What are the treatment options for osteopenia?

Osteopenia Treatment

For osteopenia, treatment decisions should be based on fracture risk assessment using FRAX, with pharmacological therapy initiated when 10-year hip fracture risk is ≥3% or major osteoporotic fracture risk is ≥20%, using oral bisphosphonates (such as alendronate) as first-line therapy. 1, 2

Risk Assessment and Treatment Thresholds

All patients with osteopenia require fracture risk calculation using the FRAX tool, which incorporates BMD and clinical risk factors to determine overall fracture risk 1, 2.

Pharmacological treatment thresholds:

• 10-year hip fracture risk ≥3% 3, 1, 2
• 10-year major osteoporotic fracture risk ≥20% 3, 1, 2
• T-score below -2.0 with additional risk factors 1
• Presence of vertebral fractures (significantly increases future fracture risk) 1

If fracture risk does not meet these thresholds, defer bone-modifying agents and repeat DEXA in 2 years (or 1 year if medically indicated) 3.

Non-Pharmacological Interventions (All Patients)

These interventions should be implemented for all patients with osteopenia, regardless of whether pharmacological therapy is initiated 3, 1, 2:

Calcium and Vitamin D supplementation:

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

Exercise and fall prevention:

• Regular weight-bearing and muscle-strengthening exercises (at least 30 minutes of moderate activity daily) 1, 2
• Balance training exercises (tai chi, physical therapy, dancing) to reduce fall risk 1, 2
• Fall prevention strategies including vision/hearing checks, medication review, and home safety assessment 1

Lifestyle modifications:

• Tobacco cessation 3, 1
• Limit alcohol consumption to 1-2 drinks per day maximum 1
• Maintain weight in recommended range 1

Pharmacological Treatment

First-line therapy: Oral bisphosphonates (alendronate) 1, 2, 4

• Preferred due to safety, cost, and efficacy profile 1
• Alendronate inhibits osteoclast activity, reduces bone resorption, and has demonstrated anti-fracture efficacy at vertebral and non-vertebral sites including the hip 5
• Reduces fracture risk by approximately 50% 6

Critical administration instructions to prevent esophageal complications 5:

• Take with full glass (6-8 ounces) of water
• Remain upright (do not lie down) for at least 30 minutes after administration
• Take on empty stomach, first thing in morning
• Failure to follow these instructions increases risk of severe esophageal adverse events 5

Alternative pharmacological options:

• IV bisphosphonates: For patients who cannot tolerate oral bisphosphonates 1
• Denosumab: For patients at high fracture risk or who cannot tolerate bisphosphonates 1, 2
• Teriparatide: Anabolic agent for high-risk patients, may be considered as initial therapy in very high-risk patients 1, 4
• Selective estrogen receptor modulators (SERMs): Alternative option 1

Special Populations

Cancer survivors:

• Cancer treatments (particularly those causing hypogonadism such as GnRH agonists, aromatase inhibitors, anti-androgens) accelerate bone loss 3, 1, 2
• For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred agents 3, 1, 2
• Perform dental screening exam before initiating bone-modifying agents to reduce risk of medication-related osteonecrosis of the jaw 1

Glucocorticoid users:

• Adjust FRAX calculation by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 if prednisone dose >7.5 mg/day 1
• Reassess fracture risk every 12 months 1
• Ensure adequate calcium and vitamin D intake (especially important in this population as glucocorticoids decrease calcium absorption) 5

Chronic liver disease:

• Perform BMD measurement 1
• Ensure adequate nutrition (low BMI is independent risk factor) 1
• Supplement with calcium and vitamin D3 1
• Avoid anabolic steroids 1

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 3, 1, 2
• BMD assessment should not be conducted more than annually 3, 1, 2
• When T-scores improve on treatment, consider discontinuation of bone-modifying agent and follow with periodic DEXA scans 1

Critical Pitfalls to Avoid

Before initiating bisphosphonates:

• Correct hypocalcemia before starting therapy (contraindication) 5
• Treat vitamin D deficiency 5
• Ensure creatinine clearance ≥35 mL/min (bisphosphonates not recommended below this threshold) 5
• Perform dental screening to reduce ONJ risk 1

Common treatment errors:

• Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 1
• Poor adherence to preventive therapies (only 5-62% of at-risk patients receive appropriate preventive therapies) 1
• Not considering individual risk-benefit profile, particularly in patients with comorbidities 1
• Inadequate patient education on proper bisphosphonate administration technique 5

Bisphosphonate-specific warnings:

• Osteonecrosis of the jaw (ONJ): Risk increases with duration of exposure; consider discontinuation before invasive dental procedures based on individual benefit/risk assessment 5
• Atypical femoral fractures: Evaluate any patient with thigh or groin pain for incomplete femur fracture; assess contralateral limb; consider interrupting therapy 5
• Severe musculoskeletal pain: May occur (one day to several months after starting); discontinue if severe symptoms develop 5