What are the guidelines for treating osteopenia?

Osteopenia Treatment Guidelines

Osteopenia treatment should be based on fracture risk assessment using the FRAX tool, with pharmacological treatment reserved for patients with a 10-year hip fracture risk ≥3% or major osteoporotic fracture risk ≥20%, or those with T-scores below -2.0 with additional risk factors. 1, 2

Risk Assessment and Treatment Thresholds

Calculate fracture risk using the FRAX tool (World Health Organization Fracture Risk Assessment Tool), which incorporates bone mineral density (BMD) and clinical risk factors to determine overall fracture probability. 1, 2 While FRAX is widely used, note that no randomized controlled trials demonstrate benefit when FRAX scores guide treatment decisions—one post-hoc analysis with raloxifene showed treatment efficacy did not vary by FRAX score. 3

Pharmacological treatment thresholds:

• 10-year hip fracture risk ≥3%, OR 1, 2
• 10-year major osteoporotic fracture risk ≥20%, OR 1, 2
• T-score below -2.0 with additional risk factors 1

Key risk factors that increase fracture probability:

• Lower body weight/low BMI 3, 1
• Current smoking 3, 2
• Family history of hip fracture (especially maternal) 3, 1
• Oral glucocorticoid use (adjust FRAX by 1.15 for major fracture risk and 1.2 for hip fracture risk if prednisone >7.5 mg/day) 1, 2
• Hypogonadism 1, 2
• Excessive alcohol consumption 3, 2
• History of fragility fracture 1

Non-Pharmacological Interventions (Universal for All Patients)

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+, targeting serum level ≥20 ng/mL 1, 2, 4, 5
• Higher-risk patients (age >70, institutionalized, chronically ill, malabsorption syndromes) require additional vitamin D 5, 6

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 1, 2

Fall prevention strategies:

• Vision and hearing assessments 1
• Medication review for fall-risk drugs 1
• Home safety evaluation 1

Pharmacological Treatment

First-Line Therapy

Oral bisphosphonates (alendronate, risedronate) are first-line therapy due to established safety profile, cost-effectiveness, and efficacy. 1, 2 Post-hoc analysis of risedronate in women with advanced osteopenia (T-score near -2.5) showed 73% reduction in fragility fractures compared to placebo over 1.5-3 years, similar to reductions seen in osteoporosis. 3 This benefit likely extends across all bisphosphonates based on data in osteoporotic women. 3

Critical administration instructions for oral bisphosphonates:

• Take with plain water (6-8 ounces) first thing upon arising, at least 30 minutes before any food, beverage, or other medication 4
• Do NOT take with orange juice or coffee—this markedly reduces absorption 4
• Remain upright (do not lie down) for at least 30 minutes after dosing 4
• Swallow whole; do not chew or suck tablets (risk of oropharyngeal ulceration) 4
• Failure to follow these instructions increases risk of esophageal problems 4

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

1. IV bisphosphonates (zoledronic acid) 1, 2
2. Denosumab 1, 2
3. Teriparatide (for high-risk patients) 1, 2
4. Raloxifene (selective estrogen receptor modulator) 1, 2

Critical warning about denosumab: Never interrupt denosumab therapy without switching to another agent—post-treatment bone loss progresses rapidly. 6 In contrast, bisphosphonates can be interrupted after 5 years with slow progressive bone loss. 6

Raloxifene considerations:

• May increase hot flashes; not effective for reducing menopausal symptoms 5
• Discontinue 72 hours before prolonged immobilization (surgery, bed rest, travel) due to increased venous thromboembolism risk 5
• Reduces invasive breast cancer risk in postmenopausal women 5

Special Populations

Glucocorticoid-induced osteopenia:

• Reassess fracture risk every 12 months 1, 2
• Adjust FRAX calculations as noted above 1, 2
• Poor adherence is common—only 5-62% of glucocorticoid patients receive appropriate preventive therapy 1, 2

Cancer survivors:

• Cancer treatments accelerate bone loss, particularly those causing hypogonadism 1
• Bisphosphonates or denosumab are preferred agents 1
• Mandatory dental screening before initiating bone mineral agents to reduce medication-related osteonecrosis of the jaw risk 1
• Consider discontinuing bone mineral agents when T-scores improve, with periodic DXA follow-up 1

Chronic liver disease:

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

Monitoring

DXA scanning frequency:

• Repeat every 2 years to monitor bone density and treatment response 1, 2
• Do NOT perform more frequently than annually 1, 2
• For glucocorticoid patients: clinical fracture risk reassessment every 12 months 1, 2

Critical Pitfalls to Avoid

Identify and treat secondary causes of osteopenia:

• Vitamin D deficiency 1, 2
• Hypogonadism 1, 2
• Alcoholism 1, 2
• Glucocorticoid exposure 1, 2

Common medication errors:

• Improper bisphosphonate administration technique (see detailed instructions above) 4
• Interrupting denosumab without alternative therapy 6
• Failing to provide calcium/vitamin D supplementation 4, 5
• Not considering individual risk-benefit profile, particularly in patients with comorbidities 1

The balance of benefits and harms is most favorable when fracture risk is high. Women <65 years with osteopenia and women ≥65 years with mild osteopenia (T-score -1.0 to -1.5) benefit less than women ≥65 years with severe osteopenia (T-score <-2.0). 3 Given limited evidence and increased adverse effects with prolonged bisphosphonate use, reserve pharmacological treatment for appropriately selected high-risk patients. 3