Treatment Options for Osteopenia
For patients with osteopenia, treatment decisions should be based primarily on fracture risk assessment rather than bone mineral density alone, with pharmacological therapy recommended for those at high risk of fracture. 1, 2
Risk Assessment and Diagnosis
- Fracture risk should be calculated using the FRAX tool, which incorporates BMD and clinical risk factors to determine overall fracture risk 2, 3
- 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% 2, 4
- 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 2, 4
- Secondary causes of osteopenia should be identified and treated, including vitamin D deficiency, hypogonadism, alcoholism, and glucocorticoid exposure 2, 3
Non-Pharmacological Management
- Calcium intake should be optimized to 1,000-1,200 mg/day through diet or supplements 2, 3
- Vitamin D intake should be 600-800 IU/day with a target serum level ≥20 ng/ml 2, 5
- Regular weight-bearing and resistance training exercises are recommended to improve bone density 2, 6
- Lifestyle modifications include maintaining healthy weight, smoking cessation, and limiting alcohol intake to 1-2 alcoholic beverages per day 2, 3
- Fall prevention strategies should be implemented for all patients with osteopenia 2, 3
Pharmacological Treatment
For High-Risk Patients (Age ≥65 with Advanced Osteopenia)
- Oral bisphosphonates (such as alendronate) are recommended as first-line therapy due to safety, cost, and efficacy 1, 2
- Low-quality evidence shows that treatment with bisphosphonates in women with advanced osteopenia (T-score near -2.5) may reduce fracture risk by up to 73% compared to placebo 1
- The benefit of fracture reduction is likely to be similar across all bisphosphonates, based on data in osteoporotic women 1
Alternative Therapies
- If oral bisphosphonates are not appropriate, alternative options include IV bisphosphonates, teriparatide, and denosumab 2, 3
- ACP strongly recommends against using menopausal estrogen therapy, menopausal estrogen plus progestogen therapy, or raloxifene for the treatment of osteopenia 1
- Raloxifene is associated with serious harms, such as thromboembolism, and should not be used as first-line treatment 1
Special Populations
- Patients with chronic liver disease should have BMD testing and additional assessment for vitamin D deficiency, thyroid function, and hypogonadism 1, 3
- For patients on long-term glucocorticoid therapy, particularly at doses >7.5 mg/day of prednisone, bone-modifying agents should be considered 2, 4
- Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss and should be considered for earlier intervention 2, 3
Monitoring and Follow-up
- Repeat DXA should be performed every 2 years to monitor treatment response, but not more frequently than annually 2, 4
- Clinical fracture risk reassessment should be performed every 12 months, especially for patients on glucocorticoids 2, 4
- Medication adherence should be assessed regularly, as non-adherence is common and reduces treatment effectiveness 2, 4
Important Considerations and Pitfalls
- Osteopenia is not a disease but a risk factor for fractures; the label alone should not cause unnecessary anxiety 7, 8
- 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 1
- Before initiating a bone-modifying agent, a dental screening exam should be performed to reduce the risk of medication-related osteonecrosis of the jaw 2, 3
- Despite appropriate recommendations, adherence to preventive therapies for bone health is often poor 2, 4
- Most fractures occur in patients with osteopenia rather than osteoporosis due to the larger number of individuals in this category 8