What treatment should be recommended for a patient with osteopenia?

Management of Osteopenia

For patients with osteopenia, treatment decisions should be based on fracture risk assessment using FRAX, not BMD alone—pharmacologic therapy is indicated when 10-year major osteoporotic fracture risk is ≥20% or hip fracture risk is ≥3%, while all patients should optimize calcium (1000-1200 mg/day) and vitamin D (600-800 IU/day) intake along with lifestyle modifications. 1

Risk Stratification is Essential

Osteopenia (T-score between -1.0 and -2.5) affects over 60% of White women older than 64 years, and most fractures actually occur in osteopenic individuals rather than those with osteoporosis due to their greater numbers 2. However, an osteopenic T-score alone does not constitute a treatment imperative 3.

Calculate 10-year fracture risk using the WHO Fracture Risk Assessment Tool (FRAX) to determine who needs pharmacologic intervention 1:

• Treat if 10-year major osteoporotic fracture risk ≥20% 1
• Treat if 10-year hip fracture risk ≥3% 1
• Treat if history of low-trauma/fragility fracture, regardless of FRAX score or BMD 1, 3

Additional High-Risk Features Warranting Treatment Consideration

• History of height loss (evaluate for vertebral fractures with spine radiographs or DXA vertebral fracture assessment) 1
• Parental history of hip fracture 1
• Body weight <127 lb (58 kg) 1
• Medications causing bone loss (especially glucocorticoids) 1
• Chronic diseases affecting bone (inflammatory bowel disease, rheumatoid arthritis, chronic liver/kidney disease) 4

Universal Recommendations for All Osteopenic Patients

Calcium and Vitamin D Supplementation

All patients with osteopenia should receive:

• Calcium: 1000-1200 mg/day (from diet and/or supplements) 1, 5
• Vitamin D: 600-800 IU/day (up to 1000 IU/day in those at risk for deficiency) 1, 5
• Target serum vitamin D level ≥20 ng/mL 1

Patients over age 70, nursing home bound, chronically ill, or with gastrointestinal malabsorption may require higher vitamin D doses 6. For known vitamin D deficiency, use repletion regimens such as ergocalciferol 50,000 IU weekly for 8-12 weeks, then maintenance dosing 1.

Lifestyle Modifications

Implement the following non-pharmacologic interventions 1, 4:

• Weight-bearing exercise: 30 minutes at least 3 days per week (walking, jogging) 1
• Muscle resistance exercises (squats, push-ups) 4
• Balance exercises (heel raises, standing on one foot) to prevent falls 4
• Smoking cessation (strong recommendation) 1
• Limit alcohol intake to 1-2 drinks per day 1
• Maintain healthy body weight 1

Pharmacologic Treatment for High-Risk Osteopenic Patients

First-Line Therapy: Oral Bisphosphonates

For postmenopausal women and men ≥50 years meeting treatment thresholds, oral bisphosphonates are first-line therapy 1, 3. Evidence shows that bisphosphonates cost-effectively reduce fractures in older osteopenic women, with major osteoporotic fracture risks of 10-15% being acceptable indications for treatment with generic bisphosphonates in motivated patients older than 65 years 2.

Options include:

• Alendronate 70 mg weekly 1
• Risedronate 35 mg weekly or 150 mg monthly 1
• Ibandronate 150 mg monthly 1

Alternative Therapies (in order of preference when bisphosphonates inappropriate)

If oral bisphosphonates are contraindicated or not tolerated (e.g., esophageal abnormalities, inability to remain upright 30 minutes, patient preference) 1:

1. IV bisphosphonates (zoledronic acid 5 mg IV annually) 1
2. Raloxifene (60 mg daily) for younger postmenopausal women—good option in this population but note increased risk of venous thromboembolism and hot flashes 1, 6
3. Denosumab for high fracture risk patients 1
4. Teriparatide (anabolic therapy) typically reserved for severe osteoporosis or treatment failures, not routine osteopenia 1, 7, 3

Special Populations

For glucocorticoid-induced osteopenia (patients on ≥7.5 mg/day prednisone for ≥3 months):

• Calcium and vitamin D supplementation is mandatory for all patients on systemic steroids 1
• Consider oral bisphosphonates for moderate-to-high risk patients 1

For premenopausal women and men <50 years:

• Treatment generally not indicated unless history of fragility fracture, Z-score <-2.3, or bone loss ≥10%/year 1
• Focus on correcting secondary causes and optimizing calcium/vitamin D 3, 8

Evaluation for Secondary Causes

All patients with osteopenia warrant evaluation for secondary causes of bone loss 1, 3:

• Vitamin D deficiency (most common—check 25-hydroxyvitamin D level) 1
• Hypogonadism (testosterone in men, estrogen in premenopausal women) 1
• Hyperthyroidism, hyperparathyroidism 1
• Malabsorption syndromes 1
• Medications (glucocorticoids, anticonvulsants, proton pump inhibitors) 1

Common Pitfalls to Avoid

• Do not treat based on T-score alone—osteopenia is a risk factor, not an automatic indication for pharmacologic therapy 2, 3
• Do not use FRAX in patients <50 years—it has not been validated in this population 1
• Do not overlook vertebral fractures—they are often clinically silent but change management 1
• Do not forget to correct vitamin D deficiency before starting bisphosphonates—hypocalcemia risk increases 1
• Do not continue bisphosphonates indefinitely without reassessment—consider drug holidays after 3-5 years in appropriate patients 4

Monitoring

• Repeat DXA every 2-3 years for low-risk osteopenic patients not on treatment 1
• Repeat DXA every 1-2 years for patients on treatment or at higher risk 1
• Reassess fracture risk annually using clinical factors 1