What treatment is recommended for a patient with a T score of -1.6 and a C score of -0.9 for the left total hip, indicating osteopenia?

Management of Osteopenia with T-score -1.6

For a patient with a T-score of -1.6 (osteopenia) and Z-score of -0.9 (normal for age), begin with non-pharmacological interventions including weight-bearing exercise, calcium supplementation (1000-1200 mg/day), and vitamin D (800-1000 IU/day), while calculating 10-year fracture risk using FRAX to determine if pharmacological therapy is warranted. 1, 2

Understanding Your Bone Density Results

• Your T-score of -1.6 classifies you as having osteopenia (low bone mass), which falls in the WHO-defined range of -1.0 to -2.5 1, 3
• Your Z-score of -0.9 is within normal limits for your age, indicating no secondary cause of bone loss requiring investigation 1
• Critical context: Most osteoporotic fractures actually occur in people with osteopenia rather than osteoporosis, so this diagnosis requires appropriate management 4, 5

Initial Non-Pharmacological Management (Start Here)

• Weight-bearing exercise: Implement a regular regimen to maintain and potentially improve bone density 1, 2
• Calcium intake: Ensure 1000-1200 mg/day through diet or supplements 1, 2
• Vitamin D supplementation: Take 800-1000 IU daily 1, 2
• Lifestyle modifications: Stop smoking and limit alcohol consumption 1, 2

Fracture Risk Assessment (Essential Next Step)

• Calculate your 10-year fracture risk using FRAX (available online at www.sheffield.ac.uk/FRAX) to determine if you need medication 1, 2
• This is crucial because T-score alone does not determine treatment need—the number needed to treat for osteopenia is >100 compared to 10-20 for osteoporosis 4

When Pharmacological Therapy Is Indicated

You should receive medication if you have:

• A personal history of fragility fracture after age 50 1, 2
• OR two or more of these risk factors: 1, 2
  • Family history of hip fracture
  • Current or past smoking
  • BMI <24 kg/m²
  • Oral glucocorticoid use for >6 months

Pharmacological Treatment Options (If Indicated)

First-line therapy: Bisphosphonates 1, 2

• Risedronate 35 mg once weekly or 150 mg once monthly 2
• Ibandronate 150 mg once monthly 2
• Zoledronic acid 5 mg IV every 2 years 1, 2

Alternative option:

• Denosumab 60 mg subcutaneously every 6 months, particularly if you cannot tolerate bisphosphonates 1, 2
• Warning: Never discontinue denosumab without transitioning to another antiresorptive agent due to risk of rebound bone loss 2

Monitoring Strategy

• Repeat BMD measurement in 1-2 years to assess for progression 1, 2
• Critical: Use the same DXA facility, machine, software, and positioning for accurate comparison 1, 2
• A significant change in BMD is considered ≥1.1% 2

Common Pitfalls to Avoid

• Do not start medication based on T-score alone—many patients with osteopenia do not need pharmacological treatment 4, 5
• Do not ignore calcium and vitamin D deficiency before considering pharmacologic therapy 2
• Do not focus solely on BMD—fracture risk is a continuum, and overall risk assessment is essential 1
• If you are premenopausal or a man under 50, Z-scores (not T-scores) should guide diagnosis 1, 2

Special Consideration for Your Hip Measurement

• Your measurement was taken at the total hip, which is an appropriate site for BMD assessment 6
• Lumbar spine measurements may be artificially elevated by degenerative changes, potentially masking true bone loss 2