Treatment Options for Osteopenia
For patients with osteopenia, treatment decisions should be based on fracture risk assessment rather than bone mineral density alone, with pharmacological therapy recommended primarily for those at high risk for fracture. 1, 2
Risk Assessment
- 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, 3
- 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, 3
- The presence of a fragility fracture indicates severe osteoporosis and warrants treatment without the need for BMD measurement 2
- Women 65 years or older with severe osteopenia (T-score < -2.0) are at higher risk for fracture than those with mild osteopenia (T-score between -1.0 and -1.5) 4
Non-Pharmacological Management
- Calcium intake should be optimized to 1,000-1,200 mg/day through diet or supplements 1, 3, 5
- Vitamin D intake should be 600-800 IU/day with a target serum level ≥20 ng/ml 1, 3, 6
- Regular weight-bearing and resistance training exercises are recommended to improve bone density 1, 3, 5
- 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 1, 2
Pharmacological Treatment
First-Line Therapy
- Oral bisphosphonates (such as alendronate) are recommended as first-line therapy for high-risk patients due to safety, cost, and efficacy 1, 3, 7
- Low-quality evidence shows that treatment with bisphosphonates in women with advanced osteopenia may reduce fracture risk by up to 73% compared to placebo 4
- Alendronate works by inhibiting osteoclast activity, reducing bone resorption without directly inhibiting bone formation 7
Alternative Therapies
- If oral bisphosphonates are not appropriate, alternative options include (in order of preference):
Treatment Considerations for Special Populations
- Patients on long-term glucocorticoid therapy, particularly at doses >7.5 mg/day of prednisone, should be considered for bone-modifying agents 1, 3
- Cancer survivors may have baseline risks for osteoporosis plus added risks from treatment-related bone loss and should be considered for earlier intervention 1, 2
- Patients with chronic liver disease should have BMD testing and additional assessment for vitamin D deficiency, thyroid function, and hypogonadism 4, 2
Monitoring and Follow-up
- Repeat DXA should be performed every 2 years to monitor treatment response, but not more frequently than annually 1, 3
- Clinical fracture risk reassessment should be performed every 12 months, especially for patients on glucocorticoids 1, 3
- Medication adherence should be assessed regularly, as non-adherence is common and reduces treatment effectiveness 1
Common Pitfalls to Avoid
- Treating osteopenia based solely on BMD without considering overall fracture risk 9, 10
- Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 1, 2
- Not considering the risk-benefit profile of medications for individual patients, particularly with prolonged use of bisphosphonates 4
- Poor adherence to preventive therapies - only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 1, 3
- Using menopausal estrogen therapy, menopausal estrogen plus progestogen therapy, or raloxifene for the treatment of osteopenia, as these are not recommended 4
- Assuming all patients with osteopenia need pharmacological treatment - the diagnosis of osteopenia alone is not an indication for treatment 9, 10