What is the recommended treatment for a patient with osteopenia, as indicated by a lumbar spine T score of -1.9 and femoral neck T scores of -1.2?

Management of Osteopenia with Your Bone Density Results

Based on your T-scores (lumbar spine -1.9, femoral neck -1.2), you should focus on non-pharmacological interventions including calcium, vitamin D, and exercise, while calculating your FRAX score to determine if pharmacological treatment is warranted. 1

Immediate Risk Assessment Required

Your bone density results place you in the osteopenia range, but treatment decisions should not be based on T-scores alone 2, 3. You need:

• FRAX calculation to determine your 10-year fracture risk using your BMD and clinical risk factors 1, 4
• Pharmacological treatment is indicated if FRAX shows:
  • 10-year hip fracture risk ≥3%, OR
  • 10-year major osteoporotic fracture risk ≥20% 5, 1

Treatment should be strongly considered if your T-score is below -2.0 with additional risk factors (age >65, prior fracture, family history of hip fracture, smoking, glucocorticoid use, low body weight) 1

Non-Pharmacological Interventions (Start Immediately)

Calcium and Vitamin D Supplementation

• Calcium: 1,000-1,200 mg daily (through diet or supplements) 5, 1, 4
• Vitamin D: 800-1,000 IU daily with target serum level ≥20 ng/mL 5, 1
• These are foundational regardless of whether you need medication 6

Exercise Program

• Weight-bearing exercises (walking, jogging, dancing) 1, 4
• Resistance/progressive strengthening exercises 5, 1
• Balance training (tai chi, physical therapy) to reduce fall risk 1
• Aim for at least 30 minutes of moderate activity daily 1

Lifestyle Modifications

• Stop smoking immediately if applicable 5, 1
• Limit alcohol to 1-2 drinks per day maximum 1, 4
• Maintain healthy body weight (low BMI is an independent risk factor) 1, 4

Pharmacological Treatment Decision Algorithm

When to Start Medication

Start bisphosphonates (alendronate as first-line) if: 5, 1, 7

1. FRAX meets treatment thresholds (hip ≥3% or major osteoporotic ≥20%) 1, 4
2. History of fragility fracture (even without osteoporosis on DEXA) 5, 1
3. T-score approaching -2.0 with multiple risk factors 1
4. Chronic glucocorticoid use (>7.5 mg prednisone daily for >3 months) 5, 4
5. Cancer treatments causing bone loss (aromatase inhibitors, androgen deprivation, GnRH agonists) 5

First-Line Medication Choice

Oral bisphosphonates (alendronate) are first-line due to safety, cost, and efficacy 5, 1, 7:

• Dosing: 70 mg once weekly (or 10 mg daily) 8
• Administration: Take on empty stomach in morning, 30-60 minutes before food, remain upright for 30 minutes 4, 8
• Contraindications: Esophageal abnormalities, inability to stand/sit upright for 30 minutes, hypocalcemia 5

Alternative Options if Bisphosphonates Not Tolerated

• IV bisphosphonates (zoledronic acid) 5, 1
• Denosumab (subcutaneous, 60 mg every 6 months) 5, 1
• Raloxifene (for younger postmenopausal women) 5
• Teriparatide (reserved for severe osteoporosis or high fracture risk) 5, 7

Monitoring Strategy

If Treatment Is Deferred (FRAX below threshold)

• Repeat DEXA in 2 years to monitor bone density trends 5, 1, 4
• Reassess FRAX annually as age increases fracture risk 4
• Continue non-pharmacological interventions aggressively 1, 4

If Treatment Is Started

• Repeat DEXA every 2 years (not more frequently than annually) 5, 1, 4
• Monitor adherence closely (only 5-62% maintain adequate adherence) 1
• Assess for secondary causes (vitamin D deficiency, hypogonadism, thyroid disease, alcoholism) 1

Critical Pitfalls to Avoid

• Do not treat based on T-score alone without FRAX assessment - the number needed to treat in osteopenia without high fracture risk exceeds 100 3
• Do not ignore secondary causes of bone loss (vitamin D deficiency is extremely common and easily correctable) 1
• Do not start bisphosphonates without ensuring adequate calcium and vitamin D 4
• Do not use bisphosphonates if recent esophageal banding/sclerotherapy (risk of esophageal injury) 5
• Ensure dental screening before starting bisphosphonates or denosumab to reduce osteonecrosis of jaw risk 4

Your Next Steps

1. Calculate your FRAX score at https://frax.shef.ac.uk (requires your age, weight, height, and risk factors) 1
2. Start calcium 1,200 mg and vitamin D 800-1,000 IU daily immediately 5, 1
3. Begin weight-bearing and resistance exercise program 1
4. If FRAX meets treatment thresholds, start alendronate 70 mg weekly 5, 1
5. Schedule DEXA follow-up in 2 years (or 1 year if treatment started) 1, 4