What are the medical management options for osteopenia?

Medical Management of Osteopenia

For patients with osteopenia, medical management should include lifestyle modifications, adequate calcium and vitamin D intake, and consideration of pharmacologic therapy based on fracture risk assessment. 1

Risk Assessment

• Fracture risk should be calculated using the FRAX tool, which incorporates BMD and clinical risk factors to determine overall fracture risk 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% 2, 1
• Strong risk factors include oral prednisolone use, hypogonadism, height loss >4 cm, x-ray evidence of osteopenia, early maternal hip fracture (<60 years), 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, 1

Non-Pharmacological Interventions

Calcium and Vitamin D

• Daily calcium intake should be 1,000 mg for ages 19-50 and 1,200 mg for ages 51 and older 2, 1
• Vitamin D intake should be 600 IU for ages 19-70 and 800 IU for ages 71 and older, with a target serum level of ≥20 ng/mL 2, 3
• Supplementation with calcium (1 g/day) and vitamin D3 (800 U/day) is recommended, especially for patients with risk factors 2

Exercise and Lifestyle Modifications

• Regular weight-bearing and muscle-strengthening exercises help improve bone density 3, 1
• Adults should aim for at least 30 minutes of moderate physical activity daily 1, 4
• Balance training exercises such as tai chi can help reduce fall risk 3, 1
• Smoking cessation and limiting alcohol consumption (1-2 drinks per day maximum) are essential 2, 1
• Fall prevention strategies including vision and hearing checks, medication review, and home safety assessment should be implemented 1, 4

Pharmacological Treatment

When to Initiate Treatment

• Treatment should be considered in patients with a T-score between -1.0 and -2.5 when FRAX indicates high fracture risk 2
• Treatment is strongly recommended for patients with a BMD below a T-score of −2.0, particularly with additional risk factors 3, 1
• Pharmacologic therapy should be offered to patients with a 10-year probability of ≥20% for major osteoporotic fractures or ≥3% for hip fractures based on FRAX 2, 3

Treatment Options

• Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, efficacy, and cost-effectiveness 1, 5
• Alendronate inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 5
• IV bisphosphonates are an alternative for patients who cannot tolerate oral bisphosphonates 1, 6
• Denosumab is an alternative therapy for patients who cannot tolerate bisphosphonates 3, 1
• Teriparatide may be considered for high-risk patients 1, 7
• Selective estrogen receptor modulators (SERMs) like raloxifene can be a good initial treatment in younger postmenopausal women 2, 6

Special Populations

Cancer Survivors

• Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss 2, 3
• For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 2, 3

Chronic Liver Disease

• Patients with chronic liver disease should have BMD measurement 2
• Ensure adequate nutrition as low body mass index is an independent risk factor 2

Inflammatory Bowel Disease

• Osteopenia is present in 40-50% of all IBD patients 2
• Treatment of underlying disease activity is important, particularly in young patients 2

Glucocorticoid Users

• 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 for patients on glucocorticoids 1

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 2, 3
• Bone mineral density assessment should not be conducted more than annually 2, 3
• Patients should be monitored for medication adherence 3, 8

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, 4
• Patients taking oral bisphosphonates should take them with a full glass of water (6-8 ounces) and remain upright for at least 30 minutes to avoid esophageal adverse effects 5
• Hypocalcemia must be corrected before initiating therapy with bisphosphonates 5
• Bisphosphonates are not recommended for patients with creatinine clearance less than 35 mL/min 5