What are the management recommendations for a patient with osteopenia diagnosed by DEXA (Dual-Energy X-ray Absorptiometry) scan?

Management of Osteopenia

All patients with osteopenia diagnosed by DEXA scan should receive calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) supplementation, engage in weight-bearing exercise, and undergo fracture risk assessment using the FRAX tool to determine if pharmacologic therapy with bisphosphonates is warranted. 1, 2

Initial Assessment and Risk Stratification

When osteopenia is identified on DEXA (T-score between -1.0 and -2.5), calculate the 10-year fracture risk using the FRAX tool, which incorporates BMD along with clinical risk factors including age, sex, prior fracture history, parental hip fracture, smoking status, glucocorticoid use, rheumatoid arthritis, secondary osteoporosis causes, and alcohol consumption. 1, 2

Key risk factors to assess include:

• History of fragility fracture (increases vertebral fracture risk 5-fold and hip fracture risk 2-fold) 2
• Body weight less than 127 pounds (58 kg) 1
• Current smoking or excessive alcohol use (>2 drinks/day) 1
• Long-term glucocorticoid therapy (≥2.5 mg/day prednisone for ≥3 months) 2
• Parental history of hip fracture 1
• Cancer treatments causing hypogonadism 1, 2

Obtain lateral spine X-rays to identify existing vertebral fractures, which significantly elevate future fracture risk even when BMD values don't indicate osteoporosis. 2

Check serum 25-hydroxyvitamin D levels (target ≥20 ng/mL) and evaluate for secondary causes of bone loss including hyperparathyroidism, hyperthyroidism, hypogonadism, malabsorption disorders, and chronic inflammatory conditions. 1, 2

Non-Pharmacologic Management (Required for All Patients)

Calcium and Vitamin D:

• Ages 19-50: 1,000 mg calcium, 600 IU vitamin D daily 1
• Ages 51-70: 1,200 mg calcium, 600 IU vitamin D daily 1
• Ages 71+: 1,200 mg calcium, 800 IU vitamin D daily 1
• Target serum vitamin D level ≥20 ng/mL (some guidelines suggest ≥30 ng/mL) 1, 2

Exercise prescription: Prescribe weight-bearing exercises combined with resistance training and balance exercises for at least 30 minutes daily, at least 3 times per week. 1, 2 This reduces fall risk by 23% and provides significant BMD benefits. 2

Lifestyle modifications:

• Complete smoking cessation 1
• Limit alcohol to maximum 1-2 drinks per day 1, 2
• Implement fall prevention strategies including home safety assessment, vision checks, and balance training 1, 2
• Maintain healthy body weight (low BMI is an independent risk factor) 1

Pharmacologic Treatment Thresholds

Initiate bisphosphonate therapy when any of the following criteria are met:

• FRAX 10-year risk of major osteoporotic fracture ≥20% 1, 2
• FRAX 10-year risk of hip fracture ≥3% 1, 2
• History of prior fragility fracture that has not been treated 1, 2
• Significant osteopenia (T-score approaching -2.5) with additional risk factors 1
• Glucocorticoid-induced bone loss with T-score <-1.5 (lower threshold than postmenopausal osteoporosis) 3

For patients on chronic glucocorticoids (>7.5 mg/day prednisone): Adjust FRAX scores upward by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2. 2

First-Line Pharmacologic Therapy

Oral bisphosphonates are first-line therapy due to safety, cost, and efficacy. 1, 2

Specific agents:

• Alendronate: Take with full glass of plain water (6-8 oz) first thing upon arising, at least 30 minutes before any food, beverage, or other medication. Remain upright for at least 30 minutes after dosing. 4
• Risedronate: Weekly dosing with similar administration requirements 1
• Ibandronate: Monthly oral or quarterly IV option 1

Alternative agents when oral bisphosphonates are contraindicated or not tolerated:

• IV zoledronic acid (annual infusion) 1
• Denosumab (subcutaneous injection every 6 months) 1
• Raloxifene (selective estrogen receptor modulator) for younger postmenopausal women 1, 5

Before initiating bisphosphonates: Perform dental screening examination to reduce risk of medication-related osteonecrosis of the jaw. 2 Ensure adequate calcium and vitamin D status. 2

Monitoring Strategy

If pharmacologic therapy is NOT initiated (FRAX <20% major osteoporotic fracture and <3% hip fracture):

• Repeat DEXA scan in 2 years, or in 1 year if medically indicated (rapid bone loss expected, new risk factors) 1, 2
• Recalculate FRAX score at each DEXA scan 2
• Do not perform DEXA more frequently than annually 1

If pharmacologic therapy IS initiated:

• Repeat DEXA every 2 years to assess treatment response 1, 2
• Continue bisphosphonates for at least 3-5 years if fracture risk remains elevated 2
• Monitor medication adherence regularly (up to 64% of patients are non-adherent by 12 months) 2
• When T-scores improve to normal range, consider discontinuation with periodic follow-up DEXA scans 1

Special Population Considerations

Cancer survivors: Consider earlier intervention with bisphosphonates given baseline plus treatment-related risks, particularly those receiving aromatase inhibitors, GnRH agonists, or androgen deprivation therapy. 1, 2

Chronic liver disease patients: Ensure calcium (1,000-1,500 mg/day) and vitamin D (400-800 IU/day) supplementation. Bisphosphonates are well-tolerated but exercise caution in cirrhotics with recent esophageal banding/sclerotherapy. 1

Men with hypogonadism: Assess serum total testosterone as part of pre-treatment evaluation and consider testosterone supplementation in appropriate candidates. 2

Patients with spinal deformity: Obtain forearm DEXA in addition to hip scan, as spine measurements may be inaccurate due to degenerative changes. The forearm detects osteopenia/osteoporosis in 41% of cases missed by hip alone. 6

Common Pitfalls to Avoid

• Do not delay lifestyle modifications while waiting for the next DEXA scan—calcium, vitamin D, and exercise should begin immediately upon diagnosis. 2
• Avoid excessive calcium supplementation (>2,000 mg/day) which may increase cardiovascular risk. 2
• Do not rely solely on hip DEXA in patients with spinal deformity—obtain forearm measurements to avoid missing 17% of osteopenia/osteoporosis diagnoses. 6
• Ensure proper bisphosphonate administration with plain water only (not orange juice or coffee, which markedly reduce absorption) and maintain upright position for 30 minutes to prevent esophageal complications. 4
• Do not assume adequate vitamin D status—standard supplementation doses may be inadequate if deficiency is present; check serum levels. 2