What are the treatment options for osteopenia?

Osteopenia Treatment

Treatment for osteopenia should be based on fracture risk assessment using the FRAX tool, with pharmacological therapy reserved for patients with 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%, while all patients should receive lifestyle modifications and adequate calcium/vitamin D supplementation. 1, 2, 3

Risk Stratification First

Calculate fracture risk using FRAX before deciding on treatment intensity, as this incorporates both BMD and clinical risk factors to determine overall fracture probability. 1, 3

High-Risk Features Warranting Treatment Consideration:

• T-score below -2.0 with additional risk factors 1
• Presence of vertebral fractures (significantly increases future fracture risk) 1
• Oral glucocorticoid use (adjust FRAX by 1.15 for major fracture risk and 1.2 for hip fracture risk if prednisone >7.5 mg/day) 3
• History of fragility fracture (indicates severe osteoporosis and warrants treatment without needing BMD measurement) 1
• Hypogonadism, early maternal hip fracture, low BMI, height loss 1

Non-Pharmacological Interventions (For ALL Patients)

Calcium and Vitamin D:

• 1,000 mg calcium daily for ages 19-50; 1,200 mg daily for ages 51+ 1, 2, 3
• 600 IU vitamin D 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 Program:

• At least 30 minutes of moderate weight-bearing exercise daily 1
• Muscle-strengthening exercises to improve bone density 1, 2, 3
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 1, 2, 3

Lifestyle Modifications:

• Smoking cessation 1, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 3
• Maintain healthy body weight (low BMI is an independent risk factor) 1

Fall Prevention:

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

Pharmacological Treatment Algorithm

Indications for Drug Therapy:

Start pharmacological treatment when FRAX shows:

• 10-year hip fracture risk ≥3%, OR 1, 2, 3
• 10-year major osteoporotic fracture risk ≥20% 1, 2, 3

First-Line Therapy:

Oral bisphosphonates (alendronate) are the first-line choice due to proven safety, cost-effectiveness, and efficacy in reducing fracture risk. 1, 3, 4

Alternative Therapies (in order of consideration):

1. IV bisphosphonates - for patients who cannot tolerate oral formulations 1
2. Denosumab - for patients who cannot tolerate bisphosphonates or are at high fracture risk 1, 2, 3
3. Teriparatide - anabolic agent for high-risk patients or those who have failed antiresorptive therapy 1, 4
4. Selective estrogen receptor modulators (SERMs) - alternative option 1, 3

Special Population Considerations

Cancer Survivors:

• Cancer treatments accelerate bone loss, especially those causing hypogonadism 1, 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 mineral agents to reduce osteonecrosis of the jaw risk 1

Glucocorticoid Users:

• Reassess clinical fracture risk every 12 months 1, 3
• Adjust FRAX calculations as noted above 3
• Note: Only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies - don't miss these patients 1, 3

Chronic Liver Disease:

• Measure BMD and supplement with calcium/vitamin D3 1
• Avoid anabolic steroids 1
• Ensure adequate nutrition (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 conduct BMD assessment more than annually 1, 2
• When T-scores improve on treatment, consider discontinuation of bone mineral agents and follow with periodic DXA scans 1

Critical Pitfalls to Avoid

• Failing to identify secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) - always screen for these 1, 3
• Over-treating patients with low fracture risk - use FRAX to guide decisions, not just T-scores alone 3
• Poor medication adherence - counsel patients on importance of compliance 1, 3
• Not considering individual risk-benefit profiles, particularly in patients with comorbidities 1
• Missing high-risk glucocorticoid users who need preventive therapy 1, 3