Should osteopenia be treated?

Treatment of Osteopenia

Treatment of osteopenia should be individualized based on fracture risk assessment rather than bone mineral density alone, with pharmacologic therapy recommended only for those at high risk for fracture. 1

Risk Assessment for Treatment Decisions

• Osteopenia (T-score between -1.0 and -2.5) is not itself an indication for pharmacologic treatment; decisions should be based on comprehensive fracture risk assessment 1
• Treatment should be considered for osteopenic women 65 years or older at high risk for fracture after discussing patient preferences, fracture risk profile, and benefits/harms of medications 1
• The 10-year risk of fracture should be calculated using tools such as FRAX (World Health Organization Fracture Risk Assessment Tool) 1, 2
• Consider pharmacologic treatment if the 10-year risk of all osteoporotic fracture is ≥20% or risk of hip fracture is ≥3% 1, 2
• Women with severe osteopenia (T-score < -2.0) near the osteoporosis threshold have greater benefit from treatment than those with mild osteopenia (T-score between -1.0 and -1.5) 1

Non-Pharmacologic Interventions (For All Patients)

• Regular weight-bearing exercise (30 minutes at least 3 days per week) is recommended to improve bone density and reduce fracture risk 1, 2, 3
• Ensure adequate calcium intake (1000-1500 mg daily) and vitamin D supplementation (800-1000 IU daily) 1, 2
• Implement fall prevention strategies, including balance training and home hazard assessment 1, 3
• Recommend smoking cessation and limiting alcohol consumption 1, 2

Pharmacologic Treatment (For High-Risk Patients Only)

• Bisphosphonates (particularly risedronate) have shown efficacy in reducing fracture risk in osteopenic women near the osteoporosis threshold 1
• Low-quality evidence showed that treatment with risedronate in women with advanced osteopenia significantly reduced the risk for fragility fracture compared with placebo (73% lower than placebo) 1
• The American College of Physicians believes that the benefit of fracture reduction is likely to be similar across all bisphosphonates, based on data in osteoporotic women 1
• Alendronate has been shown to prevent bone loss in the majority of patients and induce significant increases in bone mass 4
• Avoid menopausal estrogen therapy or raloxifene for osteopenia treatment due to serious potential harms including thromboembolism 1

Monitoring

• Repeat bone density scans approximately every 2 years to monitor bone density in patients with osteopenia 1, 2
• Avoid performing bone density scans more frequently than annually 1, 2
• For patients on pharmacologic therapy, treatment duration is typically 5 years with reassessment of fracture risk afterward 2

Special Considerations

• Secondary causes of osteopenia should be evaluated and treated before initiating therapy for osteopenia 1, 3
• Patients on long-term glucocorticoid therapy are at especially high risk for developing osteoporosis and may require earlier intervention 1, 3
• The risk of adverse effects increases with prolonged use of bisphosphonates, so the benefit-to-harm ratio should be carefully considered 1

Common Pitfalls

• Treating based solely on bone mineral density without considering overall fracture risk 5, 6
• Failing to recognize that most fractures occur in people with osteopenia rather than osteoporosis due to the larger number of individuals with osteopenia 6
• Overlooking the rapid bone loss that occurs after discontinuation of hormone therapy, which increases fracture risk 7
• Underestimating the importance of non-pharmacologic interventions in reducing fracture risk 8, 3