What is the recommended treatment for osteopenia?

Treatment Recommendations for Osteopenia

For patients with osteopenia, the recommended treatment includes lifestyle modifications, calcium and vitamin D supplementation, with pharmacologic therapy reserved for those at high risk of fracture based on risk assessment tools such as FRAX. 1

Definition and Risk Assessment

• Osteopenia is defined as bone mineral density (BMD) with a T-score between -1.0 and -2.5, representing lower than normal bone density but not as low as osteoporosis 2
• Risk assessment should include evaluation of fracture risk using tools such as FRAX (WHO Fracture Risk Assessment Tool) to guide treatment decisions 1
• Treatment decisions should be based on the 10-year risk of fracture rather than BMD alone 1

Non-Pharmacologic Management (First-Line for All Patients)

Lifestyle Modifications

• Regular weight-bearing exercise (30 minutes at least 3 days per week) 1
• Tobacco cessation and limiting alcohol consumption 1
• Fall prevention strategies for those at risk 1

Nutritional Support

• Calcium supplementation (1000-1500 mg daily) 1
• Vitamin D supplementation (800-1000 IU daily) 1
• Adequate protein intake to maintain bone health 3

Pharmacologic Treatment

When to Consider Medication

• For osteopenic women 65 years or older at high risk of fracture (FRAX 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%) 1
• For patients with additional risk factors such as glucocorticoid use, organ transplantation, or cancer treatments 1

First-Line Pharmacologic Options

• Oral bisphosphonates (particularly risedronate) have shown efficacy in reducing fracture risk in women with advanced osteopenia 1
• Low-quality evidence supports that treatment with risedronate in women with osteopenia near the osteoporosis threshold may reduce fracture risk by up to 73% compared to placebo 1

Special Populations

• For glucocorticoid-induced bone loss: oral bisphosphonates are recommended for adults receiving high-dose glucocorticoids (≥30 mg/day of prednisone or equivalent) 1
• For cancer survivors: bisphosphonates or denosumab may be indicated when FRAX score exceeds thresholds or when BMD demonstrates significant osteopenia with additional risk factors 1

Monitoring and Follow-up

• Repeat DXA scan every 2 years to monitor bone density in patients with osteopenia 1
• DXA should not be performed more than annually 1
• For patients on pharmacologic therapy, bone density monitoring during the initial 5-year treatment period is not recommended 1

Treatment Duration

• For patients who initiate pharmacologic therapy, treatment is typically continued for 5 years 1
• Reassessment of fracture risk after 5 years should guide decisions about continuing or discontinuing therapy 1

Common Pitfalls and Considerations

• Overtreatment of low-risk patients: Not all patients with osteopenia require pharmacologic intervention 1
• Undertreatment of high-risk patients: Patients with multiple risk factors may benefit from treatment even with T-scores in the osteopenic range 1
• Women of childbearing potential: Special considerations are needed regarding bisphosphonate therapy due to potential fetal harm 1
• Medication adherence: 30-50% of patients do not take osteoporosis medications correctly, emphasizing the need for patient education 4

Treatment Algorithm

1. Assess fracture risk using FRAX and BMD measurement
2. Implement lifestyle modifications and calcium/vitamin D supplementation for all patients
3. For patients with FRAX score showing 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%:
   • Consider oral bisphosphonate therapy (preferably risedronate) 1
4. For patients with osteopenia but lower fracture risk:
   • Continue non-pharmacologic management and reassess in 2 years 1

Remember that the benefit of fracture reduction with bisphosphonates is most favorable when the risk for fracture is high, particularly in women 65 years or older with severe osteopenia (T score < –2.0) 1.