What is the treatment for osteopenia?

Treatment of Osteopenia

For patients with osteopenia, treatment should be initiated based on fracture risk assessment using the FRAX tool, with pharmacological therapy recommended when 10-year hip fracture risk is ≥3% or major osteoporotic fracture risk is ≥20%, using oral bisphosphonates as first-line therapy. 1, 2

Risk Assessment and Treatment Thresholds

• Calculate fracture risk using the FRAX tool rather than relying solely on bone mineral density T-scores to guide treatment decisions 1, 2
• Initiate pharmacological treatment when FRAX shows 10-year hip fracture risk ≥3% OR 10-year major osteoporotic fracture risk ≥20% 1, 2
• For patients on glucocorticoids >7.5 mg/day prednisone, adjust FRAX calculation by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 1, 2
• Identify and treat secondary causes including vitamin D deficiency, hypogonadism, alcoholism, and glucocorticoid exposure before initiating therapy 1, 2

Non-Pharmacological Management (All Patients)

• Optimize calcium intake to 1,000-1,200 mg/day through diet or supplements 3, 1, 2
• Ensure vitamin D intake of 600-800 IU/day with target serum level ≥20 ng/mL 3, 1, 2
• Prescribe regular weight-bearing and resistance training exercises to improve bone density 3, 1, 2
• Implement lifestyle modifications: maintain healthy weight, smoking cessation, and limit alcohol to 1-2 drinks per day 1, 2
• Institute fall prevention strategies for all osteopenic patients 1

Pharmacological Treatment Algorithm

First-Line Therapy

• Oral bisphosphonates (specifically alendronate) are recommended as first-line therapy due to safety, cost, and efficacy 1, 2
• Alendronate inhibits osteoclast activity, reduces bone resorption by approximately 50-70%, and decreases bone formation markers by 40-50% within 3-6 months 4
• Low-quality evidence shows bisphosphonates in women with advanced osteopenia may reduce fracture risk 1

Alternative Therapies (If Oral Bisphosphonates Not Appropriate)

The American College of Rheumatology recommends the following alternatives in order of preference: 1, 2

1. IV bisphosphonates (first alternative)
2. Teriparatide (anabolic agent that increases lumbar spine BMD by 7.2% at 18 months) 5
3. Denosumab (anti-resorptive)
4. Raloxifene (for women who cannot tolerate first-line agents) 6

Special Populations

• Glucocorticoid-induced osteopenia: Consider bone-modifying agents particularly at prednisone doses >7.5 mg/day 1
• Cancer survivors: Consider earlier intervention due to baseline risks plus treatment-related bone loss 1
• Chronic liver disease patients: Perform additional assessment for vitamin D deficiency, thyroid function, and hypogonadism 1

Monitoring and Follow-Up

• Perform repeat DXA every 2 years to monitor treatment response, but not more frequently than annually 1, 2
• Reassess clinical fracture risk every 12 months, especially for glucocorticoid users 1, 2
• Assess medication adherence regularly, as non-adherence is common (only 5-62% of at-risk patients receive appropriate therapy) 2

Critical Safety Considerations

• Before initiating bisphosphonates: Perform dental screening exam to reduce risk of medication-related osteonecrosis of the jaw 1
• Bisphosphonate duration: Reassess need after 5 years; risk of severe adverse effects increases with prolonged use, so benefits most favorable when fracture risk is high 1
• Denosumab discontinuation: Never interrupt denosumab without switching to another therapy, as post-treatment bone loss progresses rapidly 6
• Teriparatide warning: Caused osteosarcoma in rats during drug testing, though no increased risk observed in adult humans; should not be used in children or young adults with growing bones 5

Common Pitfalls to Avoid

• Do not rely solely on T-scores for treatment decisions; always calculate FRAX scores 1, 2
• Do not assume adequate calcium/vitamin D intake without assessment; deficiency is common and must be corrected 1, 2
• Do not stop denosumab abruptly; this causes rapid bone loss requiring transition to alternative therapy 6
• FRAX has not been validated in HIV-infected persons and may underestimate fracture risk in this population 1
• Adherence to bone health therapies is poor; implement strategies to improve compliance 2