What is the treatment for osteopenia?

Treatment of Osteopenia

For patients with osteopenia, treatment decisions should be individualized based on fracture risk assessment rather than BMD alone, with bisphosphonates recommended as first-line therapy for those at high risk of fracture. 1

Risk Assessment for Treatment Decision

• Treatment decisions for osteopenia should not be based solely on T-score but should incorporate comprehensive fracture risk assessment 1, 2
• Patients with osteopenia who have had a previous fragility fracture should receive pharmacological treatment regardless of BMD 3, 2
• For osteopenic women ≥65 years without fractures, calculate 10-year fracture risk using FRAX or other risk assessment tools 1
• Consider treatment when 10-year risk of major osteoporotic fracture is ≥20% or hip fracture risk is ≥3% 1
• Women with severe osteopenia (T-score <-2.0) benefit more from treatment than those with mild osteopenia (T-score between -1.0 and -1.5) 1

First-Line Pharmacological Treatment

• Bisphosphonates are recommended as first-line therapy for both men and women with high-risk osteopenia 1
• Oral bisphosphonates (alendronate 70mg weekly or risedronate 35mg weekly) are preferred due to extensive clinical experience, efficacy, and lower cost 3, 4
• Bisphosphonates work by inhibiting osteoclast activity, reducing bone resorption without directly inhibiting bone formation 4
• Zoledronic acid 5mg IV annually is recommended for patients with GI intolerance to oral bisphosphonates or compliance concerns 3

Second-Line Treatment Options

• Denosumab (RANK ligand inhibitor) is recommended as second-line treatment for patients who have contraindications to or experience adverse effects from bisphosphonates 1, 3
• Denosumab is particularly beneficial for patients with renal impairment who cannot take bisphosphonates 3
• For women with very high fracture risk, consider anabolic agents (teriparatide, romosozumab) followed by bisphosphonates 1, 3, 5

Non-Pharmacological Interventions

• All patients with osteopenia should receive calcium (1,000-1,500 mg daily) and vitamin D (800-1,000 IU daily) supplementation 1, 3
• Weight-bearing exercise (30 minutes at least 3 days per week) is recommended to improve BMD 1, 3
• Smoking cessation and limiting alcohol intake are strongly recommended 1, 3
• Fall prevention strategies, including home safety assessment and balance training, should be implemented 3

Monitoring and Follow-Up

• BMD testing is not routinely recommended during the first 5 years of treatment 3
• Regular clinical assessment for treatment adherence, side effects, and new fractures should be performed 3
• Duration of treatment is typically 3-5 years, with reassessment of fracture risk afterward 3

Special Considerations

• Secondary causes of osteopenia (vitamin D deficiency, hypogonadism, glucocorticoid use, etc.) should be identified and treated 1
• Patients with osteopenia due to glucocorticoid use may benefit from earlier intervention with bisphosphonates 1
• HIV-infected individuals with osteopenia should receive adequate calcium and vitamin D, with consideration of bisphosphonates for those at high fracture risk 1
• Avoid estrogen therapy or raloxifene for treatment of osteopenia in postmenopausal women due to unfavorable risk-benefit profile 1

Common Pitfalls to Avoid

• Treating based on T-score alone without considering overall fracture risk 2, 6
• Failing to identify and address secondary causes of bone loss 1
• Inadequate calcium and vitamin D supplementation alongside pharmacological treatment 3, 4
• Not considering fall prevention strategies as part of comprehensive management 3
• Overlooking the fact that most fractures occur in people with osteopenia rather than osteoporosis due to the larger population size 6