What is the recommended treatment for osteopenia?

Treatment for Osteopenia

Osteopenia treatment should be guided by fracture risk assessment using the FRAX tool, with pharmacological therapy (oral bisphosphonates as first-line) reserved for patients with 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%, while all patients should receive lifestyle modifications, calcium, and vitamin D supplementation. 1, 2

Risk Assessment and Treatment Thresholds

The decision to treat osteopenia pharmacologically depends entirely on fracture risk, not bone density alone:

• Calculate 10-year fracture risk using the FRAX tool, which incorporates BMD and clinical risk factors 1, 2
• Pharmacological treatment is indicated when FRAX shows ≥3% hip fracture risk OR ≥20% major osteoporotic fracture risk 1, 2, 3
• Treatment should be strongly considered when T-score is below -2.0 with additional risk factors 2
• The presence of a vertebral fracture significantly increases future fracture risk and warrants treatment consideration 2

Special FRAX adjustments for glucocorticoid users:

• Multiply major osteoporotic fracture risk by 1.15 if prednisone dose >7.5 mg/day 1, 2
• Multiply hip fracture risk by 1.2 if prednisone dose >7.5 mg/day 1, 2

Non-Pharmacological Management (All Patients)

Every patient with osteopenia requires these interventions regardless of fracture risk:

Calcium and Vitamin D:

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

Exercise:

• Regular weight-bearing exercises (walking, jogging, stair climbing) 1, 2, 3
• Resistance training exercises 1
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 2, 3
• Aim for at least 30 minutes of moderate physical activity daily 2

Lifestyle modifications:

• Smoking cessation 1, 2, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 2
• Maintain healthy body weight (low BMI is an independent risk factor) 1, 2
• Implement fall prevention strategies including vision/hearing checks, medication review, and home safety assessment 1, 2

Pharmacological Treatment

For patients meeting FRAX treatment thresholds:

First-line therapy:

• Oral bisphosphonates (such as alendronate) are the recommended first-line treatment due to safety, cost, and efficacy 1, 2, 3
• Alendronate inhibits osteoclast activity, reduces bone resorption, and allows bone formation to exceed resorption at remodeling sites 4
• Low-quality evidence shows bisphosphonates in women with advanced osteopenia may reduce fracture risk 1
• The fracture reduction benefit is likely similar across all bisphosphonates 1

Alternative agents (if oral bisphosphonates not appropriate):

• IV bisphosphonates 1, 2
• Denosumab (for high-risk patients or bisphosphonate intolerance) 1, 2, 3
• Teriparatide (for high-risk patients) 1, 2
• Raloxifene (selective estrogen receptor modulator) 1, 2

Special Populations Requiring Earlier Intervention

Glucocorticoid users:

• Patients on long-term glucocorticoids, particularly >7.5 mg/day prednisone, should be considered for bone-modifying agents 1
• Reassess clinical fracture risk every 12 months 1, 2
• Common pitfall: Only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 1, 2

Cancer survivors:

• Baseline risks plus treatment-related bone loss warrant earlier intervention 1
• Cancer treatments causing hypogonadism accelerate bone loss 2, 3
• Bisphosphonates or denosumab are preferred agents 2, 3
• Perform dental screening exam before initiating bone-modifying agents to reduce osteonecrosis of jaw risk 1, 2

Chronic liver disease:

• Perform BMD testing 1, 2
• Assess for vitamin D deficiency, thyroid function, and hypogonadism 1
• Provide calcium and vitamin D3 supplementation 2
• Avoid anabolic steroids 2

Monitoring

Treatment response assessment:

• Repeat DXA every 2 years to monitor treatment response 1, 2, 3
• Do not perform BMD assessment more frequently than annually 1, 2, 3
• Assess medication adherence regularly (non-adherence is common and reduces effectiveness) 1
• When T-scores improve, consider discontinuation of bone-modifying agents and follow with periodic DXA scans 2

Critical Pitfalls to Avoid

Before starting treatment:

• Identify and treat secondary causes: vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure 1, 2
• Perform dental screening before bisphosphonates or denosumab 1, 2

During treatment:

• The risk of severe adverse effects increases with prolonged bisphosphonate use, so benefits most favorable when fracture risk is high 1
• FRAX has not been validated in HIV-infected persons and may underestimate fracture risk in this population 1
• Poor adherence is extremely common—address barriers proactively 1, 2