What are the treatment options for osteopenia?

Treatment Options for Osteopenia

For patients with osteopenia, treatment should focus on non-pharmacological interventions including calcium and vitamin D supplementation, weight-bearing exercise, and lifestyle modifications, with pharmacological therapy reserved for those with high fracture risk based on FRAX assessment. 1, 2

Risk Assessment

• Fracture risk should be calculated using the FRAX tool, which incorporates BMD and clinical risk factors to determine overall fracture risk 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, 2
• Osteopenia by itself is not an indication for pharmacological treatment; decisions should be based on overall fracture risk 3

Non-Pharmacological Interventions

Calcium and Vitamin D

• Daily calcium intake of 1,000 mg for ages 19-50 and 1,200 mg for ages 51 and older 1
• Daily vitamin D intake of 600 IU for ages 19-70 and 800 IU for ages 71 and older, with a target serum level of ≥20 ng/mL 1, 2

Exercise

• Regular weight-bearing and muscle-strengthening exercises help improve bone density 4, 1
• Balance training exercises such as tai chi, physical therapy, and dancing can help reduce fall risk 4, 1
• Adults should aim for at least 30 minutes of moderate physical activity daily 4

Lifestyle Modifications

• Smoking cessation and limiting alcohol consumption (1-2 drinks per day maximum) 1, 2
• Fall prevention strategies including vision and hearing checks, medication review, and home safety assessment 4
• Maintaining weight in the recommended range 2

Pharmacological Treatment

When to Consider Medication

• Pharmacological treatment is indicated for patients with high fracture risk based on FRAX assessment 1, 2
• Treatment should be strongly considered in patients with a BMD below a T-score of −2.0, particularly with additional risk factors 4
• Presence of vertebral fractures significantly increases future fracture risk and warrants treatment consideration 4, 5

First-Line Therapy

• Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy 2, 6
• Important precautions with bisphosphonates include taking with a full glass of water and remaining upright for 30 minutes after administration to prevent esophageal adverse effects 6

Alternative Therapies

• For patients who cannot tolerate bisphosphonates, alternatives include:
  • IV bisphosphonates 2
  • Denosumab 1, 2
  • Teriparatide (for high-risk patients) 2, 7
  • Selective estrogen receptor modulators (SERMs) 4, 5

Special Populations

Cancer Patients

• Cancer treatments can accelerate bone loss, particularly those causing hypogonadism 1
• For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 1

Glucocorticoid Users

• 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 for patients on glucocorticoids 2

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 1, 2
• Bone mineral density assessment should not be conducted more than annually 1, 2

Common Pitfalls to Avoid

• Treating based solely on T-score without considering overall fracture risk 3, 5
• Poor adherence to preventive therapies is common; only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 2
• Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 2
• Overlooking the importance of calcium and vitamin D supplementation when initiating pharmacological therapy 6