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 should only be initiated when FRAX calculation shows a 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 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 risk factors that warrant heightened concern include: 1

• Oral glucocorticoid use (especially >7.5 mg/day prednisone)
• Hypogonadism
• Height loss or x-ray evidence of osteopenia
• Early maternal hip fracture
• Low body mass index
• Presence of fragility fracture (indicates severe osteoporosis requiring immediate treatment)

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

Non-Pharmacological Interventions (Universal for All Patients)

Calcium and Vitamin D Supplementation

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

Exercise Prescription

• 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 weight in recommended range (low BMI is an independent risk factor) 1, 3

Fall Prevention Strategies

• Vision and hearing checks 1, 3
• Medication review (minimize drugs causing drowsiness or hypotension) 1, 3
• Home safety assessment 1, 3

Pharmacological Treatment (Risk-Based Thresholds)

When to Initiate Pharmacotherapy

Start medication when any of the following apply: 1, 2, 3

• FRAX shows 10-year hip fracture risk ≥3%
• FRAX shows 10-year major osteoporotic fracture risk ≥20%
• T-score below -2.0 with additional risk factors
• Presence of vertebral fractures (significantly increases future fracture risk)

First-Line Therapy

Oral bisphosphonates (alendronate) are the first-line pharmacological treatment due to superior safety profile, cost-effectiveness, and proven efficacy in reducing fractures. 1, 3, 4 Alendronate works by binding to bone hydroxyapatite and inhibiting osteoclast activity, reducing bone resorption without directly affecting bone formation. 5 It decreases urinary markers of bone resorption by approximately 50-70% and reduces fracture risk by about 50%. 5, 6

Alternative Therapies (When Bisphosphonates Inappropriate)

If oral bisphosphonates cannot be tolerated or are contraindicated, consider in order: 1, 2, 3

1. IV bisphosphonates (for GI intolerance to oral formulations)
2. Denosumab (for high-risk patients or bisphosphonate intolerance)
3. Teriparatide (anabolic agent for very high-risk patients or treatment failures) 1, 7
4. Selective estrogen receptor modulators (SERMs) 1, 3

Important caveat for teriparatide: This anabolic agent caused osteosarcoma in rat studies, though no increased risk has been observed in humans. 7 It should be reserved for high-risk patients who have failed antiresorptive therapy or cannot tolerate other options. 4

Special Population Considerations

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 safety measure: Perform dental screening exam before initiating bone mineral agents to reduce risk of medication-related osteonecrosis of the jaw. 1

Glucocorticoid Users

These patients are at especially high risk and may sustain fractures at higher BMD than non-users. 1, 3, 6 Reassess clinical fracture risk every 12 months. 1, 3 Pitfall alert: Only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies—don't miss these high-risk patients. 1, 3

Chronic Liver Disease

Measure BMD and supplement with calcium and vitamin D3. 1 Avoid anabolic steroids in this population. 1 Ensure adequate nutrition as low BMI is an independent risk factor. 1

Monitoring Strategy

• Repeat DEXA every 2 years to monitor bone density and treatment response 1, 2, 3
• Do not perform BMD assessment more frequently than annually 1, 2
• For patients on pharmacological treatment, the American College of Physicians recommends against bone density monitoring during the initial 5-year treatment period 3
• When T-scores improve on treatment, consider discontinuation of bone mineral agents and follow with periodic DXA scans 1

Critical Pitfalls to Avoid

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

2. Over-treating low-risk patients: Don't reflexively prescribe pharmacotherapy for every T-score between -1 and -2.5. Use FRAX to guide decisions. 3

3. Under-treating glucocorticoid users: This population has disproportionately poor treatment rates despite very high fracture risk. 1, 3

4. Ignoring individual risk-benefit profiles: Consider comorbidities and medication-specific risks (e.g., osteonecrosis of jaw with bisphosphonates/denosumab, osteosarcoma concern with teriparatide) when selecting agents. 1, 7