What are the treatment options for osteopenia?

Osteopenia Treatment

For osteopenia, treatment decisions should be based on fracture risk assessment using FRAX, not BMD alone—pharmacological treatment with oral bisphosphonates (alendronate) is indicated when 10-year hip fracture risk is ≥3% or major osteoporotic fracture risk is ≥20%, while all patients regardless of risk should receive calcium, vitamin D, weight-bearing exercise, and lifestyle modifications. 1, 2

Risk Stratification First

• Calculate fracture risk using the FRAX tool which incorporates BMD T-score, age, sex, prior fracture history, family history, smoking, alcohol use, and glucocorticoid exposure 1, 2
• The diagnosis of osteopenia (T-score between -1.0 and -2.5) alone does not determine treatment—most fractures actually occur in osteopenic individuals due to their larger population size, but individual fracture risk varies widely within this range 3
• Treatment thresholds: Pharmacological therapy is indicated when FRAX shows 10-year hip fracture risk ≥3% OR 10-year major osteoporotic fracture risk ≥20% 1, 2
• Consider treatment at lower thresholds (T-score below -2.0) when additional risk factors are present, such as prevalent vertebral fractures, glucocorticoid use >7.5 mg/day prednisone, or cancer treatments causing hypogonadism 1

Non-Pharmacological Interventions (All Patients)

Calcium and Vitamin D:

• Daily calcium intake: 1,000 mg for ages 19-50; 1,200 mg for ages 51+ 1, 2, 4
• Daily vitamin D intake: 600 IU for ages 19-70; 800 IU for ages 71+ 1, 2, 4
• Target serum vitamin D level ≥20 ng/mL 1, 2

Exercise:

• Regular weight-bearing exercises (walking, jogging, dancing) and muscle-strengthening activities improve bone density 1, 2
• Balance training exercises including tai chi, physical therapy, and dancing reduce fall risk 1, 2
• Aim for at least 30 minutes of moderate physical activity daily 1

Lifestyle Modifications:

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

Fall Prevention:

• Vision and hearing checks 1
• Medication review to minimize drugs causing drowsiness or hypotension 1
• Home safety assessment to remove fall hazards 1

Pharmacological Treatment (High-Risk Patients)

First-Line Therapy:

• Oral bisphosphonates (alendronate) are first-line due to proven efficacy, safety profile, and low cost 1, 2, 5
• Alendronate inhibits osteoclast activity, reduces bone resorption by 50-70%, and reduces fracture risk by approximately 50% 5
• Critical administration instructions to prevent esophageal complications: take with full glass (6-8 oz) of water, remain upright for 30 minutes after dosing, take on empty stomach 5
• Correct hypocalcemia and vitamin D deficiency before initiating bisphosphonates 5

Alternative Agents:

• IV bisphosphonates for patients unable to tolerate oral formulations 1
• Denosumab for patients who cannot tolerate bisphosphonates or at very high fracture risk 1, 2
• Teriparatide (anabolic agent) reserved for highest-risk patients, particularly those with severe osteopenia approaching osteoporosis or with prevalent vertebral fractures 1, 6
• Selective estrogen receptor modulators (SERMs) as alternative therapy 1

Special Populations Requiring Adjusted Approach

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, 4
• Treatment often warranted at lower BMD thresholds due to glucocorticoid-induced bone quality deterioration 5

Cancer Survivors:

• Cancer treatments (especially those causing hypogonadism) accelerate bone loss 1, 2, 4
• Bisphosphonates or denosumab are preferred agents when additional risk factors present 1, 2, 4
• Mandatory dental screening before initiating bone mineral agents to reduce osteonecrosis of jaw risk 1

Chronic Liver Disease:

• Screen for osteopenia, especially with cirrhosis or severe cholestasis 4
• Ensure adequate nutrition (low BMI is independent risk factor) 1
• Calcium and vitamin D supplementation plus weight-bearing exercise 1, 4
• Avoid anabolic steroids 1

Monitoring

• Repeat DEXA scan every 2 years to monitor bone density and treatment response 1, 2, 4
• Do not perform BMD assessment more frequently than annually (not cost-effective and changes may not be clinically meaningful) 1, 2
• High-risk patients (glucocorticoid users, cholestatic liver disease) may require yearly monitoring 4
• When T-scores improve significantly on treatment, consider discontinuation of bone mineral agents with periodic follow-up DEXA scans 1

Critical Pitfalls to Avoid

• Do not treat based on BMD alone—always calculate FRAX score as fracture risk varies widely within the osteopenic range 3
• Do not miss secondary causes: screen for vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure, hyperthyroidism, hyperparathyroidism 1
• Poor medication adherence is common—only 5-62% of high-risk patients receive appropriate preventive therapy 1
• Bisphosphonate administration errors cause serious esophageal complications—patients must understand to take with full glass of water and remain upright for 30 minutes 5
• Dental screening before bisphosphonates/denosumab is mandatory to prevent osteonecrosis of jaw, especially in cancer patients 1, 5
• Do not use bisphosphonates if creatinine clearance <35 mL/min 5
• Assess for atypical femoral fractures—any patient on bisphosphonates with thigh or groin pain requires evaluation 5