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 elevated fracture risk—specifically when FRAX shows ≥3% 10-year hip fracture risk or ≥20% major osteoporotic fracture risk. 1, 2, 3

Risk Stratification First

Before considering any treatment, calculate fracture risk using the FRAX tool, which incorporates both BMD and clinical risk factors to determine overall fracture probability. 1, 3 This is the critical decision point that determines whether you proceed with lifestyle measures alone or add pharmacological therapy.

Key FRAX thresholds for pharmacological treatment: 1, 2, 3

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

Special adjustment for glucocorticoid users: If the patient takes prednisone >7.5 mg/day, multiply the FRAX major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2. 1, 3

Additional high-risk indicators warranting treatment consideration: 1, 3

• T-score below -2.0 with additional risk factors
• Presence of vertebral fractures (indicates severe osteoporosis regardless of BMD)
• Fragility fracture history

Non-Pharmacological Interventions (For All Patients)

These foundational measures apply to every patient with osteopenia, regardless of fracture risk: 1, 2, 3

Calcium supplementation: 1, 2, 3

• Ages 19-50: 1,000 mg daily
• Ages 51+: 1,200 mg daily

Vitamin D supplementation: 1, 2, 3

• Ages 19-70: 600 IU daily
• Ages 71+: 800 IU daily
• Target serum level: ≥20 ng/mL

Exercise regimen: 1, 2, 3

• Weight-bearing exercises (walking, jogging, dancing)
• Muscle-strengthening exercises
• Balance training (tai chi, physical therapy) to reduce fall risk
• Minimum 30 minutes of moderate physical activity daily

Lifestyle modifications: 1, 3

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

Fall prevention strategies: 1, 3

• Vision and hearing assessments
• Medication review (identify drugs increasing fall risk)
• Home safety evaluation

Pharmacological Treatment (Only for High-Risk Patients)

First-line therapy: Oral bisphosphonates (alendronate) 1, 2, 3

Oral bisphosphonates are the initial pharmacological choice due to their proven safety profile, cost-effectiveness, and efficacy in reducing fracture risk. 1, 3 Alendronate works by binding to bone hydroxyapatite and inhibiting osteoclast activity, reducing bone resorption without directly affecting bone formation. 4 This leads to progressive gains in bone mass as bone formation exceeds resorption at remodeling sites. 4

Critical administration instructions to prevent esophageal complications: 4

• Take with full glass (6-8 ounces) of water
• Remain upright (sitting or standing) for at least 30 minutes after dosing
• Take on empty stomach, first thing in morning
• Do not lie down after taking medication

Alternative therapies (if bisphosphonates contraindicated or not tolerated): 1, 2, 3

• IV bisphosphonates: For patients unable to tolerate oral formulations
• Denosumab: For high fracture risk or bisphosphonate intolerance
• Teriparatide: Anabolic agent reserved for very high-risk patients (consider as initial therapy in this subset) 1, 3, 5
• Selective estrogen receptor modulators (SERMs): Alternative option

Special Populations Requiring Tailored Approaches

Cancer survivors: 1, 2, 3

• Cancer treatments (especially those causing hypogonadism) accelerate bone loss
• Preferred agents: bisphosphonates or denosumab
• Mandatory dental screening before initiating bone mineral agents to reduce osteonecrosis of the jaw risk

Glucocorticoid users: 1, 3

• Reassess clinical fracture risk every 12 months
• Apply FRAX adjustment factors (multiply by 1.15 for major osteoporotic fracture, 1.2 for hip fracture if prednisone >7.5 mg/day)
• Note: Only 5-62% of glucocorticoid users receive appropriate preventive therapy—don't miss these patients

Chronic liver disease patients: 1

• Obtain BMD measurement
• Ensure adequate nutrition (low BMI is independent risk factor)
• Supplement with calcium and vitamin D3
• Avoid anabolic steroids

Liver transplant recipients: 2, 3

• Regular weight-bearing exercise
• Calcium and vitamin D supplementation

Monitoring Strategy

DEXA scan frequency: 1, 2, 3

• Repeat every 2 years to monitor bone density and treatment response
• Do NOT perform more frequently than annually (not clinically useful)
• Important caveat: The American College of Physicians recommends against bone density monitoring during the first 5 years of pharmacological treatment 3

For glucocorticoid users: Clinical fracture risk reassessment every 12 months. 1, 3

When to consider discontinuing bone mineral agents: When T-scores improve, consider stopping and follow with periodic DEXA scans. 1

Critical Pitfalls to Avoid

Poor medication adherence: This is extremely common—actively address barriers to compliance at every visit. 1, 3

Missing secondary causes of osteopenia: 1, 3

• Vitamin D deficiency
• Hypogonadism
• Alcoholism
• Glucocorticoid exposure

Over-treating low-risk patients: Do not initiate pharmacological therapy in patients who don't meet FRAX thresholds—this exposes them to medication risks without proven benefit. 3

Improper bisphosphonate administration: Failure to follow dosing instructions (remaining upright, taking with full glass of water) dramatically increases risk of severe esophageal adverse events. 4

Ignoring medication-specific risks: 4, 5

• Bisphosphonates: osteonecrosis of the jaw, atypical femoral fractures, esophageal complications
• Teriparatide: theoretical osteosarcoma risk (seen in rats, not established in humans), hypercalcemia, orthostatic hypotension

Dental neglect in patients on bone mineral agents: Perform dental screening before initiating therapy to prevent osteonecrosis of the jaw. 1