What is the treatment for osteopenia?

Treatment for Osteopenia

Treatment for osteopenia should be based on fracture risk assessment using the FRAX tool, with pharmacological therapy (oral bisphosphonates as first-line) reserved for patients with 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%, while all patients should receive calcium, vitamin D, and lifestyle modifications. 1, 2

Risk Stratification First

Calculate fracture risk using FRAX rather than relying solely on bone mineral density measurements. 1, 2, 3

• Treatment thresholds: 10-year hip fracture risk ≥3% OR major osteoporotic fracture risk ≥20% 1, 2, 3
• For patients on glucocorticoids >7.5 mg/day prednisone, adjust FRAX by multiplying by 1.15 for major osteoporotic fracture and 1.2 for hip fracture 1, 2, 3
• Identify and treat secondary causes: vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure 1, 2
• Presence of fragility fracture indicates severe osteoporosis and warrants immediate treatment without needing BMD measurement 3

Non-Pharmacological Management (All Patients)

Every patient with osteopenia requires calcium, vitamin D, exercise, and lifestyle modifications regardless of fracture risk. 1, 2, 3

Supplementation

• Calcium: 1,000-1,200 mg/day through diet or supplements 1, 2, 3
• Vitamin D: 600-800 IU/day with target serum level ≥20 ng/mL 1, 2, 3

Exercise

• Regular weight-bearing and resistance training exercises to improve bone density 1, 2, 3
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 3
• Aim for at least 30 minutes of moderate physical activity daily 3

Lifestyle Modifications

• Smoking cessation 1, 2, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 2, 3
• Maintain healthy weight (low BMI is an independent risk factor) 1, 2, 3
• Fall prevention: vision/hearing checks, medication review, home safety assessment 3

Pharmacological Treatment (High-Risk Patients Only)

Oral bisphosphonates (alendronate) are first-line therapy for osteopenic patients meeting treatment thresholds based on safety, cost, and efficacy. 1, 2, 3

First-Line: Oral Bisphosphonates

• Alendronate inhibits osteoclast activity, reduces bone resorption, and leads to progressive gains in bone mass 4
• Reduces urinary markers of bone resorption by 50-70% within 1 month, reaching plateau at 3-6 months 4
• Evidence shows fracture reduction in women with advanced osteopenia, though quality is lower than for osteoporosis 1
• Critical caveat: Perform dental screening exam before initiating bisphosphonates to reduce risk of medication-related osteonecrosis of the jaw 1, 3

Alternative Therapies (in order of preference if oral bisphosphonates not tolerated)

1. IV bisphosphonates 1, 2, 3
2. Teriparatide (anabolic agent for high-risk patients) 1, 2, 3, 5
3. Denosumab 1, 2, 3
4. Raloxifene (SERM) 1, 2, 3

When to Consider Anabolic Agents First

• T-score below -2.0 with additional risk factors 3
• Presence of vertebral fractures (significantly increases future fracture risk) 3
• Very high-risk patients where anabolic therapy may be initial option 6
• Note: Teriparatide caused osteosarcoma in rats; inform patients though no increased risk observed in humans 5

Special Populations

Glucocorticoid Users

• Consider bone-modifying agents for long-term therapy, particularly >7.5 mg/day prednisone 1
• Reassess clinical fracture risk every 12 months 1, 2, 3
• Pitfall: Only 5-62% of patients on glucocorticoids receive appropriate preventive therapies—adherence is critically poor 1, 2, 3

Cancer Survivors

• Baseline risks plus treatment-related bone loss warrant earlier intervention 1, 3
• Bisphosphonates or denosumab are preferred agents 3

Chronic Liver Disease

• Obtain BMD testing 3
• Assess for vitamin D deficiency, thyroid function, hypogonadism 1
• Avoid anabolic steroids 3

Monitoring

• Repeat DXA every 2 years to monitor treatment response (not more frequently than annually) 1, 2, 3
• Reassess medication adherence regularly—non-adherence is common and reduces effectiveness 1
• When T-scores improve on bone-modifying agents, consider discontinuation with periodic DXA follow-up 3

Critical Pitfalls to Avoid

• Do not treat based on T-score alone—the number needed to treat in osteopenia (NNT >100) is much higher than in osteoporosis (NNT 10-20) 7
• Do not ignore secondary causes of osteopenia that require specific treatment 1, 2, 3
• Do not overlook poor adherence—this is the most common reason for treatment failure 1, 2, 3
• Do not forget dental screening before bisphosphonates 1, 3
• Do not use bisphosphonates indefinitely—risk of severe adverse effects increases with prolonged use; balance is most favorable when fracture risk is high 1