What are the treatment guidelines for osteopenia?

Osteopenia Treatment Guidelines

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

Risk Assessment and Treatment Thresholds

• Calculate fracture risk using the FRAX tool, which incorporates bone mineral density (BMD) and clinical risk factors to determine overall fracture risk 1, 3
• Pharmacological treatment is indicated when FRAX shows 10-year hip fracture risk ≥3% OR 10-year major osteoporotic fracture risk ≥20% 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 fragility fracture indicates severe osteoporosis and warrants immediate treatment without requiring BMD measurement 1

Special FRAX adjustments for glucocorticoid users: If prednisone dose is >7.5 mg/day, multiply the FRAX major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 1, 2, 3

Non-Pharmacological Interventions (All Patients)

Calcium and Vitamin D supplementation:

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

Exercise recommendations:

• Regular weight-bearing and muscle-strengthening exercises to improve bone density 1, 2
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 1
• Minimum 30 minutes of moderate physical activity daily 1

Lifestyle modifications:

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

Fall prevention strategies:

• Vision and hearing checks 1
• Medication review for drugs that increase fall risk 1
• Home safety assessment 1

Pharmacological Treatment

First-line therapy:

• Oral bisphosphonates (such as alendronate) are the first-line treatment due to safety, cost, and efficacy 1, 2, 3
• Alendronate inhibits osteoclast activity, reduces bone resorption, and leads to progressive gains in bone mass 4
• Treatment with bisphosphonates in women with advanced osteopenia reduces fracture risk 3

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

1. IV bisphosphonates 1, 2
2. Denosumab 1, 2
3. Teriparatide (for high-risk patients) 1, 2
4. Selective estrogen receptor modulators (SERMs) 1, 2

Anabolic agents: Teriparatide is an anabolic agent that increases bone formation and should be considered for high-risk patients or those who have failed antiresorptive therapy 5, 6

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:

• Adjust FRAX scores as noted above (multiply by 1.15 for major fracture, 1.2 for hip fracture if prednisone >7.5 mg/day) 1, 2, 3
• Reassess clinical fracture risk every 12 months 1, 2, 3
• Patients on long-term glucocorticoid therapy, particularly at doses >7.5 mg/day prednisone, should be considered for bone-modifying agents 3

Chronic liver disease:

• Obtain BMD measurement 1
• Supplement with calcium and vitamin D3 1
• Avoid anabolic steroids 1
• Ensure adequate nutrition as low BMI is an independent risk factor 1

Monitoring

• Repeat DEXA every 2 years to monitor bone density and treatment response 1, 2, 3
• Do not perform BMD assessment more frequently than annually 1, 2, 3
• For glucocorticoid users, perform clinical fracture risk reassessment every 12 months 1, 2, 3
• When T-scores improve on treatment, consider discontinuation of bone-modifying agent and follow with periodic DXA scans 1

Critical Pitfalls to Avoid

• Poor medication adherence is extremely common—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
• Relying solely on BMD T-scores without calculating FRAX scores leads to under-treatment of high-risk patients 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