What is the treatment for osteopenia?

Treatment for Osteopenia

For patients with osteopenia, pharmacological treatment should be initiated when the 10-year risk of hip fracture is ≥3% or major osteoporotic fracture is ≥20% as calculated by the FRAX tool. 1, 2

Risk Assessment and Diagnosis

• Fracture risk should be calculated using the FRAX tool to guide treatment decisions rather than relying solely on bone mineral density (BMD) measurements 1, 2
• Bone mineral density testing with dual-energy x-ray absorptiometry (DXA) is recommended when one or more risk factors for osteoporotic fracture are present 2
• For patients on glucocorticoids, the FRAX calculation 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
• Secondary causes of osteopenia should be identified and treated, including vitamin D deficiency, hypogonadism, alcoholism, and glucocorticoid exposure 3

Non-Pharmacological Management

• Calcium intake should be optimized to 1,000-1,200 mg/day through diet or supplements 1, 2
• Vitamin D intake should be 600-800 IU/day with a target serum level ≥20 ng/ml 1, 2
• Regular weight-bearing and resistance training exercises are recommended to improve bone density 1, 2
• Lifestyle modifications include maintaining healthy weight, smoking cessation, and limiting alcohol intake to 1-2 alcoholic beverages per day 1, 2
• Fall prevention strategies should be implemented for all patients with osteopenia 2

Pharmacological Treatment

When to Initiate Treatment

• Treatment is recommended for osteopenic women 65 years of age or older who are at high risk for fracture based on FRAX scores (≥3% for hip fracture or ≥20% for major osteoporotic fracture) 3, 1, 2
• Low-quality evidence shows that treatment with bisphosphonates in women with advanced osteopenia (T-score between -2.0 and -2.5) may reduce fracture risk 3
• Patients on long-term glucocorticoid therapy, particularly at doses >7.5 mg/day of prednisone, should be considered for bone-modifying agents 2

First-Line Treatment Options

• Oral bisphosphonates, such as alendronate, are recommended as first-line therapy due to safety, cost, and efficacy 1, 2
• Alendronate works by inhibiting osteoclast activity, reducing bone resorption without directly inhibiting bone formation 4
• The benefit of fracture reduction is likely to be similar across all bisphosphonates, based on data in osteoporotic women 3

Alternative Treatment Options

• If oral bisphosphonates are not appropriate, alternative options include IV bisphosphonates, teriparatide, denosumab, and raloxifene 1, 2
• Teriparatide is an anabolic agent that increases lumbar spine BMD and may be considered for high-risk patients 5, 6
• The combination of antiresorptive and anabolic agents may increase BMD compared to monotherapy, but more data on fracture risk reduction is needed 6

Monitoring and Follow-up

• Repeat DXA should be performed every 2 years to monitor treatment response, but not more frequently than annually 1, 2
• Clinical fracture risk reassessment should be performed every 12 months, especially for patients on glucocorticoids 1
• Medication adherence should be assessed regularly, as non-adherence is common and reduces treatment effectiveness 2

Special Considerations

• Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss and should be considered for earlier intervention 3, 2
• Patients with chronic liver disease should have BMD testing and additional assessment for vitamin D deficiency, thyroid function, and hypogonadism 2
• The risk of severe adverse effects increases with prolonged use of bisphosphonates, so the balance of benefits and harms is most favorable when fracture risk is high 3
• Before initiating a bone-modifying agent, a dental screening exam should be performed to reduce the risk of medication-related osteonecrosis of the jaw 3

Common Pitfalls

• Adherence to preventive therapies for bone health is often poor, with only 5-62% of patients on glucocorticoid therapy receiving appropriate preventive therapies 1
• FRAX has not been validated in HIV-infected persons and may underestimate fracture risk in this population 3
• Treating osteopenia based solely on T-score without considering other risk factors leads to unnecessary treatment in low-risk individuals 7
• The number needed to treat for osteopenic patients without other risk factors is much higher (NNT>100) compared to patients with fractures and T-scores below -2.5 (NNT 10-20) 7