What are the recommended treatments for osteopenia?

Recommended Treatments for Osteopenia

For patients with osteopenia, treatment should be based on fracture risk assessment using the FRAX tool, with pharmacological therapy recommended when 10-year risk of hip fracture is ≥3% or 10-year risk of major osteoporotic fracture is ≥20%. 1, 2, 3

Risk Assessment and Diagnosis

• FRAX tool should be used to calculate fracture risk, incorporating BMD and clinical risk factors to determine overall fracture risk 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, 2
• Dual energy x-ray absorptiometry (DEXA) should be performed in all women 65 years and older, and in postmenopausal women younger than 65 with risk factors 3
• The presence of a fragility fracture indicates severe osteoporosis and warrants treatment without the need for BMD measurement 2

Non-Pharmacological Interventions

• Calcium intake should be optimized to 1,000-1,200 mg/day (1,000 mg for ages 19-50 and 1,200 mg for ages 51 and older) 1, 2, 3
• Vitamin D intake should be 600-800 IU/day (600 IU for ages 19-70 and 800 IU for ages 71 and older) with a target serum level of ≥20 ng/ml 1, 2, 3
• Regular weight-bearing and resistance training exercises are recommended to improve bone density 1, 2, 3
• Balance training exercises such as tai chi, physical therapy, and dancing can help reduce fall risk 2, 3
• Lifestyle modifications include maintaining weight in recommended range, smoking cessation, and limiting alcohol intake to 1-2 alcoholic beverages per day 1, 2
• Fall prevention strategies including vision and hearing checks, medication review, and home safety assessment are recommended 2

Pharmacological Treatment

• Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy for adults ≥40 years at moderate-to-high fracture risk 1, 2, 3
• Alendronate works by inhibiting osteoclast activity, reducing bone resorption without directly inhibiting bone formation 4
• Alternative therapies if oral bisphosphonates are not appropriate (in order of preference) include IV bisphosphonates, teriparatide, denosumab, and raloxifene 1, 2
• Denosumab is an alternative for patients at high risk of fracture or who cannot tolerate bisphosphonates 3
• Treatment should be strongly considered in patients with a BMD below a T-score of −2.0, particularly with additional risk factors 2

Special Populations

• For patients on glucocorticoids, clinical fracture risk reassessment should be performed every 12 months 1, 2
• Cancer treatments can accelerate bone loss, particularly those causing hypogonadism 2, 3
• For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 2, 3
• Liver transplant patients with osteopenia should perform regular weight-bearing exercise and receive calcium and vitamin D supplementation 3
• Anabolic steroids should be avoided in patients with chronic liver disease 2

Monitoring

• Repeat DEXA should be performed every 2 years or as clinically indicated to monitor treatment response 1, 2, 3
• Bone mineral density assessment should not be conducted more than annually 1, 2, 3

Common Pitfalls to Avoid

• Poor adherence to preventive therapies is common; only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 1, 2
• Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) is a common pitfall 1, 2
• Inadequate calcium and vitamin D supplementation can limit the effectiveness of pharmacological treatments 5
• Neglecting non-pharmacological interventions such as weight-bearing exercise and fall prevention strategies can reduce treatment effectiveness 6, 7