What are the treatment options for osteopenia?

Osteopenia Treatment

For most patients with osteopenia, treatment begins with non-pharmacological interventions (calcium, vitamin D, exercise, lifestyle modifications), and pharmacological therapy is reserved only for those with high fracture risk as determined by FRAX calculation showing 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%. 1, 2, 3

Risk Stratification First

Before deciding on treatment, calculate fracture risk using the FRAX tool, which incorporates both bone mineral density (BMD) and clinical risk factors to determine overall fracture probability. 1, 3 This is the critical first step that determines whether you proceed with lifestyle measures alone or add pharmacological therapy.

Key thresholds for pharmacological treatment: 1, 2, 3

• 10-year hip fracture risk ≥3%, OR
• 10-year major osteoporotic fracture risk ≥20%

Additional treatment considerations: 1, 3

• T-score below -2.0 with additional risk factors warrants strong consideration for treatment
• Presence of vertebral fractures significantly increases future fracture risk and warrants treatment regardless of BMD
• For patients on glucocorticoids >7.5 mg/day prednisone, adjust fracture risk upward by multiplying by 1.15 for major osteoporotic fracture and 1.2 for hip fracture 1, 3

Non-Pharmacological Interventions (For All Patients)

Calcium and Vitamin D Supplementation

• Calcium: 1,000 mg daily for ages 19-50; 1,200 mg daily for ages 51 and older 1, 2, 3
• Vitamin D: 600 IU daily for ages 19-70; 800 IU daily for ages 71 and older 1, 2, 3
• Target serum vitamin D level ≥20 ng/mL 1, 2
• Correct vitamin D deficiency before initiating any pharmacological therapy 4

Exercise Regimen

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

Lifestyle Modifications

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

Fall Prevention Strategies

• Vision and hearing checks 1
• Medication review to identify drugs that increase fall risk 1
• Home safety assessment 1

Pharmacological Treatment (Only for High-Risk Patients)

First-Line Therapy

Oral bisphosphonates (alendronate) are the first-line pharmacological therapy due to their safety profile, cost-effectiveness, and proven efficacy in reducing fractures. 1, 3 Alendronate works by binding to bone hydroxyapatite and specifically inhibiting osteoclast activity, reducing bone resorption without directly affecting bone formation. 4

Critical administration instructions to prevent esophageal complications: 4

• Take first thing in the morning on an empty stomach
• Swallow with a full glass (6-8 oz) of plain water only—not mineral water, coffee, tea, soda, or juice
• Remain upright (sitting or standing) for at least 30 minutes after taking
• Do not lie down for at least 30 minutes
• Wait at least 30 minutes before eating, drinking anything else, or taking other medications

Contraindications to oral bisphosphonates: 4

• Esophageal abnormalities that delay esophageal emptying
• Inability to stand or sit upright for at least 30 minutes
• Hypocalcemia (must be corrected first)
• Creatinine clearance <35 mL/min 4

Alternative Therapies (When Oral Bisphosphonates Are Not Appropriate)

If oral bisphosphonates cannot be tolerated or are contraindicated: 1, 3

• IV bisphosphonates for patients who cannot tolerate oral formulations
• Denosumab for patients who cannot tolerate bisphosphonates or are at high fracture risk
• Teriparatide (anabolic agent) for very high-risk patients
• Selective estrogen receptor modulators (SERMs) as an alternative option

Special Populations

Cancer Survivors

Cancer treatments, particularly those causing hypogonadism, accelerate bone loss. 1, 2, 3 For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents. 1, 2, 3

Critical caveat: Before initiating any bone mineral agent in cancer survivors, perform a dental screening exam to reduce the risk of medication-related osteonecrosis of the jaw. 1

Glucocorticoid Users

Patients on chronic glucocorticoids require special attention as sustained use commonly causes osteoporosis through inhibited bone formation and increased bone resorption. 4 Reassess clinical fracture risk every 12 months for these patients. 1, 3 Ensure adequate calcium and vitamin D intake as glucocorticoids decrease calcium absorption. 4

Chronic Liver Disease

Patients with chronic liver disease should have BMD measurement and receive calcium and vitamin D3 supplementation. 1 Avoid anabolic steroids in this population. 1

Monitoring

• Repeat DEXA scan every 2 years to monitor bone density and treatment response 1, 2, 3
• Do not conduct BMD assessment more frequently than annually 1, 2
• For patients on glucocorticoids, perform clinical fracture risk reassessment every 12 months 1, 3

Critical Pitfalls to Avoid

Poor adherence is extremely common: Only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies. 1, 3 Emphasize the importance of compliance with both non-pharmacological and pharmacological interventions.

Failing to identify secondary causes: Always screen for and treat vitamin D deficiency, hypogonadism, alcoholism, and glucocorticoid exposure before attributing bone loss to primary osteopenia. 1, 3

Over-treating low-risk patients: Do not initiate pharmacological therapy in patients who do not meet FRAX thresholds, as this exposes them to potential side effects without proven benefit. 3

Improper bisphosphonate administration: Esophageal complications occur when patients lie down after taking oral bisphosphonates, fail to take with a full glass of water, or continue taking despite esophageal symptoms. 4 Ensure patients understand and can comply with dosing instructions; if mental disability prevents compliance, use only under appropriate supervision. 4

Ignoring serious adverse effects: Be vigilant for severe bone/joint/muscle pain, osteonecrosis of the jaw (especially with invasive dental procedures), and atypical femoral fractures (prodromal thigh pain may precede complete fracture by weeks to months). 4 Discontinue bisphosphonates if severe symptoms develop.