What are the treatment guidelines for osteopenia?

Osteopenia Treatment Guidelines

Risk Assessment and Treatment Thresholds

Pharmacological treatment for osteopenia should be initiated when FRAX calculation shows a 10-year risk of hip fracture ≥3% or major osteoporotic fracture ≥20%, rather than treating based on bone density alone. 1, 2, 3

• Calculate fracture risk using the FRAX tool, which incorporates BMD and clinical risk factors to determine overall fracture risk 1, 3
• For patients on glucocorticoids (>7.5 mg/day prednisone), adjust FRAX by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 1, 2, 3
• Treatment should be strongly considered in patients with BMD T-score below -2.0, particularly with additional risk factors 1
• The presence of a vertebral fracture significantly increases future fracture risk and warrants treatment consideration 1
• Identify and treat secondary causes including vitamin D deficiency, hypogonadism, alcoholism, and glucocorticoid exposure 2, 3

Non-Pharmacological Interventions (Required for All Patients)

• Calcium: 1,000 mg/day for ages 19-50; 1,200 mg/day for ages 51 and older 1, 2, 3
• Vitamin D: 600 IU/day for ages 19-70; 800 IU/day for ages 71 and older, targeting serum level ≥20 ng/mL 1, 2, 3
• Exercise: Regular weight-bearing and muscle-strengthening exercises to improve bone density 1, 2, 3
• Balance training: Tai chi, physical therapy, or dancing to reduce fall risk 1
• Lifestyle modifications: Smoking cessation and limit alcohol to 1-2 drinks per day maximum 1, 2, 3
• Fall prevention: Vision and hearing checks, medication review, and home safety assessment 1
• Maintain weight in the recommended range, as low BMI is an independent risk factor 1, 2

Pharmacological Treatment Algorithm

First-Line Therapy

• Oral bisphosphonates (such as alendronate) are first-line therapy due to safety, cost, and efficacy 1, 2, 3
• Alendronate inhibits osteoclast activity, reduces bone resorption by approximately 50-70%, and decreases bone formation markers by approximately 50% within 3-6 months 4
• Low-quality evidence shows bisphosphonates in women with advanced osteopenia may reduce fracture risk 3

Alternative Therapies (in order of preference when oral bisphosphonates are not appropriate)

1. IV bisphosphonates 1, 2, 3
2. Denosumab 1, 2, 3
3. Teriparatide (for high-risk patients) 1, 2
4. Raloxifene (selective estrogen receptor modulator) 1, 2, 5
   • Raloxifene reduces invasive breast cancer risk but increases risk of venous thromboembolism and fatal stroke 5
   • Should be discontinued 72 hours prior to prolonged immobilization 5

Special Populations

Cancer Survivors

• Cancer treatments can accelerate bone loss, particularly those causing hypogonadism 1, 3
• For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are preferred 1, 3
• Perform dental screening exam before initiating bone-modifying agents to reduce risk of medication-related osteonecrosis of the jaw 1, 3

Glucocorticoid Users

• Patients on long-term glucocorticoid therapy, particularly at doses >7.5 mg/day prednisone, should be considered for bone-modifying agents 3
• Clinical fracture risk reassessment should be performed every 12 months 1, 2, 3
• Only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies, representing a major treatment gap 2, 3

Chronic Liver Disease

• BMD measurement is recommended 1, 2
• Supplementation with calcium and vitamin D3 is advised 1, 2
• Avoid anabolic steroids 1

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 1, 2, 3
• Bone mineral density assessment should not be conducted more frequently than annually 1, 2, 3
• For patients on glucocorticoids, perform clinical fracture risk reassessment every 12 months 1, 2, 3
• When T-scores improve, consider discontinuation of bone-modifying agents and follow up with periodic DXA scans 1

Critical Pitfalls to Avoid

• Poor medication adherence is extremely common and reduces treatment effectiveness - only 5-62% of patients on glucocorticoid therapy receive appropriate preventive therapies 2, 3
• Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) 2, 3
• Not considering the risk-benefit profile of medications for individual patients, particularly those with comorbidities 1
• FRAX has not been validated in HIV-infected persons and may underestimate fracture risk in this population 3
• The risk of severe adverse effects increases with prolonged bisphosphonate use, so the balance of benefits and harms is most favorable when fracture risk is high 3