What is the management of osteopenia?

Explaining and Managing Osteopenia

What is Osteopenia?

Osteopenia is a condition characterized by lower-than-normal bone mineral density (BMD) with T-scores between -1 and -2.5 on dual-energy X-ray absorptiometry (DXA) scanning. 1 It represents an intermediate state between normal bone density and osteoporosis, and while it carries a lower fracture risk than osteoporosis, the greater prevalence of osteopenia means most fractures actually occur in people with osteopenia rather than osteoporosis. 2

Explaining Osteopenia to Patients

When explaining osteopenia to patients, focus on these key points:

• Osteopenia means your bones are weaker than normal but not as weak as in osteoporosis 1
• It's a warning sign that you may develop osteoporosis if preventive measures aren't taken 3
• Bone density naturally decreases with age, but certain factors can accelerate this process 3
• Having osteopenia increases your risk of fractures, particularly as you age 2
• With proper management, bone loss can be slowed or even improved 4

Diagnostic Assessment

• DXA scan is the gold standard for diagnosis, with measurements of the lumbar spine and hip being most valuable 5
• Risk assessment should include calculation of 10-year fracture risk using the FRAX tool, which incorporates BMD and clinical risk factors 3
• Lateral spine X-rays should be considered to identify existing vertebral fractures, which significantly increase future fracture risk 5
• Laboratory testing should be performed to identify secondary causes of bone loss (vitamin D deficiency, hyperparathyroidism, hypogonadism) 5
• BMD testing should be repeated every 2 years, or annually if medically indicated, but not more frequently than once per year 3

Non-Pharmacological Management

The cornerstone of osteopenia management includes lifestyle modifications, adequate calcium and vitamin D intake, and regular weight-bearing exercise. 3, 4

Lifestyle Modifications:

• Regular weight-bearing and resistance exercises to improve bone density 3
• Smoking cessation and limiting alcohol consumption (maximum 1-2 drinks per day) 6
• Fall prevention strategies including balance training, home safety assessment, and vision checks 3
• Maintaining weight in the recommended range, as low body mass index is an independent risk factor 6

Nutritional Support:

• Ensure adequate calcium intake of 1,000-1,200 mg/day through diet or supplements 3
• Optimize vitamin D intake of 600-800 IU/day, with a target serum level ≥20 ng/ml 3
• For patients with chronic liver disease, calcium (1,000-1,500 mg/day) and vitamin D (400-800 IU/day) supplementation is recommended 6

Pharmacological Management

Pharmacological therapy should be considered based on fracture risk rather than BMD alone. 3

When to Consider Medication:

• FRAX calculation shows a 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20% 3
• Patients with significant osteopenia and additional risk factors 3
• History of fragility fracture 6
• Long-term glucocorticoid therapy, particularly at doses >7.5 mg/day of prednisone 3

First-Line Medications:

• Oral bisphosphonates (such as alendronate) are first-line therapy due to safety, cost, and efficacy 3, 7
• Alendronate inhibits osteoclast activity, reducing bone resorption without directly inhibiting bone formation 7
• Take on an empty stomach in the morning, 0.5–2 hours before food and other drugs, and at a different time to calcium supplements 6

Alternative Options:

• IV bisphosphonates (zoledronate) for those who cannot tolerate oral bisphosphonates 3
• Denosumab for patients at high risk of fracture or who cannot tolerate bisphosphonates 3
• For very high-risk patients, anabolic agents like teriparatide may be considered 8, 9

Special Populations

Chronic Liver Disease:

• Patients with cirrhosis or severe cholestasis should have BMD testing 6
• Avoid anabolic steroids as they can cause abnormal liver biochemistry 6

Cancer Survivors:

• Cancer treatments can accelerate bone loss, particularly those causing hypogonadism 5
• Bisphosphonates have been shown to preserve bone density in premenopausal women receiving chemotherapy 5

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 5

Monitoring and Follow-up

• Monitor BMD every 2 years to assess treatment response 3
• Assess medication adherence regularly, as non-adherence is common 5
• If pharmacological therapy is deferred, repeat DXA in 2 years or in 1 year if medically indicated 3

Common Pitfalls to Avoid

• Failing to calculate fracture risk beyond just BMD measurement 3
• Not addressing modifiable risk factors before starting medication 4
• Inadequate calcium and vitamin D supplementation before or during treatment 3
• Poor medication adherence, which significantly reduces treatment effectiveness 5
• Stopping denosumab without transitioning to another therapy, as rapid bone loss can occur 4
• Overlooking secondary causes of osteopenia that may require specific treatment 5