What is the treatment plan for an older adult, possibly female, with a history of decreased bone density and a T score between -1 and -2.5 indicating osteopenia?

Treatment Plan for Osteopenia (T-score -1.0 to -2.5)

For older adults with osteopenia, treatment decisions depend on comprehensive fracture risk assessment rather than T-score alone, with bisphosphonates recommended as first-line therapy when 10-year major osteoporotic fracture risk exceeds 10-15% or hip fracture risk exceeds 3%. 1, 2

Risk Stratification: The Critical First Step

The diagnosis of osteopenia is not an automatic indication for pharmacologic treatment—most fractures occur in osteopenic patients simply because this population is so large, but individual risk varies dramatically. 3, 4

Calculate fracture risk using the WHO FRAX tool (available at www.shef.ac.uk/FRAX), which incorporates: 1, 2

• Age
• Current T-score
• Body mass index
• Prior fragility fracture after age 50
• Parental history of hip fracture
• Current smoking status
• Glucocorticoid use >3 months
• Rheumatoid arthritis
• Secondary osteoporosis causes
• Alcohol consumption ≥3 units daily

Treatment thresholds for women ≥65 years with osteopenia: 1, 2

• 10-year major osteoporotic fracture risk ≥10-15%, OR
• 10-year hip fracture risk ≥3%, OR
• History of fragility fracture after age 50, OR
• T-score between -2.0 and -2.5 with ≥2 additional risk factors

For males with osteopenia, evidence is limited but treatment thresholds are extrapolated from female data using similar risk calculations. 1

Universal Non-Pharmacologic Interventions (All Patients)

Every patient with osteopenia requires these foundational measures regardless of whether pharmacologic therapy is initiated: 2, 5

Calcium and Vitamin D:

• Calcium 1,000-1,200 mg daily (preferably through dietary sources: dairy, leafy greens, fortified foods) 2, 5
• Vitamin D 800-1,000 IU daily (ensure 25-hydroxyvitamin D level >30 ng/mL before starting bisphosphonates) 2, 5

Lifestyle modifications:

• Weight-bearing exercise 30 minutes at least 3 days weekly (walking, jogging, resistance training) 1, 5
• Smoking cessation (mandatory—smoking accelerates bone loss) 1, 5
• Limit alcohol to <3 units daily 2, 5
• Fall prevention strategies: home safety assessment, balance exercises, vision correction, medication review for sedating drugs 5

Pharmacologic Treatment Algorithm

First-Line: Oral Bisphosphonates

When fracture risk meets treatment thresholds, initiate oral bisphosphonates (strong recommendation for postmenopausal women, conditional for men): 1, 2

Preferred agent: Alendronate 70 mg once weekly (most cost-effective, generic available) 1, 2

Alternatives:

• Risedronate 35 mg once weekly or 150 mg once monthly 1, 2
• Ibandronate 150 mg once monthly 2

Critical administration instructions to prevent esophageal complications: 1

• Take first thing in morning on empty stomach with 8 oz plain water
• Remain upright (sitting or standing) for 30-60 minutes
• No food, drink, or other medications for 30-60 minutes
• Contraindicated if unable to stand/sit upright or esophageal motility disorders present

Second-Line Options

If oral bisphosphonates are contraindicated or not tolerated: 1, 2

• Zoledronic acid 5 mg IV every 2 years (preferred if GI intolerance, adherence concerns, or contraindication to oral formulations) 1, 2
• Denosumab 60 mg subcutaneously every 6 months (RANK ligand inhibitor; note: increased infection risk, rebound bone loss if discontinued without transition to bisphosphonate) 1, 2

Agents NOT Recommended for Osteopenia

The American College of Physicians recommends against: 1

• Menopausal estrogen therapy (with or without progestogen)
• Raloxifene (SERM)
• Teriparatide or romosozumab (reserved for very high fracture risk/established osteoporosis only) 1

Treatment Duration and Monitoring

Initial treatment duration: 5 years 1

After 5 years, reassess fracture risk and consider drug holiday for bisphosphonates in patients at lower ongoing risk. Continue treatment beyond 5 years for patients with: 1

• Prior hip or vertebral fracture
• Very high ongoing fracture risk
• T-score remains ≤-2.5

DXA monitoring strategy: 2

• Repeat DXA in 1-2 years using the same facility and same machine (critical for accurate comparison) 2
• Significant change defined as ≥1.1% change in BMD 2
• Do not monitor BMD during the first 5 years of treatment—fracture reduction occurs even without BMD increase 1

Beware: Lumbar spine T-scores may be falsely elevated by degenerative changes (osteophytes, facet sclerosis) in older adults, potentially masking true bone loss. 2

Common Pitfalls to Avoid

Adherence issues: Poor adherence to bisphosphonates is common due to GI side effects, dosing inconvenience, and absence of symptoms. 1 Address this proactively with patient education about fracture risk and proper administration technique.

Inadequate vitamin D repletion: Starting bisphosphonates without ensuring adequate vitamin D can precipitate hypocalcemia, particularly with IV zoledronic acid. 1, 2

Treating T-score alone: The T-score is only one component of fracture risk—age, prior fracture, and other clinical factors often matter more than the absolute BMD value. 3, 4

Ignoring secondary causes: Before initiating treatment, evaluate for secondary osteoporosis causes (hypogonadism, hyperthyroidism, hyperparathyroidism, celiac disease, vitamin D deficiency, medications like glucocorticoids). 1 These require specific management beyond standard osteoporosis therapy.