Diagnosis and Treatment of Osteoporosis and Osteopenia
Diagnosis
Bone mineral density (BMD) testing via dual-energy X-ray absorptiometry (DEXA) should be performed in all women 65 years and older, and in postmenopausal women younger than 65 years with risk factors for fracture. 1
Who Should Be Screened
- All women ≥65 years of age 1
- Postmenopausal women <65 years with risk factors:
- Patients with chronic liver disease, especially cirrhosis or severe cholestasis 1
- Patients with risk factors such as:
Diagnostic Criteria
- Normal: T-score ≥ -1.0 1
- Osteopenia: T-score between -1.0 and -2.5 1
- Osteoporosis: T-score ≤ -2.5 1
- Severe/established osteoporosis: T-score ≤ -2.5 plus fragility fracture 1
Additional Assessment for Patients with Osteoporosis
- Thyroid function tests 1
- Bone function tests (calcium, phosphate) 1
- 25-OH vitamin D levels 1, 2
- Sex hormone levels (estradiol, LH/FSH in women; testosterone/SHBG/LH/FSH in men) 1
- Lateral X-rays of dorsal and lumbar spine to identify vertebral fractures 1
- FRAX calculation to determine 10-year fracture risk 2
Treatment
Non-Pharmacological Management
Calcium and Vitamin D
- Recommended daily calcium intake: 1, 2
- Ages 9-18: 1,300 mg
- Ages 19-50: 1,000 mg
- Ages 51+: 1,200 mg
- Recommended daily vitamin D intake: 1, 2
- Ages 19-70: 600 IU
- Ages 71+: 800 IU
- Target serum vitamin D level: ≥20 ng/mL (50 nmol/L) 1, 2
Lifestyle Modifications
- Regular weight-bearing and muscle-strengthening exercises 2, 3
- Balance training to reduce fall risk (tai chi, physical therapy) 2, 4
- Smoking cessation 1, 2
- Reduction in alcohol intake if excessive 1, 2
- Fall prevention strategies (vision checks, medication review, home safety) 2, 5
- Maintaining healthy body weight 2, 3
Pharmacological Treatment
Indications for Treatment
- T-score ≤ -2.5 (osteoporosis) 1
- T-score between -1.0 and -2.5 (osteopenia) with:
- History of fragility fracture (regardless of BMD) 1
- T-score below -1.5 in patients with chronic liver disease 1
First-Line Therapy
- Bisphosphonates: 1, 2, 3
- Alendronate: 5 mg daily or 35 mg weekly (prevention); 10 mg daily or 70 mg weekly (treatment)
- Risedronate: 5 mg daily, 35 mg weekly, 75 mg on two consecutive days monthly, or 150 mg monthly
Alternative Therapies
- Denosumab: For patients who cannot tolerate bisphosphonates 2, 6, 3
- Raloxifene: Good initial treatment for younger postmenopausal women 1, 3
- Teriparatide: Typically used for severe osteoporosis or patients with fractures 1, 2, 3
- Calcitonin: Weaker evidence, use only in patients with less serious osteoporosis who cannot tolerate other treatments 1
Special Populations
Chronic Liver Disease
- Calcium (1,000-1,500 mg/day) and vitamin D3 (400-800 IU/day) supplementation 1
- Regular weight-bearing exercise 1
- BMD monitoring every 2-3 years for normal BMD, yearly for osteopenia/osteoporosis 1
- Consider bisphosphonate therapy for patients with osteoporosis or recurrent fractures 1
Glucocorticoid-Induced Osteoporosis
- Adjust fracture risk calculation (multiply by 1.15 for major osteoporotic fracture risk and 1.2 for hip fracture risk if prednisone dose >7.5 mg/day) 2
- Reassess clinical fracture risk every 12 months 2
Cancer Treatment-Related Bone Loss
- Bisphosphonates or denosumab preferred for cancer survivors with osteopenia and additional risk factors 2
Monitoring
- Repeat DEXA every 2 years to monitor BMD and treatment response 2
- More frequent monitoring (yearly) for high-risk patients:
Common Pitfalls to Avoid
- Poor adherence to preventive therapies 2
- Failure to identify and treat secondary causes of osteopenia/osteoporosis 2
- Inadequate calcium and vitamin D supplementation 3, 4
- Not treating patients with fragility fractures despite normal BMD 1
- Not considering treatment in patients with T-scores between -1.0 and -2.5 with high fracture risk 1, 2