What is the treatment for osteopenia?

Treatment of Osteopenia

The treatment of osteopenia should focus on fracture risk assessment using FRAX tool, lifestyle modifications, calcium and vitamin D supplementation, with pharmacological therapy reserved for those with high fracture risk (10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%). 1, 2, 3, 4

Assessment and Risk Stratification

• Fracture risk should be calculated using the FRAX tool, which incorporates BMD and clinical risk factors to determine overall fracture risk 2, 4
• 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, 4
• 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
• Presence of a fragility fracture denotes severe osteoporosis and warrants treatment without the need for BMD measurement 1

Non-Pharmacological Interventions

• Calcium intake should be optimized to 1,000-1,200 mg/day for all adults 1, 2, 3
• Vitamin D intake should be 600-800 IU/day with a target serum level of ≥20 ng/mL 2, 3, 4
• Regular weight-bearing and resistance training exercises are recommended to improve bone density 1, 2, 3
• Lifestyle modifications include maintaining weight in recommended range, smoking cessation, and limiting alcohol intake to 1-2 alcoholic beverages per day 1, 2, 4
• Fall prevention strategies including vision and hearing checks, medication review, and home safety assessment are recommended 3, 4

Pharmacological Treatment

• Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy for patients at moderate-to-high fracture risk 1, 2, 4, 5
• Alendronate reduces bone resorption without directly inhibiting bone formation, leading to progressive gains in bone mass 5
• Alternative therapies if oral bisphosphonates are not appropriate include IV bisphosphonates, teriparatide, denosumab, and raloxifene 2, 4
• Teriparatide is an anabolic agent that can increase lumbar spine BMD compared to baseline, particularly useful in glucocorticoid-induced osteoporosis 6
• The American College of Physicians recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women 1

Special Populations

Cancer Survivors

• Cancer treatments can accelerate bone loss, particularly those causing hypogonadism from endocrine therapy 1
• For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 1, 3

Patients on Glucocorticoids

• Clinical fracture risk reassessment should be performed every 12 months for patients on glucocorticoids 2
• Patients on glucocorticoids ≥7.5 mg prednisolone daily for at least 3 months should be considered for preventive therapy 7

Chronic Liver Disease

• Patients with chronic liver disease (cirrhosis or severe cholestasis) should have BMD performed and be considered for treatment 1
• Anabolic steroids should be avoided in patients with chronic liver disease due to potential liver toxicity 1

Monitoring

• Repeat DEXA should be performed every 2 years or as clinically indicated to monitor treatment response 1, 2, 3
• The American College of Physicians recommends against bone density monitoring during the 5-year pharmacological treatment period for osteoporosis in women 1
• Bone mineral density assessment should not be conducted more than annually 1, 3

Important Pitfalls to Avoid

• Osteopenia is not a disease by itself and the label can cause unnecessary anxiety; it encompasses a wide range of fracture risks 8
• Treating based solely on T-score in the osteopenic range is not advisable as the number needed to treat is much higher (NNT>100) than in patients with fractures and T-scores below -2.5 (NNT 10-20) 9
• Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) is a common pitfall 1, 4
• Poor adherence to preventive therapies is common; only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 2
• Inadequate calcium and vitamin D supplementation is common, even when supplements are provided free of charge 10