What are the treatment options for osteopenia?

Treatment Options for Osteopenia

Pharmacological treatment for osteopenia should be guided by fracture risk assessment using the FRAX tool, with treatment 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 and Diagnosis

• FRAX calculation is recommended to determine overall fracture risk by incorporating BMD and clinical risk factors 1
• Treatment should be strongly considered in patients with a BMD below a T-score of −2.0, particularly with additional risk factors 1
• The presence of vertebral fractures significantly increases future fracture risk and warrants treatment consideration 1
• DEXA should be performed in all women 65 years and older, and in postmenopausal women younger than 65 with risk factors 2

Non-Pharmacological Interventions

• Daily calcium intake recommendations:

  • Ages 19-50: 1,000 mg
  • Ages 51 and older: 1,200 mg 1, 2

• Daily vitamin D intake recommendations:

  • Ages 19-70: 600 IU
  • Ages 71 and older: 800 IU
  • Target serum level: ≥20 ng/mL 1, 2

• 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

• Lifestyle modifications:

  • Smoking cessation
  • Limiting alcohol consumption (1-2 drinks per day maximum)
  • Maintaining weight in recommended range 1, 2

• Fall prevention strategies including vision and hearing checks, medication review, and home safety assessment 1

Pharmacological Treatment

First-Line Therapy

• Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy 1, 2, 3
• Alendronate inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 4
• Alendronate 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 it 4

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
• Selective estrogen receptor modulators (SERMs) 1

Special Populations

• 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
• 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
• Patients with chronic liver disease should have BMD measurement and ensure adequate nutrition 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
• Lying down after taking oral bisphosphonates, failing to swallow with a full glass of water, or continuing medication after developing esophageal symptoms can increase risk of esophageal adverse effects 4
• Hypocalcemia must be corrected before initiating therapy with bisphosphonates 4
• Rare but serious side effects of bisphosphonates include osteonecrosis of the jaw and atypical femoral fractures 4