What are the treatment options for osteopenia?

Osteopenia Treatment

Osteopenia does not automatically require pharmacological treatment—treatment decisions should be based on fracture risk assessment using FRAX, with medication initiated only when 10-year hip fracture risk is ≥3% or major osteoporotic fracture risk is ≥20%, or when significant osteopenia exists with additional risk factors. 1, 2

Risk Assessment and Treatment Thresholds

All patients with osteopenia require fracture risk stratification using the FRAX tool, which incorporates BMD and clinical risk factors 3, 1. The specific thresholds that trigger pharmacological intervention are:

• 10-year hip fracture risk ≥3% 3, 1, 2
• 10-year major osteoporotic fracture risk ≥20% 3, 1, 2
• T-score below -2.0 with additional risk factors 1
• History of fragility fracture (this indicates severe osteoporosis and warrants immediate treatment without needing BMD measurement) 1

If FRAX scores fall below these thresholds and no significant risk factors exist, defer pharmacological treatment and repeat DEXA in 2 years (or 1 year if medically indicated). 3

Non-Pharmacological Management (Universal for All Patients)

Every patient with osteopenia requires counseling on bone-healthy lifestyle modifications 3, 1:

• Calcium intake: 1,000 mg daily for ages 19-50; 1,200 mg daily for ages 51+ 1, 2
• Vitamin D intake: 600 IU daily for ages 19-70; 800 IU daily for ages 71+, targeting serum level ≥20 ng/mL 1, 2
• Weight-bearing and muscle-strengthening exercises performed regularly 3, 1, 2
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 1, 2
• Tobacco cessation 3, 1
• Limit alcohol consumption to 1-2 drinks per day maximum 1
• Fall prevention strategies including vision/hearing checks, medication review, and home safety assessment 1

Pharmacological Treatment

First-Line Therapy

Oral bisphosphonates (particularly alendronate) are the first-line pharmacological treatment due to their safety profile, cost-effectiveness, and proven efficacy 1, 2. Alendronate works by binding to bone hydroxyapatite and inhibiting osteoclast activity, reducing bone resorption without directly affecting bone formation 4.

Alternative Agents

When oral bisphosphonates cannot be used:

• IV bisphosphonates for patients who cannot tolerate oral formulations 3, 1
• Denosumab for patients at high fracture risk or with bisphosphonate intolerance 3, 1, 2
• Teriparatide (anabolic agent) reserved for very high-risk patients 1, 5
• Selective estrogen receptor modulators (SERMs) as an alternative option 1

Special Populations Requiring Heightened Vigilance

Cancer Survivors

Patients with nonmetastatic cancer face baseline osteoporosis risks plus treatment-related bone loss from hypogonadism (oophorectomy, GnRH agonists, chemotherapy-induced ovarian failure, aromatase inhibitors, anti-androgens) 3. For cancer survivors with osteopenia and additional risk factors, bisphosphonates or denosumab are the preferred agents. 3, 1, 2

Critical caveat: Before initiating bone-modifying agents in cancer survivors, perform a dental screening exam to reduce the risk of medication-related osteonecrosis of the jaw 1.

Glucocorticoid Users

Patients on glucocorticoids require adjusted fracture risk assessment—multiply major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 if prednisone dose exceeds 7.5 mg/day 1. Clinical fracture risk should be reassessed every 12 months in this population 1. The risk-benefit of treatment at glucocorticoid doses below 7.5 mg prednisone equivalent has not been established 4.

Chronic Liver Disease

Patients with chronic liver disease should have BMD measurement and receive calcium and vitamin D3 supplementation 1. Avoid anabolic steroids in this population. 1

Monitoring Strategy

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

Critical Pitfalls to Avoid

Bisphosphonate Administration Errors

Alendronate requires strict adherence to dosing instructions to prevent severe esophageal adverse events 4. Patients must:

• Take with a full glass (6-8 ounces) of water 4
• Remain upright (not lie down) after administration 4
• Discontinue immediately if esophageal irritation symptoms develop 4

Patients who cannot comply with these instructions due to mental disability should only use alendronate under appropriate supervision 4.

Mineral Metabolism Issues

Correct hypocalcemia before initiating bisphosphonate therapy 4. Treat vitamin D deficiency and other disorders affecting mineral metabolism prior to starting treatment 4. Monitor serum calcium and symptoms of hypocalcemia during therapy, particularly in patients with Paget's disease or those receiving glucocorticoids 4.

Rare but Serious Complications

• Osteonecrosis of the jaw (ONJ): Risk increases with duration of bisphosphonate exposure 4. For patients requiring invasive dental procedures, consider discontinuation based on individual benefit/risk assessment 4.
• Atypical femoral fractures: Any patient with bisphosphonate exposure presenting with thigh or groin pain should be evaluated for incomplete femur fracture 4. Assess the contralateral limb and consider interrupting bisphosphonate therapy 4.
• Musculoskeletal pain: Severe and occasionally incapacitating bone, joint, and/or muscle pain can occur 4. Discontinue if severe symptoms develop 4.

Undertreatment

Poor adherence to preventive therapies is common—only 5-62% of patients on glucocorticoid therapy receive appropriate preventive treatment 1. Failing to identify and treat secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) represents another common pitfall 1.

Renal Considerations

Alendronate is not recommended for patients with creatinine clearance less than 35 mL/min 4.