What are the treatment options for osteopenia?

Osteopenia Treatment: Risk-Stratified Approach

Most patients with osteopenia do not require pharmacological treatment and should focus on non-pharmacological interventions, unless FRAX assessment shows a 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%, in which case oral bisphosphonates are first-line therapy. 1, 2, 3

Step 1: Calculate Fracture Risk Using FRAX

• Use the FRAX tool to incorporate BMD and clinical risk factors (age, prior fracture, parental hip fracture, smoking, glucocorticoid use, rheumatoid arthritis, secondary osteoporosis, alcohol intake) to determine 10-year fracture probability 1, 3
• Pharmacological treatment thresholds:
  • 10-year hip fracture risk ≥3% OR
  • 10-year major osteoporotic fracture risk ≥20% 1, 2, 3
• Special adjustment for glucocorticoid users: Multiply major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 if prednisone dose >7.5 mg/day 1, 3
• Consider treatment strongly if T-score <-2.0 with additional risk factors (even if FRAX thresholds not met) 1, 3

Step 2: Non-Pharmacological Interventions (All Patients)

Calcium and Vitamin D Supplementation

• Calcium: 1,000 mg daily for ages 19-50; 1,200 mg daily for ages 51+ 1, 2, 3
• Vitamin D: 600 IU daily for ages 19-70; 800 IU daily for ages 71+ 1, 2, 3
• Target serum vitamin D level ≥20 ng/mL 1, 2

Exercise Program

• Weight-bearing and muscle-strengthening exercises to improve bone density 1, 2, 3
• Minimum 30 minutes of moderate physical activity daily 1
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 1, 2, 3

Lifestyle Modifications

• Smoking cessation (mandatory) 1, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 3
• Maintain healthy body weight (low BMI is an independent risk factor) 1

Fall Prevention

• Vision and hearing checks 1, 3
• Medication review (identify drugs increasing fall risk) 1, 3
• Home safety assessment (remove tripping hazards, improve lighting) 1, 3

Step 3: Pharmacological Treatment (High-Risk Patients Only)

First-Line: Oral Bisphosphonates

• Alendronate is first-line therapy due to proven safety, low cost, and efficacy in reducing fractures 1, 3, 4
• Prescribe for patients meeting FRAX thresholds or with T-score <-2.0 plus risk factors 1, 3

Alternative Agents (If Bisphosphonates Not Tolerated or Contraindicated)

• IV bisphosphonates for patients unable to tolerate oral formulations 1
• Denosumab for bisphosphonate intolerance or high fracture risk 1, 2, 3
• Teriparatide (anabolic agent) for very high-risk patients or therapeutic failure 1, 4
• Selective estrogen receptor modulators (SERMs) as alternative option 1, 3

Step 4: Special Population Considerations

Cancer Survivors

• Cancer treatments causing hypogonadism accelerate bone loss 1, 2, 3
• Bisphosphonates or denosumab are preferred agents for cancer survivors with osteopenia plus additional risk factors 1, 2, 3
• Perform dental screening exam before initiating bone mineral agents to reduce osteonecrosis of jaw risk 1

Glucocorticoid Users

• Adjust FRAX calculations upward (multiply by 1.15 for major fracture, 1.2 for hip fracture if prednisone >7.5 mg/day) 1, 3
• Reassess fracture risk every 12 months 1, 3
• Note: Only 5-62% of glucocorticoid users receive appropriate preventive therapy (common pitfall) 1, 3

Chronic Liver Disease

• Measure BMD in all patients with chronic liver disease 1
• Provide calcium and vitamin D3 supplementation 1
• Avoid anabolic steroids 1

Step 5: Monitoring

• Repeat DEXA scan every 2 years to monitor bone density and treatment response 1, 2, 3
• Do not perform BMD assessment more frequently than annually 1, 2
• For glucocorticoid users, reassess clinical fracture risk every 12 months 1, 3
• When T-scores improve on treatment, consider discontinuation and follow with periodic DEXA scans 1

Critical Pitfalls to Avoid

• Do not over-treat low-risk patients with pharmacological therapy (most osteopenia patients do not need medications) 3
• Always screen for secondary causes: vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure, hyperthyroidism 1, 3
• Do not rely on BMD alone—use FRAX to incorporate clinical risk factors 1, 3
• Do not ignore the presence of fragility fractures—this indicates severe osteoporosis requiring treatment regardless of BMD 1
• Address medication adherence proactively—poor adherence is extremely common 1, 3