What medications are used to treat osteopenia?

Medications for Osteopenia Treatment

Bisphosphonates are the first-line pharmacological treatment for osteopenia, with oral alendronate being the most commonly recommended medication due to its established efficacy, safety profile, and cost-effectiveness. 1

First-Line Medications

Bisphosphonates

• Oral Bisphosphonates:

  • Alendronate (Fosamax):
    • Prevention dosing: 5 mg daily or 35 mg once weekly 1, 2
    • Treatment dosing: 10 mg daily or 70 mg once weekly 1, 2
    • Weekly dosing is therapeutically equivalent to daily dosing with better convenience and potentially improved adherence 3, 4
  • Risedronate (Actonel):
    • Prevention and treatment: 5 mg daily, 35 mg weekly, 75 mg on two consecutive days monthly, or 150 mg monthly 1
  • Ibandronate (Boniva):
    • Prevention and treatment: 150 mg monthly orally or 3 mg IV every three months 1

• Intravenous Bisphosphonates:

  • Zoledronic acid (Reclast):
    • Prevention: 5 mg IV every two years 1
    • Treatment: 5 mg IV annually 1
    • Contraindicated in patients with hypocalcemia, creatinine clearance <35 mL/min/1.73 m², or hypersensitivity 1

Second-Line Medications

Selective Estrogen Receptor Modulators (SERMs)

• Raloxifene (Evista):
  • Prevention and treatment: 60 mg daily 1
  • Good initial option for younger postmenopausal women 1
  • Contraindicated in patients with venous thromboembolism, pregnancy, or breastfeeding 1

RANK Ligand Inhibitor

• Denosumab (Prolia):
  • Treatment: 60 mg subcutaneously every six months 1
  • Option for patients with high fracture risk 1
  • Contraindicated in patients with hypocalcemia 1
  • Caution: When discontinued, there may be increased risk of vertebral fractures 1

Third-Line Medications

Parathyroid Hormone

• Teriparatide (Forteo):
  • Treatment (high fracture risk): 20 mcg subcutaneously daily 1
  • Typically reserved for patients with severe osteoporosis or who have had fractures 1
  • Contraindicated in patients with hypersensitivity to teriparatide 1

Calcitonin

• Calcitonin-salmon (Fortical, Miacalcin):
  • Treatment: 200 IU daily nasal spray or 100 IU subcutaneously/intramuscularly every other day 1
  • Only for women more than five years past menopause 1
  • Has weaker efficacy data compared to other options; should be used only in women with less serious osteoporosis who cannot tolerate other treatments 1

Special Considerations

Treatment Duration

• Bisphosphonate therapy is typically recommended for 5 years 1
• There appears to be a trend toward interrupting therapy after 5-10 years 1
• Bone mineral density monitoring during the 5-year pharmacologic treatment period is not recommended 1

Combination Therapy

• Combination therapy is not recommended 1

Calcium and Vitamin D Supplementation

• All patients should receive adequate calcium and vitamin D intake 1:
  • Ages 19-50: 1,000 mg calcium, 600 IU vitamin D daily
  • Ages 51-70: 1,200 mg calcium, 600 IU vitamin D daily
  • Ages 71+: 1,200 mg calcium, 800 IU vitamin D daily

Treatment Algorithm Based on Fracture Risk

For Adults ≥40 years:

• Very high fracture risk (prior fracture, BMD T-score ≤-3.5, or high-dose glucocorticoids): Consider anabolic agents (teriparatide) over antiresorptives 1
• High fracture risk (T-score ≤-2.5 or 10-year fracture risk ≥20%): Oral bisphosphonates strongly recommended; denosumab or teriparatide are alternatives 1
• Moderate fracture risk (T-score between -1.0 and -2.5): Consider oral bisphosphonates, denosumab, or teriparatide based on individual factors 1

Common Pitfalls to Avoid

• Administering alendronate to patients with significant renal impairment (GFR <35 mL/min/1.73m²) 5
• Discontinuing denosumab without follow-up bisphosphonate therapy (risk of rebound bone loss) 1
• Failing to ensure patients can remain upright for at least 30 minutes after taking oral bisphosphonates 1
• Not addressing modifiable risk factors (smoking, alcohol intake, inactivity) alongside pharmacological treatment 1
• Using calcitonin as first-line therapy due to its weaker efficacy data 1