What is the treatment for a patient with a T score of -2.2 indicating osteoporosis on a Dual-Energy X-ray Absorptiometry (DEXA) scan?

Management of T-score -2.2 on DEXA Scan

A T-score of -2.2 indicates osteopenia (low bone mass), not osteoporosis, and does not automatically require pharmacologic treatment—you must calculate the 10-year fracture risk using FRAX to determine if medication is warranted. 1, 2

Diagnostic Classification

• A T-score of -2.2 falls within the osteopenia range (T-score between -1.0 and -2.5), which is below normal bone density but above the osteoporosis threshold of ≤-2.5 1, 2
• The WHO classification system defines this as "low bone mass" rather than osteoporosis 1, 3
• Approximately 50% of fragility fractures occur in patients with osteopenia (T-scores between -1.0 and -2.5), so fracture risk assessment is critical 1, 3

Immediate Risk Assessment Required

You must use the FRAX tool to calculate 10-year fracture probability before making treatment decisions. 1, 4

The FRAX calculation incorporates:

• Hip BMD measurement 1
• Age and gender 1
• Height and weight 1
• Family history of hip fracture 1
• Current smoking status 1
• Glucocorticoid use >3 months 1
• Rheumatoid arthritis 1
• Alcohol consumption (≥3 units/day) 1

Treatment Decision Algorithm

Non-Pharmacologic Interventions (Recommended for ALL patients with T-score -2.2)

• Calcium supplementation: 1000-1200 mg/day through diet or supplements 2, 4, 5
• Vitamin D supplementation: 800-1000 IU/day 2, 4, 5
• Weight-bearing exercise regimen to maintain and potentially improve bone density 4, 5
• Muscle resistance exercises (squats, push-ups) and balance exercises (heel raises, standing on one foot) 5
• Smoking cessation if applicable 4, 5
• Limit alcohol consumption to <3 units/day 4, 5

Pharmacologic Treatment Indications

Initiate pharmacologic therapy if ANY of the following criteria are met: 1, 4, 3

1. FRAX shows 10-year hip fracture probability ≥3% 1, 4
2. FRAX shows 10-year major osteoporotic fracture probability ≥20% 1, 4
3. Personal history of fragility fracture after age 50 4, 3
4. Glucocorticoid therapy ≥7.5 mg prednisone equivalent/day for ≥3 months (consider treatment at T-score <-1.5 in this population) 1, 6

First-Line Pharmacologic Options (if treatment indicated)

Oral bisphosphonates are first-line therapy: 5, 7, 6

• Alendronate 70 mg once weekly (preferred for convenience) 8, 7
• Risedronate 35 mg once weekly 4
• These reduce vertebral fractures by approximately 52 per 1000 person-years and hip fractures by 6 per 1000 person-years 5

Alternative agents if bisphosphonates contraindicated or not tolerated: 5, 7

• Denosumab 60 mg subcutaneously every 6 months 4, 9, 7
• Zoledronic acid 5 mg IV annually or every 2 years 4

Monitoring Recommendations

• Repeat DEXA scan in 1-2 years to assess bone density changes and treatment response 4, 3
• Critical: Ensure follow-up scans are performed on the same DXA scanner using identical protocols, as vendor differences prohibit direct comparison 1, 3
• Compare BMD values (not T-scores) between scans to assess change 1
• Scan intervals <1 year are discouraged except in high-risk situations (e.g., initiating glucocorticoid therapy) 1

Common Pitfalls to Avoid

• Do not automatically prescribe osteoporosis medication based solely on T-score -2.2—many patients with osteopenia do not require pharmacologic treatment 1, 4, 5
• Do not skip FRAX calculation—this is essential for appropriate risk stratification in the osteopenic range 1, 4
• Do not use T-scores if patient is premenopausal or male <50 years old—use Z-scores instead for these populations 2, 3
• Do not ignore vertebral fracture assessment (VFA)—consider VFA if patient is ≥70 years (women) or ≥80 years (men), has historical height loss >4 cm, or is on chronic glucocorticoids, as vertebral fractures may indicate need for treatment regardless of T-score 1
• Do not rely on peripheral bone density measurements (heel ultrasound, forearm) for diagnosis or treatment decisions—central DEXA of spine and hip is the gold standard 1

Special Considerations

• If patient has two or more additional risk factors (family history of hip fracture, current smoking, BMI <24, oral glucocorticoid use >6 months), strongly consider pharmacologic therapy even if FRAX thresholds are not quite met 4
• For postmenopausal women age ≥50 or men age ≥50, treatment decisions are based on T-scores and FRAX 1, 2
• Fracture risk exists on a continuum—clinical judgment incorporating all risk factors is essential 1, 4