What are the treatment options for osteopenia?

Treatment Options for Osteopenia

For osteopenia, treatment decisions should be based on fracture risk assessment using the FRAX tool, with pharmacological therapy (oral bisphosphonates as first-line) recommended when 10-year hip fracture risk is ≥3% or major osteoporotic fracture risk is ≥20%, while all patients require calcium, vitamin D, and weight-bearing exercise regardless of fracture risk. 1

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 This is critical because osteopenia (T-score -1.0 to -2.5) represents a wide spectrum of risk—most fractures actually occur in osteopenic individuals simply because they outnumber those with osteoporosis. 2

Treatment thresholds:

• Pharmacological treatment indicated when FRAX shows 10-year hip fracture risk ≥3% OR 10-year major osteoporotic fracture risk ≥20%. 1, 3
• Strongly consider treatment if T-score is below -2.0, especially with additional risk factors. 1
• Immediate treatment warranted if vertebral fractures are present, as this significantly increases future fracture risk. 1

Key risk factors that lower treatment threshold:

• Oral glucocorticoid use (especially >7.5 mg/day prednisone)
• Hypogonadism
• Height loss
• Early maternal hip fracture
• Low body mass index
• Cancer treatments causing hypogonadism 1

Non-Pharmacological Interventions (Universal for All Patients)

Calcium and Vitamin D supplementation:

• Ages 19-50: 1,000 mg calcium daily
• Ages 51+: 1,200 mg calcium daily
• Ages 19-70: 600 IU vitamin D daily
• Ages 71+: 800 IU vitamin D daily
• Target serum vitamin D level ≥20 ng/mL 1, 3

Exercise regimen:

• Weight-bearing exercises (walking, jogging) improve hip and spine BMD 1, 4
• Muscle-strengthening/resistance exercises increase spine BMD 4
• Walking 3-5 miles per week can improve bone density 5
• Aim for at least 30 minutes of moderate physical activity daily 1
• Balance training (tai chi, physical therapy, dancing) reduces fall risk 1, 3

Lifestyle modifications:

• Smoking cessation (mandatory)
• Limit alcohol to 1-2 drinks per day maximum
• Maintain healthy body weight (low BMI is an independent risk factor) 1

Fall prevention strategies:

• Vision and hearing checks
• Medication review for drugs causing drowsiness or hypotension
• Home safety assessment 1

Pharmacological Treatment (When FRAX Thresholds Met)

First-line therapy: Oral bisphosphonates (alendronate)

• Recommended as first-line due to safety, cost, and efficacy 1
• Reduces fracture risk by approximately 50% 6
• Inhibits osteoclast activity without directly affecting bone formation 7
• Reduces bone resorption markers by 50-70% within 1-6 months 7

Critical administration instructions to prevent esophageal complications:

• Take with full glass (6-8 ounces) of water
• Remain upright (do not lie down) after taking
• Take on empty stomach
• Failure to follow these instructions increases risk of severe esophageal adverse events 7

Alternative pharmacological options:

• IV bisphosphonates: For patients who cannot tolerate oral formulations 1
• Denosumab: For patients who cannot tolerate bisphosphonates or at high fracture risk 1, 3
• Teriparatide: For high-risk patients (anabolic agent) 1
• Selective estrogen receptor modulators (SERMs): Alternative option 1

Special Population Considerations

Cancer survivors:

• Cancer treatments accelerate bone loss, particularly those causing hypogonadism 1, 3
• Bisphosphonates or denosumab are preferred agents 1, 3
• Mandatory dental screening before initiating bone mineral agents to reduce osteonecrosis of jaw risk 1

Glucocorticoid users:

• Adjust fracture risk by multiplying by 1.15 for major osteoporotic fracture and 1.2 for hip fracture if prednisone >7.5 mg/day 1
• Reassess clinical fracture risk every 12 months 1
• Ensure adequate calcium and vitamin D (especially important in this population) 7
• Consider treatment at lower BMD thresholds than non-glucocorticoid users 6

Chronic liver disease:

• Perform BMD measurement 1
• Supplement with calcium and vitamin D3 1
• Avoid anabolic steroids 1

Monitoring Strategy

• Repeat DEXA every 2 years to monitor bone density and treatment response 1, 3
• Do not perform BMD assessment more frequently than annually 1, 3
• When T-scores improve on treatment, consider discontinuation of bone mineral agents and follow with periodic DXA scans 1

Critical Pitfalls to Avoid

Common errors in osteopenia management:

• Failing to identify and treat secondary causes (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 1
• Poor adherence to preventive therapies—only 5-62% of patients on glucocorticoid therapy receive appropriate prevention 1
• Not correcting hypocalcemia before initiating bisphosphonates (contraindicated) 7
• Prescribing bisphosphonates to patients with creatinine clearance <35 mL/min (not recommended) 7
• Inadequate patient education about proper bisphosphonate administration, leading to esophageal complications 7

Serious adverse events to monitor:

• Osteonecrosis of the jaw: Risk increases with duration of bisphosphonate exposure; perform dental screening before initiating therapy, especially in cancer patients 1, 7
• Atypical femoral fractures: Patients reporting thigh or groin pain require evaluation for incomplete femur fracture; consider interrupting bisphosphonate therapy 7
• Severe musculoskeletal pain: May occur from one day to several months after starting; discontinue if severe symptoms develop 7