What are the treatment options for osteopenia?

Treatment Options for Osteopenia

The management of osteopenia should include both non-pharmacological interventions for all patients and pharmacological therapy for those at high risk of fracture based on FRAX assessment, with bisphosphonates being the first-line pharmacological treatment option. 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 is indicated when FRAX calculation shows a 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% 1, 2
• Bone mineral density assessment using DXA of total spine, hip, and femoral neck is recommended when one or more risk factors for osteoporotic fracture is present 3

Non-Pharmacological Interventions (For All Patients)

• Ensure adequate calcium intake: 1,000 mg daily for ages 19-50 and 1,200 mg daily for ages 51 and older 1
• Supplement vitamin D: 600 IU daily for ages 19-70 and 800 IU daily for ages 71 and older, with a target serum level of ≥20 ng/mL 1
• Engage in regular weight-bearing and muscle-strengthening exercises to improve bone density 1, 2
• Implement balance training exercises (tai chi, physical therapy, dancing) to reduce fall risk 1
• Aim for at least 30 minutes of moderate physical activity daily 1
• Quit smoking and limit alcohol consumption (maximum 1-2 drinks per day) 3, 1
• Implement fall prevention strategies including vision and hearing checks, medication review, and home safety assessment 1
• Maintain weight in the recommended range 1

Pharmacological Treatment

When to Initiate Pharmacological Therapy

• Treatment should be initiated when:
  • FRAX calculation shows a 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% 3, 1
  • BMD is below a T-score of −2.0, particularly with additional risk factors 1
  • Patient has a history of prior osteoporotic fracture 1

First-Line Therapy

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

Alternative Therapies

• IV bisphosphonates for patients who cannot tolerate oral bisphosphonates 1
• Denosumab for patients who cannot tolerate bisphosphonates or are at high risk of fracture 1, 2
• Teriparatide (anabolic agent) for high-risk patients, especially those with severe osteopenia or previous fractures 1, 5
• Selective estrogen receptor modulators (SERMs) as an alternative therapy 1

Special Populations

• Cancer survivors: Cancer treatments can accelerate bone loss, particularly those causing hypogonadism 3, 2
  • For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 3, 2
• Glucocorticoid users: Adjust fracture risk by 1.15 for major osteoporotic fracture risk and 1.2 for hip fracture risk if prednisone dose is >7.5 mg/day 1
  • Perform clinical fracture risk reassessment every 12 months 1

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 3, 1
• Bone mineral density assessment should not be conducted more than annually 3, 1

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
• Not recognizing that the presence of a fragility fracture indicates severe bone loss and warrants treatment without the need for additional BMD measurement 1
• Overlooking the importance of fall prevention strategies alongside medication management 1
• Discontinuing treatment prematurely before achieving adequate fracture protection 6