What are the treatment recommendations for a patient with a Dexascan (Dual-Energy X-ray Absorptiometry) report showing T scores of -1.0 for both the lumbar spine and femoral neck, and -0.5 for the hip?

Management of T-scores -1.0 (Lumbar Spine and Femoral Neck) and -0.5 (Hip)

These T-scores indicate osteopenia (low bone mass), not osteoporosis, and the primary next step is vertebral fracture assessment (VFA) to identify occult vertebral fractures that would change management, followed by evaluation of clinical risk factors to determine if pharmacologic treatment is warranted.

Diagnostic Classification

Your T-scores place you in the osteopenia category (T-score between -1.0 and -2.5), not osteoporosis (T-score ≤ -2.5) 1. According to WHO criteria, osteopenia represents low bone mass with increased fracture risk, but does not automatically require pharmacologic treatment 1, 2.

Critical Next Step: Vertebral Fracture Assessment

You should undergo DXA vertebral fracture assessment (VFA) immediately 1. This is rated as "usually appropriate" (rating 9/9) by the American College of Radiology for patients with T-scores less than -1.0 1.

Why VFA Matters:

• Vertebral fractures are diagnostic of osteoporosis even with osteopenic T-scores 3
• Approximately 38% of patients ≥65 years with vertebral fractures have osteopenia, not osteoporosis, by BMD criteria alone 1
• The presence of vertebral fractures would immediately change your diagnosis to osteoporosis and mandate treatment 1, 3

VFA is Indicated if You Have Any of These:

• Age ≥70 years (women) or ≥80 years (men) 1
• Historical height loss >4 cm 1
• Self-reported prior vertebral fracture 1
• Glucocorticoid use ≥5 mg prednisone daily for ≥3 months 1
• Kyphosis or acute back pain 1

Fracture Risk Assessment

Calculate your 10-year fracture probability using the WHO FRAX tool (available at www.shef.ac.uk/FRAX/) 1. This algorithm combines your BMD with clinical risk factors including:

• Age and sex 1
• Body weight 1
• Prior fracture history 1
• Parental hip fracture 1
• Current smoking 1
• Glucocorticoid use 1
• Rheumatoid arthritis 1
• Secondary osteoporosis causes 1
• Alcohol consumption 1

Treatment Thresholds:

• 10-year hip fracture probability >5%: Treatment warranted 2
• 10-year major osteoporotic fracture probability >20%: Treatment warranted 2

Evaluation for Secondary Causes

All patients with osteopenia should be evaluated for reversible secondary causes of bone loss 1, 3. Common and treatable causes include:

• Vitamin D deficiency (check 25-OH vitamin D level) 1
• Calcium malabsorption 3
• Hyperparathyroidism (check calcium, PTH) 4
• Hyperthyroidism 3
• Hypogonadism/premature menopause 1
• Chronic glucocorticoid therapy 1, 3
• Chronic inflammatory diseases 3
• Malabsorption syndromes 3

Treatment Recommendations

Non-Pharmacologic (Universal Recommendations):

All patients with osteopenia should receive 1:

• Calcium supplementation: At least 1000 mg daily 5
• Vitamin D supplementation: At least 400 IU daily (higher doses if deficient) 5, 1
• Weight-bearing exercise 1
• Fall prevention strategies 1

Pharmacologic Treatment:

Treatment is NOT automatically indicated for osteopenia alone 1, 3. However, pharmacologic therapy should be strongly considered if:

1. VFA reveals vertebral fractures (this changes diagnosis to osteoporosis) 3
2. FRAX shows high fracture risk (>5% hip or >20% major osteoporotic fracture) 2
3. Glucocorticoid-induced osteoporosis: T-score ≤-1.5 warrants treatment 3
4. Prior fragility fracture at any site 1

First-Line Pharmacologic Options (if treatment indicated):

Oral bisphosphonates are first-line therapy 3:

• Alendronate 70 mg weekly (increases BMD 2.8-3.2% at lumbar spine in one year) 6
• Alendronate 35 mg weekly for prevention in postmenopausal women 6

If bisphosphonates are contraindicated or not tolerated, denosumab 60 mg subcutaneously every 6 months is an alternative 5, 3.

Follow-Up Monitoring

Repeat DXA scan in 2-3 years or sooner if clinically indicated 1. Serial monitoring should:

• Use the same DXA machine whenever possible 1
• Compare absolute BMD values (g/cm²), not T-scores 1
• Consider change significant only if it exceeds the least significant change (LSC) of 2.8-5.6% 1

Important Caveats

Measurement Accuracy Concerns:

• Lumbar spine T-scores can be falsely elevated by osteoarthritis, aortic calcification, or vertebral fractures 1
• If you have significant spinal degenerative changes, forearm DXA may be more accurate 7, 4
• In primary hyperparathyroidism, distal forearm T-score is often the worst and identifies additional patients with osteopenia/osteoporosis 4

Age Considerations:

• If you are <65 years old, DEXA is useful to determine if treatment is needed now or can be delayed 3
• If you are ≥65 years old, the vast majority will have T-scores warranting bone protective therapy, especially with glucocorticoid use 3