What are the treatment options for osteopenia?

Osteopenia Treatment

For most patients with osteopenia, treatment begins with non-pharmacological interventions (calcium, vitamin D, exercise, lifestyle modifications), and pharmacological therapy should only be initiated when FRAX calculation shows a 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%, with oral bisphosphonates (alendronate) as first-line medication. 1, 2, 3

Risk Stratification First

Before deciding on treatment, calculate fracture risk using the FRAX tool, which incorporates both BMD and clinical risk factors to determine overall fracture probability. 1, 3 This is the critical first step that determines whether you proceed with lifestyle measures alone or add pharmacological therapy.

When to Treat with Medications

Pharmacological treatment is indicated when: 1, 2, 3

• 10-year hip fracture risk ≥3% on FRAX calculation
• 10-year major osteoporotic fracture risk ≥20% on FRAX calculation
• T-score below -2.0 with additional risk factors (presence of vertebral fractures, glucocorticoid use >7.5 mg/day prednisone, hypogonadism, early maternal hip fracture, low BMI) 1, 3

Important adjustment for glucocorticoid users: If prednisone dose is >7.5 mg/day, multiply the FRAX major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2. 1, 3

Non-Pharmacological Interventions (For All Patients)

These foundational measures should be implemented regardless of whether pharmacological therapy is initiated: 1, 2, 3

Calcium and Vitamin D Supplementation

• Calcium: 1,000 mg daily for ages 19-50; 1,200 mg daily for ages 51+ 1, 2, 3
• Vitamin D: 600 IU daily for ages 19-70; 800 IU daily for ages 71+ 1, 2, 3
• Target serum vitamin D level ≥20 ng/mL 1, 2

Exercise Regimen

• Weight-bearing and muscle-strengthening exercises to improve bone density 1, 2, 3
• Balance training exercises (tai chi, physical therapy, dancing) to reduce fall risk 1, 2, 3
• Minimum 30 minutes of moderate physical activity daily 1

Lifestyle Modifications

• Smoking cessation (mandatory) 1, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 3
• Maintain weight in recommended range (low BMI is an independent risk factor) 1

Fall Prevention Strategies

• Vision and hearing checks 1
• Medication review (to identify drugs increasing fall risk) 1
• Home safety assessment 1

Pharmacological Treatment (When FRAX Thresholds Met)

First-Line Therapy

Oral bisphosphonates (alendronate) are the first-line pharmacological treatment due to proven safety, cost-effectiveness, and efficacy in reducing fractures. 1, 2, 3, 4

Alendronate dosing:

• 70 mg once weekly for treatment of osteoporosis 5
• 35 mg once weekly for prevention of osteoporosis 5

Critical administration instructions to prevent esophageal complications: 5

• Take first thing in the morning on an empty stomach
• Swallow with full glass (6-8 oz) of plain water only (not mineral water, coffee, tea, soda, or juice)
• Remain upright (sitting or standing) for at least 30 minutes after taking
• Take before any food, drink, or other medications
• Do not lie down for at least 30 minutes after administration

Alternative Therapies (If Bisphosphonates Not Tolerated or Contraindicated)

When oral bisphosphonates are inappropriate, consider: 1, 2, 3

• IV bisphosphonates (for patients who cannot tolerate oral formulations)
• Denosumab (for high-risk patients or bisphosphonate intolerance)
• Teriparatide (anabolic agent for very high-risk patients)
• Selective estrogen receptor modulators (SERMs) (alternative option)

Contraindications to Alendronate

Do not use alendronate if: 5

• Esophageal abnormalities that delay esophageal emptying
• Inability to stand or sit upright for at least 30 minutes
• Hypocalcemia (must be corrected first)
• Creatinine clearance <35 mL/min 5

Special Populations Requiring Attention

Cancer Survivors

• Cancer treatments accelerate bone loss, particularly those causing hypogonadism 1, 2, 3
• Bisphosphonates or denosumab are preferred agents for cancer survivors with osteopenia and additional risk factors 1, 2, 3
• Dental screening exam required before initiating bone mineral agents to reduce osteonecrosis of jaw risk 1

Glucocorticoid Users

• Clinical fracture risk reassessment every 12 months 1, 3
• Adjust FRAX calculations as noted above 1, 3
• Poor adherence is common (only 5-62% receive appropriate preventive therapies) 1, 3

Chronic Liver Disease

• BMD measurement recommended 1
• Calcium and vitamin D3 supplementation 1
• Avoid anabolic steroids 1

Monitoring Strategy

• Repeat DEXA scan every 2 years to monitor bone density and treatment response 1, 2, 3
• Do not perform BMD assessment more frequently than annually 1, 2
• For glucocorticoid users: reassess fracture risk every 12 months 1, 3

Critical Pitfalls to Avoid

Failing to identify and treat secondary causes of osteopenia is a common error. Always screen for: 1, 3

• Vitamin D deficiency
• Hypogonadism
• Alcoholism
• Glucocorticoid exposure

Over-treating low-risk patients: Do not initiate pharmacological therapy in patients who do not meet FRAX thresholds, as this exposes them to medication risks without proven benefit. 3

Poor medication adherence: Ensure patients understand the critical importance of proper alendronate administration technique to prevent serious esophageal complications. 5

Ignoring dental health: Before starting bisphosphonates or denosumab, address any pending dental procedures, as these medications increase risk of osteonecrosis of the jaw. 1, 5

Serious Adverse Effects to Monitor

When prescribing alendronate, counsel patients about: 5

• Esophageal problems (irritation, ulcers, bleeding) - stop medication if chest pain, worsening heartburn, or difficulty swallowing occurs
• Osteonecrosis of the jaw (particularly with invasive dental procedures)
• Atypical femoral fractures (prodromal thigh/groin pain may precede fracture by weeks to months)
• Severe musculoskeletal pain (may require discontinuation)
• Hypocalcemia (ensure adequate calcium/vitamin D supplementation)