What treatment is recommended for a patient with osteoporosis, as indicated by a DEXA scan showing low bone density at the lumbar spine (L-L3), hip, and femoral neck?

Management of Osteopenia with Low Hip Bone Density

Based on your DEXA results showing osteopenia at the lumbar spine (T-score -0.5) and hip (T-score -1.8), with femoral neck at -1.1, you should implement comprehensive lifestyle modifications and calcium/vitamin D supplementation, with the decision to initiate pharmacologic therapy dependent on your FRAX score and additional risk factors. 1

Interpretation of Your DEXA Results

• Your T-scores indicate osteopenia (defined as T-score between -1.0 and -2.5), not osteoporosis (which requires T-score ≤ -2.5). 1

• The hip T-score of -1.8 is your lowest measurement and represents the most clinically significant finding, as hip fractures carry the highest morbidity and mortality risk. 2

• None of your measurements meet the diagnostic threshold for osteoporosis, which would require a T-score of -2.5 or lower at any site. 1

Risk Assessment Required Before Treatment Decision

You must calculate your FRAX score (available at www.sheffield.ac.uk/FRAX) to determine your 10-year fracture risk before deciding on pharmacologic treatment. 1

Thresholds for initiating bone-modifying agents:

• 10-year hip fracture risk ≥ 3%, OR 1
• 10-year major osteoporotic fracture risk ≥ 20%, OR 1
• Significant osteopenia (which you have) PLUS additional risk factors such as: 1
  • Prior fragility fracture
  • History of parental hip fracture after age 50
  • Current glucocorticoid use (≥7.5 mg prednisone daily for ≥3 months)
  • Active cancer treatment causing bone loss
  • Low body weight (<127 lb or 57.6 kg)
  • Current smoking
  • Excessive alcohol consumption

Universal Recommendations (Regardless of Treatment Decision)

All patients with osteopenia should receive the following non-pharmacologic interventions: 1

Calcium and Vitamin D Supplementation:

• Calcium: 1000-1200 mg daily (dietary intake plus supplementation if needed) 1, 2
• Vitamin D: 800-1000 IU daily 1
• These supplements increase bone density and are foundational to any osteoporosis management plan. 1

Lifestyle Modifications:

• Weight-bearing exercises (walking, jogging, dancing) and resistance training (squats, push-ups, weight lifting) to stimulate bone formation 1, 2
• Balance exercises (heel raises, standing on one foot, tai chi) to reduce fall risk 2
• Smoking cessation (smoking accelerates bone loss) 1
• Limit alcohol consumption (excessive intake increases fracture risk) 1
• Fall prevention strategies including home safety assessment, vision correction, and medication review 1

Pharmacologic Treatment Decision Algorithm

If FRAX Score is BELOW Treatment Thresholds AND No High-Risk Features:

• Defer bone-modifying agents 1
• Continue lifestyle modifications and calcium/vitamin D supplementation 1
• Repeat DEXA scan in 2 years (or in 1 year if you have conditions causing accelerated bone loss such as glucocorticoid therapy or cancer treatment) 1

If FRAX Score EXCEEDS Treatment Thresholds OR You Have High-Risk Features:

Initiate pharmacologic therapy with first-line agents: 1

First-Line Treatment Options:

Oral Bisphosphonates (preferred initial therapy for most patients): 1, 2

• Alendronate 70 mg once weekly OR 5 mg daily 3
• Increases lumbar spine BMD by 2.9-3.2% at one year in osteopenic patients 3
• Prevents bone loss at hip, femoral neck, and total body 3
• Must be taken on empty stomach with full glass of water, remaining upright for 30 minutes 3

Denosumab 60 mg subcutaneously every 6 months (if bisphosphonates contraindicated or not tolerated): 1, 4

• Increases lumbar spine BMD by 3.8-4.4% at one year 4
• Particularly useful in patients with renal impairment or gastrointestinal intolerance to bisphosphonates 4
• Critical caveat: Stopping denosumab causes rapid bone loss and rebound fracture risk; requires transition to bisphosphonate if discontinued 4

Monitoring After Treatment Initiation

• Repeat DEXA scan 1-2 years after starting treatment to assess response 1
• Use the same DXA machine for accurate comparison 5
• Compare absolute BMD values (not just T-scores) between scans to assess treatment efficacy 5
• Continue calcium, vitamin D, and lifestyle modifications indefinitely 1

Important Clinical Caveats

• If you are a premenopausal woman or man under age 50, secondary causes of bone loss should be investigated (thyroid disease, celiac disease, vitamin D deficiency, hyperparathyroidism, hypogonadism) before attributing low BMD to primary osteoporosis. 5

• If you are taking glucocorticoids (≥7.5 mg prednisone daily or equivalent), treatment thresholds are lower and pharmacologic therapy should be strongly considered even with osteopenia. 1, 4

• If you have inflammatory bowel disease, rheumatoid arthritis, chronic liver or kidney disease, you have additional risk factors that may warrant earlier treatment despite osteopenia-range T-scores. 1, 2

• Your hip T-score of -1.8 places you closer to the osteoporosis threshold than your spine measurement, making fracture risk assessment particularly important. 2