What are the management options for osteopenia?

Management of Osteopenia

Risk Assessment and Diagnosis

Management of osteopenia should be guided by fracture risk assessment using the FRAX tool rather than BMD alone, with pharmacological therapy initiated when 10-year risk reaches ≥3% for hip fracture or ≥20% for major osteoporotic fracture. 1, 2

Initial Evaluation

• Obtain DXA scan of lumbar spine, hip, and femoral neck to confirm BMD T-score between -1.0 and -2.5 1, 2
• Calculate 10-year fracture risk using FRAX tool incorporating BMD, age, prior fracture history, family history, smoking status, alcohol use, glucocorticoid use, and secondary causes of osteoporosis 1, 2
• Order lateral spine X-rays to identify existing vertebral fractures, which increase future fracture risk 5-fold for vertebral fractures and 2-fold for hip fractures 3
• Check laboratory tests for secondary causes: 25-hydroxyvitamin D level (target ≥20 ng/mL), serum calcium, thyroid function, and in men, serum total testosterone 1, 2

Monitoring Schedule

• Repeat DXA every 2 years for patients not on treatment, or annually if medically indicated (such as high-dose glucocorticoid use >7.5 mg/day prednisone) 1, 2
• For patients on treatment, monitor BMD every 2 years to assess response 1, 2

Non-Pharmacological Management (All Patients)

Calcium and Vitamin D

• Ensure calcium intake of 1,000-1,200 mg/day through diet or supplements 1, 2
• Provide vitamin D 600-800 IU/day with target serum level ≥20 ng/mL 1, 2
• For chronic liver disease patients, use calcium 1,000-1,500 mg/day and vitamin D 400-800 IU/day 1, 2

Exercise and Fall Prevention

• Prescribe regular weight-bearing exercises (walking, jogging) combined with resistance training and balance exercises (tai chi, physical therapy, dancing) for at least 30 minutes daily 3, 1, 2
• Implement fall prevention: correct vision/hearing problems, review medications affecting balance, perform home safety assessment, and consider hip protectors for high fall risk 3

Lifestyle Modifications

• Mandate smoking cessation 1, 2
• Limit alcohol to maximum 1-2 drinks per day 1, 2
• Maintain healthy body weight, as low BMI independently increases osteopenia risk 1, 2

Pharmacological Therapy

Treatment Thresholds

Initiate bone-modifying agents when: 1, 2

• FRAX shows 10-year hip fracture risk ≥3% OR major osteoporotic fracture risk ≥20%
• History of prior low-trauma fracture (especially vertebral or hip)
• Glucocorticoid therapy >7.5 mg/day prednisone (adjust FRAX by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2) 1

First-Line Therapy

• Oral bisphosphonates (alendronate) are first-line due to safety, cost, and efficacy 1, 2, 4
• Dosing: Take on empty stomach in morning, 0.5-2 hours before food and other medications, at different time from calcium supplements 2, 5
• Mechanism: Inhibits osteoclast activity, reduces bone resorption by 50-70%, with effects evident within one month 5

Alternative Options

• IV bisphosphonates (zoledronic acid) or denosumab for patients unable to tolerate oral bisphosphonates 1, 2
• Selective estrogen receptor modulators (SERMs) for younger postmenopausal women 1
• Bone-forming agents (teriparatide) followed by anti-resorptive therapy reserved for very high fracture risk 1

Important Caveats

• Perform dental screening before initiating bisphosphonates or denosumab to reduce osteonecrosis of jaw risk 1
• Monitor adherence closely, as up to 64% of patients are non-adherent by 12 months 1, 2
• Number needed to treat in osteopenia (NNT >100) is much higher than in osteoporosis (NNT 10-20), making risk stratification critical 4

Special Populations

Cancer Survivors

• Cancer treatments causing hypogonadism accelerate bone loss 3, 1
• Bisphosphonates preserve bone density in premenopausal women receiving chemotherapy 1, 2
• Consider earlier intervention given baseline plus treatment-related risks 2

Chronic Liver Disease

• Perform BMD testing in all patients with cirrhosis or severe cholestasis 1, 2
• Avoid anabolic steroids due to abnormal liver biochemistry risk 2

Glucocorticoid Users

• Patients on >7.5 mg/day prednisone require aggressive management due to inhibited bone formation and increased resorption 1, 5

Treatment Duration and Discontinuation

• Continue bisphosphonates for at least 3-5 years if fracture risk remains elevated 3
• When T-scores improve to acceptable range, consider discontinuation with periodic DXA monitoring 1
• Reassess fracture risk regularly as evidence base evolves 3