What are the treatment recommendations for osteopenia?

Osteopenia Treatment Recommendations

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

Risk Assessment Framework

Use FRAX calculation to guide all treatment decisions rather than relying solely on T-scores, as the American College of Physicians specifically recommends this approach for osteopenia management. 1, 2, 3

Treatment Thresholds

• Initiate pharmacological therapy when:

  • 10-year hip fracture risk ≥3%, OR 1, 2, 3
  • 10-year major osteoporotic fracture risk ≥20% 1, 2, 3
  • T-score below -2.0 with additional risk factors 2, 3
  • Presence of vertebral fractures (indicates severe osteoporosis regardless of BMD) 2, 4

• For glucocorticoid users: Adjust FRAX scores by multiplying by 1.15 for major osteoporotic fracture risk and 1.2 for hip fracture risk if prednisone dose >7.5 mg/day. 1, 2, 3

Important Context on Fracture Risk

Most osteoporotic fractures actually occur in individuals with osteopenia rather than osteoporosis, simply because osteopenia is far more prevalent—over 60% of White women older than 64 years have osteopenia. 5 However, the number needed to treat is much higher in osteopenia (NNT >100) compared to established osteoporosis (NNT 10-20), which is why risk stratification is critical. 4

Non-Pharmacological Management (Universal for All Patients)

Calcium and Vitamin D

• Calcium: 1,000 mg/day for ages 19-50; 1,200 mg/day for ages 51+ 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 and Lifestyle

• Weight-bearing and resistance training exercises to improve bone density 1, 2, 3
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 2, 3
• Aim for 30 minutes of moderate physical activity daily 2
• Smoking cessation 1, 2, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 2, 3
• Maintain healthy body weight (low BMI is an independent risk factor) 1, 2

Fall Prevention

• Vision and hearing checks 2, 3
• Medication review 2, 3
• Home safety assessment 2, 3

Pharmacological Treatment

First-Line Therapy

Oral bisphosphonates (specifically alendronate) are the recommended first-line pharmacological therapy due to their safety profile, low cost, and proven efficacy in reducing fractures. 1, 2, 3 Alendronate works by binding to bone hydroxyapatite and inhibiting osteoclast activity, reducing bone resorption by approximately 50-70% as measured by urinary markers. 6

Alendronate Administration (Critical for Efficacy and Safety)

• Take with plain water only (orange juice or coffee markedly reduces absorption) 6
• First thing upon arising, at least 30 minutes before any food, beverage, or medication 6
• Swallow with full glass of water (6-8 ounces) to facilitate delivery to stomach 6
• Do not chew or suck the tablet (risk of oropharyngeal ulceration) 6
• Remain upright (do not lie down) for at least 30 minutes and until after first food of the day 6
• Never take at bedtime 6

Alternative Therapies (When Oral Bisphosphonates Not Appropriate)

• IV bisphosphonates 1, 2, 3
• Denosumab (particularly useful for cancer survivors with additional risk factors) 1, 2, 3
• Teriparatide (anabolic agent for high-risk patients; note: caused osteosarcoma in rats but not shown to increase risk in humans) 1, 2, 7
• Selective estrogen receptor modulators (SERMs) 2, 3

When to Consider Anabolic Agents First-Line

Anabolic agents like teriparatide may be considered as initial therapy in very high-risk patients or those with previous vertebral fractures. 8, 9 Teriparatide increases lumbar spine BMD by 7.2%, total hip by 3.6%, and femoral neck by 3.7% in glucocorticoid-induced osteoporosis. 7 However, it must be stored refrigerated at 2-8°C and requires daily subcutaneous injection. 7

Special Populations

Glucocorticoid Users

• Consider bone-modifying agents for long-term use, particularly at doses >7.5 mg/day prednisone 1
• Reassess clinical fracture risk every 12 months 1, 2, 3
• Adjust FRAX calculations as noted above 1, 2, 3
• Common pitfall: Only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies—adherence is poor. 1, 2, 3

Cancer Survivors

• Cancer treatments accelerate bone loss, particularly those causing hypogonadism 2, 3
• Bisphosphonates or denosumab are preferred agents for cancer survivors with osteopenia and additional risk factors 1, 2, 3
• Perform dental screening exam before initiating bone-modifying agents to reduce risk of medication-related osteonecrosis of the jaw 1, 2

Chronic Liver Disease

• Obtain BMD measurement 1, 2
• Assess for vitamin D deficiency, thyroid function, and hypogonadism 1
• Supplement with calcium and vitamin D3 2
• Avoid anabolic steroids 2

Monitoring

• Repeat DXA every 2 years to monitor bone density and treatment response 1, 2, 3
• Do not perform DXA more frequently than annually 2, 3
• The American College of Physicians recommends against bone density monitoring during the 5-year pharmacological treatment period 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

• Do not treat based on T-score alone—most fractures occur in osteopenic individuals, but NNT is high without proper risk stratification. 4, 5
• Do not fail to identify secondary causes: vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure. 1, 2, 3
• Do not over-treat low-risk patients with pharmacological therapy. 3
• Do not ignore proper bisphosphonate administration instructions—failure to follow these increases risk of esophageal problems. 6
• FRAX has not been validated in HIV-infected persons and may underestimate fracture risk in this population. 1