What is the plan of care for a postmenopausal woman or older adult with osteopenia and a history of low bone density?

Plan of Care for Osteopenia

For postmenopausal women or older adults with osteopenia, pharmacologic treatment with bisphosphonates should be offered only to those aged 65 years or older who are at high risk for fracture based on individualized fracture risk assessment, patient preferences, and a discussion of benefits, harms, and costs—not based solely on bone density values. 1

Risk Stratification and Treatment Decision

Who Should Receive Pharmacologic Treatment

• Postmenopausal women ≥65 years with osteopenia (T-score between -1.0 and -2.5) warrant consideration for bisphosphonate therapy when they have:

  • History of fragility fracture 1
  • Multiple clinical risk factors (advanced age, parental hip fracture, current smoking, alcohol intake ≥3 drinks daily, low body weight, rheumatoid arthritis) 1
  • Significant decline in hip bone mineral density despite adequate calcium and vitamin D 2
  • High FRAX score indicating elevated 10-year fracture probability 1

• The decision must be made through shared decision-making that weighs the patient's fracture risk profile against medication benefits, harms (including osteonecrosis of the jaw and atypical femoral fractures), and costs 1, 2

Who Should NOT Receive Pharmacologic Treatment

• Younger postmenopausal women with osteopenia and no additional risk factors should focus on lifestyle modifications and calcium/vitamin D supplementation alone 3
• Osteopenia by itself is not an indication for treatment—it encompasses a wide range of fracture risks 3

First-Line Pharmacologic Treatment (When Indicated)

Bisphosphonates are the preferred first-line agents due to their favorable benefit-harm-cost profile and availability as generics 1, 4, 2:

• Alendronate 70 mg once weekly (oral) 4, 2
• Risedronate 35 mg once weekly (oral) 4, 2
• Zoledronic acid 5 mg once yearly (intravenous)—particularly useful for patients with compliance concerns or gastrointestinal intolerance 4, 2

Evidence Supporting Bisphosphonates in Osteopenia

• Zoledronic acid may reduce the risk of clinical vertebral fractures in postmenopausal women with low bone mass, though evidence is very uncertain for hip fractures 1
• Bisphosphonates provide residual bone protection for years after discontinuation 4, 2

Essential Non-Pharmacologic Interventions (For ALL Patients)

Calcium and Vitamin D Supplementation

• Calcium: 1,000-1,200 mg daily 4, 5, 2
• Vitamin D: 600-800 IU daily 4, 5, 2
• These are mandatory adjuncts to any pharmacologic therapy and essential even without medication 1, 5, 2

Lifestyle Modifications

• Weight-bearing exercise (walking 3-5 miles per week can improve bone density) 5, 6
• Smoking cessation 1, 5
• Limit alcohol intake to <3 drinks daily 1, 5
• Fall prevention strategies 1, 5

Treatment Duration and Monitoring

Duration

• Treat for 5 years initially, then reassess fracture risk to determine if continuation is needed 1, 5, 2
• Patients at low fracture risk should be considered for drug discontinuation after 3-5 years 1

Monitoring

• Do NOT routinely monitor bone density during the initial 5-year treatment period—fracture reduction occurs even without BMD increases 1, 5, 2
• Reassess fracture risk after 5 years using clinical factors, not repeat DXA 1, 5

Agents to AVOID

Strongly Recommended AGAINST

• Raloxifene: Increases risk of venous thromboembolism, pulmonary embolism, and fatal stroke 1, 4, 2
• Menopausal estrogen therapy (with or without progestogen): Unfavorable benefit-harm profile 1, 4, 2

Insufficient as Monotherapy

• Calcium or vitamin D alone: Uncertain effect on fracture risk reduction and insufficient without other interventions 4, 2

Alternative Agents (Second-Line)

• Denosumab (Prolia) 60 mg subcutaneously every 6 months: Reduces vertebral, nonvertebral, and hip fractures but carries risk of rapid rebound bone loss and multiple vertebral fractures upon discontinuation 2, 7
  • If denosumab is discontinued, transition to a bisphosphonate to prevent rebound 5, 2

Critical Pitfalls to Avoid

• Do not treat based on T-score alone—osteopenia is not a disease and the label can cause unnecessary anxiety 3
• Do not use bone density monitoring to guide continuation during the initial 5-year period 1, 5
• Do not prescribe raloxifene or estrogen therapy for osteopenia or osteoporosis treatment 1, 4
• Ensure adequate calcium and vitamin D before and during any pharmacologic treatment to prevent hypocalcemia, especially in patients with chronic kidney disease 7