What are the guidelines for treating osteopenia?

Guidelines for Treatment of Osteopenia

Treatment for osteopenia should be based on fracture risk assessment rather than bone mineral density (BMD) alone, with pharmacological therapy recommended for those at high risk of fracture.

Risk Assessment and Treatment Decision-Making

• Fracture risk should be calculated using the FRAX tool, which incorporates BMD and clinical risk factors to determine overall fracture risk 1, 2
• Pharmacological treatment should be considered when FRAX calculation shows a 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% 1, 2
• The presence of a fragility fracture indicates severe osteoporosis and warrants treatment without the need for BMD measurement 3, 2
• Strong risk factors include oral glucocorticoid use (prednisolone ≥5 mg for ≥3 months), hypogonadism, height loss >4 cm, x-ray evidence of osteopenia, early maternal hip fracture (<60 years), and low body mass index (<19 kg/m²) 3, 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

Non-Pharmacological Interventions

• Optimize calcium intake to 1,000-1,200 mg/day through diet or supplements 1, 2
• Ensure vitamin D intake of 600-800 IU/day with a target serum level ≥20 ng/mL 1, 2
• Implement regular weight-bearing and resistance training exercises to improve bone density 1, 2
• Recommend balance training exercises (tai chi, physical therapy) to reduce fall risk 2
• Advise smoking cessation and limiting alcohol consumption (1-2 drinks per day maximum) 2
• Implement fall prevention strategies including vision and hearing checks, medication review, and home safety assessment 2
• Maintain weight in the recommended range as low body mass index is an independent risk factor 3, 2

Pharmacological Treatment

• Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy for adults at moderate-to-high fracture risk 1, 2
• Alendronate should be taken with plain water first thing upon arising, at least 30 minutes before food, and patients should remain upright for at least 30 minutes afterward 4
• Alternative therapies if oral bisphosphonates are not appropriate (in order of preference) include IV bisphosphonates, teriparatide, denosumab, and selective estrogen receptor modulators (SERMs) 1, 2
• Teriparatide is indicated for patients with severe osteoporosis and multiple fractures as a second-line therapy 5, 6
• The ongoing need for bisphosphonates should be assessed after five years, and treatment may be interrupted in some patients with stable bone density 6
• Denosumab therapy should not be interrupted without switching to another therapy, as post-treatment bone loss can progress rapidly 6

Special Populations

• For patients with chronic liver disease, BMD measurement is recommended, and supplementation with calcium (1 g/day) and vitamin D3 (800 U/day) is advised 3
• Cancer treatments can accelerate bone loss, particularly those causing hypogonadism; for cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 3, 2
• For patients on glucocorticoids, clinical fracture risk reassessment should be performed every 12 months 1
• Before initiating a bone mineral agent (BMA) in cancer survivors, a dental screening exam should be performed to reduce the risk of medication-related osteonecrosis of the jaw 3

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 1, 2
• Bone mineral density assessment should not be conducted more than annually 1, 2
• When T-scores improve, consider discontinuation of the BMA and follow up with periodic DXA scans 3

Common Pitfalls to Avoid

• Treating based on T-score alone without considering overall fracture risk can lead to overtreatment of low-risk patients 7
• 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) 1, 2
• Interrupting denosumab therapy without transitioning to another therapy can lead to rapid bone loss 6
• Inadequate calcium and vitamin D supplementation in high-risk individuals 8
• Not considering the risk-benefit profile of medications for individual patients, particularly in those with comorbidities 3