What are the treatment options for osteopenia?

Osteopenia Treatment

For osteopenia, treatment should be based on fracture risk assessment using FRAX, with pharmacological therapy initiated only when 10-year hip fracture risk is ≥3% or major osteoporotic fracture risk is ≥20%, while all patients should receive calcium, vitamin D, and lifestyle modifications regardless of fracture risk. 1, 2, 3

Risk Assessment and Treatment Thresholds

The cornerstone of osteopenia management is quantifying fracture risk rather than treating based on bone density alone:

• Calculate fracture risk using the FRAX tool, which incorporates BMD T-scores along with clinical risk factors (age, prior fracture, family history, smoking, alcohol use, glucocorticoid use) to determine 10-year fracture probability 1, 2, 3

• Pharmacological treatment thresholds are:

  • 10-year hip fracture risk ≥3%, OR
  • 10-year major osteoporotic fracture risk ≥20% 1, 2, 3

• Additional treatment considerations include:

  • T-score below -2.0 with additional risk factors 1, 3
  • History of fragility fracture (indicates severe osteoporosis requiring treatment without needing BMD measurement) 1
  • Presence of vertebral fractures on imaging 1

• For patients on glucocorticoids >7.5 mg/day prednisone equivalent, adjust FRAX scores upward by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 3

Non-Pharmacological Interventions (Universal for All Patients)

These lifestyle modifications should be implemented for every patient with osteopenia, regardless of whether pharmacological therapy is initiated:

Calcium and Vitamin D:

• Calcium: 1,000 mg daily for ages 19-50; 1,200 mg daily for ages 51+ 1, 2, 3
• Vitamin D: 600 IU daily for ages 19-70; 800 IU daily for ages 71+ 1, 2, 3
• Target serum vitamin D level ≥20 ng/mL 1, 2

Exercise and Physical Activity:

• Regular weight-bearing exercises (walking, jogging, dancing) to improve bone density 1, 2, 3
• Muscle-strengthening exercises 1, 2, 3
• Balance training (tai chi, physical therapy) to reduce fall risk 1, 2, 3
• Aim for at least 30 minutes of moderate physical activity daily 1

Lifestyle Modifications:

• Smoking cessation 4, 1, 3
• Limit alcohol to 1-2 drinks per day maximum 1, 3
• Maintain healthy body weight (low BMI is an independent risk factor) 1

Fall Prevention:

• Vision and hearing checks 1, 3
• Medication review to minimize drugs causing drowsiness or hypotension 1, 3
• Home safety assessment to remove fall hazards 1, 3

Pharmacological Treatment

When fracture risk thresholds are met, initiate bone-modifying agents:

First-Line Therapy:

• Oral bisphosphonates (alendronate) are the preferred first-line agents due to established safety profile, cost-effectiveness, and proven efficacy in reducing fracture risk 1, 2, 3
• Alendronate works by inhibiting osteoclast activity, reducing bone resorption while allowing bone formation to continue, leading to progressive gains in bone mass 5

Alternative Agents (when oral bisphosphonates are not tolerated or appropriate):

• IV bisphosphonates for patients unable to tolerate oral formulations 4, 1, 3
• Denosumab for high-risk patients or bisphosphonate intolerance 4, 1, 2, 3
• Teriparatide (anabolic agent) for very high-risk patients, particularly those with prior fractures 1, 3, 6
• Selective estrogen receptor modulators (SERMs) 1, 3

Special Populations

Cancer Survivors:

• Cancer treatments causing hypogonadism (GnRH agonists, aromatase inhibitors, chemotherapy-induced ovarian failure) accelerate bone loss 4, 2, 3
• For cancer survivors with osteopenia plus additional risk factors, bisphosphonates or denosumab are preferred agents 4, 2, 3
• Perform dental screening before initiating bone-modifying agents to reduce risk of medication-related osteonecrosis of the jaw 1

Glucocorticoid Users:

• Patients on chronic glucocorticoids are at especially high risk and may fracture at higher T-scores than others 4
• Reassess clinical fracture risk every 12 months 3
• Consider treatment even at lower fracture risk thresholds 4

Monitoring

• Repeat DEXA scan every 2 years to monitor bone density and treatment response 4, 1, 2, 3
• Do not perform bone density assessment more frequently than annually 4, 2
• If T-scores improve significantly on treatment, consider discontinuation of bone-modifying agent with periodic follow-up DEXA scans 1

Critical Pitfalls to Avoid

Medication Administration Errors with Bisphosphonates:

• Patients must take oral bisphosphonates with a full glass (6-8 oz) of water 5
• Must remain upright (sitting or standing) for at least 30 minutes after administration 5
• Take on empty stomach, at least 30 minutes before first food or beverage of the day 5
• Failure to follow these instructions increases risk of severe esophageal adverse events 5

Common Clinical Errors:

• Over-treating low-risk patients with pharmacological therapy when lifestyle modifications alone are appropriate 3
• Poor adherence to preventive therapies (only 5-62% of glucocorticoid users receive appropriate bone protection) 1, 3
• Failing to identify and treat secondary causes: vitamin D deficiency, hypogonadism, alcoholism, medications 1, 3
• Not assessing individual risk-benefit profile, particularly in patients with comorbidities 1

Serious Adverse Events to Monitor:

• Osteonecrosis of the jaw (risk increases with duration of bisphosphonate use; consider dental evaluation before invasive procedures) 5
• Atypical femoral fractures (patients reporting thigh or groin pain require evaluation for incomplete fracture) 5
• Severe musculoskeletal pain (may require discontinuation) 5
• Hypocalcemia (must correct before initiating therapy; monitor in patients with vitamin D deficiency or malabsorption) 5

Treatment Algorithm Summary

1. All patients with osteopenia: Calcium, vitamin D, exercise, lifestyle modifications
2. Calculate FRAX score to determine 10-year fracture risk
3. If FRAX thresholds NOT met (hip <3%, major osteoporotic <20%): Continue lifestyle measures, repeat DEXA in 2 years
4. If FRAX thresholds MET or T-score <-2.0 with risk factors: Initiate oral bisphosphonate (alendronate) as first-line
5. Monitor with DEXA every 2 years and adjust therapy based on response