Treatment of Osteopenia
The management of osteopenia should include lifestyle modifications, calcium and vitamin D supplementation as first-line interventions, with pharmacological therapy reserved for those with high fracture risk based on FRAX assessment. 1, 2
Assessment and Risk Stratification
- Fracture risk should be calculated using the FRAX tool, which provides a 10-year probability of major osteoporotic fracture and hip fracture 1
- 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% 3, 1, 2
- For patients on glucocorticoids, the FRAX score 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 1
- Clinical fracture risk reassessment should be performed every 12 months for patients on glucocorticoids 1
Non-Pharmacological Interventions
- Calcium intake should be optimized to 1,000-1,200 mg/day for all adults 1, 2
- Vitamin D intake should be 600-800 IU/day with a target serum level ≥20 ng/ml 1, 2
- Regular weight-bearing and resistance training exercises are recommended to improve bone density 1, 2, 4
- Lifestyle modifications include maintaining weight in recommended range, smoking cessation, and limiting alcohol consumption 3, 1, 2
- Balance training exercises, such as tai chi, can help reduce fall risk 2
Pharmacological Treatment
When to Initiate Medication
Thresholds to initiate a bone-modifying agent include:
- FRAX 10-year risk of hip fracture ≥3% or 10-year risk of non-hip fracture ≥20% 3
- BMD demonstrates osteoporosis or significant osteopenia with additional risk factors 3
- History of prior osteoporotic fracture that has not been treated 3
Medication Options
- Oral bisphosphonates (such as alendronate) are first-line therapy due to safety, cost, and efficacy for adults at moderate-to-high fracture risk 1, 5
- Alternative therapies if oral bisphosphonates are not appropriate (in order of preference) include IV bisphosphonates, teriparatide, denosumab, and raloxifene 1, 6
- Low-quality evidence showed that treatment with risedronate in women with advanced osteopenia (T score near -2.5) may reduce fracture risk by 73% compared to placebo 3
- Bisphosphonates work by inhibiting osteoclast activity, reducing bone resorption without directly inhibiting bone formation 5
Monitoring
- Repeat DEXA should be performed every 2 years or as clinically indicated to monitor treatment response 3, 1, 2
- Bone mineral density assessment should not be conducted more than annually 3, 1, 2
- If bone density does not demonstrate osteoporosis (or significant osteopenia with additional risk factors) and FRAX calculation does not exceed treatment thresholds, repeat DXA in 2 years or in 1 year if medically indicated 3
Special Considerations
- Secondary causes of osteopenia should be identified and treated, including vitamin D deficiency, hypogonadism, alcoholism, and glucocorticoid exposure 3, 1
- Cancer treatments can accelerate bone loss, particularly those causing hypogonadism 3, 2
- For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 3, 2
- Patients with inflammatory conditions on glucocorticoids require special attention due to accelerated bone loss 1
Important Pitfalls to Avoid
- Remember that osteopenia is not a disease in itself and the label can cause unnecessary anxiety 7
- Avoid treating based solely on T-score; the number needed to treat for osteopenia alone is much higher (NNT>100) than in patients with fractures and T-scores below -2.5 (NNT 10-20) 8
- Adherence to preventive therapies for bone health is often poor, with only 5-62% of patients on glucocorticoid therapy receiving appropriate preventive therapies 1
- Do not overlook the importance of calcium and vitamin D supplementation, as most trials with bisphosphonate therapy included these supplements 3
- Be cautious with calcium dosing, as excess has been associated with hypercalcemia and kidney stones 3