What are the treatment options for osteopenia?

Treatment Options for Osteopenia

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%, with oral bisphosphonates being the first-line therapy for most patients with significant fracture risk. 1

Risk Assessment

• Fracture risk assessment using the FRAX tool is recommended to determine overall fracture risk by incorporating BMD and clinical risk factors 1
• Strong risk factors for osteoporosis include oral prednisolone use (≥5 mg for three months), hypogonadism, height loss >4 cm, x-ray evidence of osteopenia, early maternal hip fracture, and low body mass index (<19 kg/m²) 2
• The presence of a fragility fracture indicates severe osteoporosis and warrants treatment without the need for BMD measurement 2
• Treatment should be strongly considered in patients with a BMD T-score below -2.0, particularly with additional risk factors 1

Non-Pharmacological Interventions

• Lifestyle modifications are essential for all patients:

  • Regular weight-bearing and muscle-strengthening exercises 3, 1
  • Reduction in alcohol intake if excessive 2
  • Smoking cessation 3, 1
  • Maintaining adequate nutrition and healthy body weight 2, 1

• Calcium and vitamin D supplementation:

  • Daily calcium intake of 1,000-1,200 mg (1,000 mg for ages 19-50 and 1,200 mg for ages 51+) 3, 1
  • Daily vitamin D intake of 600-800 IU (600 IU for ages 19-70 and 800 IU for ages 71+) 3, 1
  • Target serum vitamin D level of ≥20 ng/mL 3, 1

• Fall prevention strategies:

  • Balance training exercises such as tai chi, physical therapy, and dancing 3, 1
  • Vision and hearing checks, medication review, and home safety assessment 1

Pharmacological Treatment Options

First-Line Therapy:

• Oral bisphosphonates (e.g., alendronate) are recommended as first-line therapy due to safety, cost, and efficacy 1, 4
  • Alendronate inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 4
  • Must be taken on an empty stomach with a full glass of water (6-8 oz), and patients should remain upright for at least 30 minutes after taking 4

Alternative Therapies:

• IV bisphosphonates for patients who cannot tolerate oral formulations 1
• Denosumab for patients who cannot tolerate bisphosphonates 3, 1
• Teriparatide for high-risk patients 1
• Selective estrogen receptor modulators (SERMs) 1

Special Populations

Glucocorticoid-Induced Osteopenia:

• 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 1
• Clinical fracture risk reassessment should be performed every 12 months 1
• Anabolic steroids should be avoided in patients with chronic liver disease 2

Cancer Patients:

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

Chronic Liver Disease:

• Patients with chronic liver disease (defined as cirrhosis or severe cholestasis) should have BMD measurement 2
• Ensure adequate nutrition as low body mass index is an independent risk factor 2
• Supplementation with calcium (1 g/day) + vitamin D3 (800 U/day) is recommended 2

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 3, 1
• Bone mineral density assessment should not be conducted more than annually 3, 1

Common Pitfalls to Avoid

• Poor adherence to preventive therapies is common 1
• Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 1
• Taking bisphosphonates incorrectly (lying down after taking, not swallowing with a full glass of water, continuing despite esophageal symptoms) 4
• Not correcting hypocalcemia before initiating bisphosphonate therapy 4
• Overlooking the risk of osteonecrosis of the jaw and atypical femur fractures with long-term bisphosphonate use 4

Remember that osteopenia itself is not a disease but rather a descriptor of bone density, and treatment decisions should be based on overall fracture risk rather than the osteopenia label alone 5.