventions

• Calcium intake should be optimized to 1,000-1,200 mg/day for all adults 2
• Vitamin D intake should be 600-800 IU/day (with a target serum level ≥20 ng/ml) 2
• Regular weight-bearing exercises and resistance training should be recommended to improve bone density 1, 3
• Lifestyle modifications should include:
  • Maintaining weight in recommended range 2
  • Smoking cessation 1, 2
  • Limiting alcohol consumption 1, 2
  • Fall prevention strategies 1

Pharmacological Treatment

When to Initiate Bone-Modifying Agents

Thresholds to initiate a bone-modifying agent include:

• FRAX calculation showing 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% 1
• BMD demonstrating osteoporosis or significant osteopenia with additional risk factors 1
• History of prior osteoporotic fracture that has not been treated 1

First-Line Treatment

• Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy 2, 4
• Alendronate inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 4
• For osteopenia, alendronate has shown efficacy in increasing BMD, particularly in patients with advanced osteopenia (T-score between -2.0 and -2.5) 1

Alternative Treatments

If oral bisphosphonates are not appropriate, alternatives include (in order of preference):

• IV bisphosphonates (zoledronic acid) - administered 5 mg every 2 years for osteopenia 1
• Denosumab - 60 mg subcutaneously every 6 months 1
• Teriparatide - an anabolic agent that may be considered for patients with high fracture risk 5
• Selective estrogen receptor modulators (SERMs) like raloxifene 2, 3

Special Populations

Patients on Glucocorticoids

• For patients on glucocorticoids, fracture risk 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
• Clinical fracture risk reassessment should be performed every 12 months 2
• Bisphosphonates are particularly effective in preventing glucocorticoid-induced bone loss 5

Patients with Chronic Liver Disease

• Patients with cirrhosis or severe cholestasis should undergo BMD measurement 1
• Anabolic steroids should be avoided in patients with chronic liver disease due to potential liver toxicity 1
• Calcium (1 g/day) and vitamin D3 (800 U/day) supplementation is recommended 1

Cancer Survivors

• Cancer survivors may have additional risk factors for bone loss due to cancer therapies (endocrine therapy, chemotherapy, glucocorticoids) 1
• In patients receiving aromatase inhibitors, bisphosphonates or denosumab have shown efficacy in preventing bone loss 1

Monitoring and Follow-up

• Repeat DXA every 2 years or as clinically indicated 1, 2
• If not initiating pharmacological therapy, lifestyle measures should be implemented and BMD repeated after 1-2 years 1
• For patients on bisphosphonates, monitoring for potential side effects (GI issues with oral formulations, acute phase response with IV formulations) is important 1

Common Pitfalls and Caveats

• Secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) should be identified and treated 1, 2
• Adherence to preventive therapies for bone health is often poor, with only 5-62% of patients on glucocorticoid therapy receiving appropriate preventive therapies 2
• The FRAX tool may underestimate fracture risk in certain populations, such as HIV-infected patients 1
• When denosumab is discontinued, there may be an increased risk of vertebral fractures, so transition to a bisphosphonate should be considered 1
• Bone mineral density assessment should not be conducted more than annually 1, 2