Treatment Options for Osteopenia
The treatment of osteopenia should be based on fracture risk assessment using the FRAX tool, with pharmacological therapy indicated when the 10-year risk of hip fracture is ≥3% or the 10-year risk of major osteoporotic fracture is ≥20%. 1, 2
Risk Assessment
- FRAX calculation incorporates bone mineral density (BMD) and clinical risk factors to determine overall fracture risk 1
- Treatment should be strongly considered in patients with a BMD T-score below -2.0, particularly with additional risk factors 1
- Presence of vertebral fractures significantly increases future fracture risk and warrants treatment consideration 1
Non-Pharmacological Interventions
Calcium and Vitamin D
- Daily calcium intake recommendation: 1,000 mg for ages 19-50 and 1,200 mg for ages 51 and older 1, 2
- Daily vitamin D intake recommendation: 600 IU for ages 19-70 and 800 IU for ages 71 and older 1, 2
- Target serum vitamin D level: ≥20 ng/mL 1, 2
Exercise and Lifestyle Modifications
- Regular weight-bearing and muscle-strengthening exercises help improve bone density 1, 2
- Balance training exercises (tai chi, physical therapy, dancing) can help reduce fall risk 1, 2
- Adults should aim for at least 30 minutes of moderate physical activity daily 1
- 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 1
- Maintaining weight in the recommended range 1
Pharmacological Treatment
Indications for Pharmacological Therapy
- High fracture risk based on FRAX assessment (10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20%) 1, 2
- T-score below -2.0, particularly with additional risk factors 1
- Presence of vertebral fractures 1
First-Line Therapy
- Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy 1, 3
- Alendronate inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 3
- Alendronate decreases urinary markers of bone resorption by approximately 50-70% 3
Alternative Therapies
- IV bisphosphonates for patients who cannot tolerate oral bisphosphonates 1
- Denosumab for patients who cannot tolerate bisphosphonates 1, 2
- Teriparatide for high-risk patients 1, 4
- Selective estrogen receptor modulators (SERMs) 1
Special Populations
Cancer Patients
- Cancer treatments can accelerate bone loss, particularly those causing hypogonadism 1, 2
- For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 1, 2
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
- Teriparatide has shown efficacy in glucocorticoid-induced osteoporosis 4
Patients with Chronic Liver Disease
- BMD measurement is recommended 1
- Ensure adequate nutrition as low body mass index is an independent risk factor 1
- Supplementation with calcium and vitamin D3 is recommended 1
- Anabolic steroids should be avoided 1
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
- Poor adherence to preventive therapies is common; only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 1
- Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 1
- Inadequate calcium and vitamin D supplementation 1, 5
- Not considering fracture risk beyond BMD alone 2, 6