From the Guidelines
For postmenopausal women with osteopenia, the primary interventions include lifestyle modifications and possibly pharmacotherapy in certain cases, with a focus on preventing progression to osteoporosis and reducing fracture risk. All women should ensure adequate calcium intake of 1000-1200 mg daily through diet or supplements, along with vitamin D supplementation of 800-1000 IU daily to maintain optimal bone health, as suggested by 1. Regular weight-bearing exercise for 30-40 minutes, 3-4 times weekly, and resistance training twice weekly are essential components of management. Smoking cessation and limiting alcohol consumption to no more than one drink daily are strongly recommended. For women with osteopenia who have additional risk factors such as previous fractures or high FRAX scores (10-year fracture risk >3% for hip or >20% for major osteoporotic fracture), pharmacotherapy may be considered, with options including bisphosphonates like alendronate (70 mg weekly), risedronate (35 mg weekly), or zoledronic acid (5 mg IV annually), which work by inhibiting bone resorption, as recommended by 1.
Key Considerations
- Fall prevention strategies, including home safety assessment, vision checks, and balance training, are also crucial as falls often precipitate fractures.
- Regular bone mineral density testing every 2-3 years is recommended to monitor progression and treatment effectiveness.
- Clinicians should assess baseline risk for fracture based on individualized assessment of bone density, history of fractures, response to prior treatments for osteoporosis, and multiple risk factors for fractures in postmenopausal females with primary osteoporosis, as suggested by 1.
- The decision to treat osteopenic women 65 years of age or older who are at a high risk for fracture should be based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications, as recommended by 1.
Pharmacotherapy
- Bisphosphonates are a primary option for pharmacotherapy, with alendronate (70 mg weekly) and zoledronic acid (5 mg IV annually) being preferred due to their strong evidence for reducing hip and vertebral fractures 1.
- Denosumab is also an option, but its use should be considered on a case-by-case basis due to its potential for mild upper GI symptoms and rash/eczema 1.
- Teriparatide may be considered for women with severe osteoporosis or those who have failed other therapies, but its use is limited by potential side effects such as upper GI symptoms, renal issues, and hypercalcemia 1.
Lifestyle Modifications
- Adequate calcium and vitamin intake should be part of fracture prevention in all postmenopausal females with low bone mass or osteoporosis, as suggested by 1.
- Regular exercise, including weight-bearing and resistance training, is essential for maintaining bone density and strength.
- Smoking cessation and limiting alcohol consumption are crucial for reducing fracture risk and promoting overall health.
From the FDA Drug Label
The primary efficacy endpoint was the occurrence of new radiographically diagnosed vertebral fractures defined as changes in the height of previously undeformed vertebrae. Teriparatide, when taken with calcium and vitamin D and compared with calcium and vitamin D alone, reduced the risk of 1 or more new vertebral fractures from 14.3% of women in the placebo group to 5. 0% in the teriparatide group Teriparatide was effective in reducing the risk for vertebral fractures regardless of age, baseline rate of bone turnover, or baseline BMD Alendronate sodium 5 mg/day prevented bone loss in the majority of patients and induced significant increases in mean bone mass at each of these sites Alendronate sodium 5 mg/day reduced the rate of bone loss at the forearm by approximately half relative to placebo
The recommended interventions in postmenopausal women with osteopenia are not directly addressed in the provided drug labels. However, based on the information provided for postmenopausal women with osteoporosis, the following interventions may be considered:
- Teriparatide may be effective in reducing the risk of vertebral fractures and increasing bone mineral density (BMD) in postmenopausal women with osteoporosis.
- Alendronate may be effective in preventing bone loss and increasing BMD in postmenopausal women with osteoporosis. It is essential to note that these interventions are specifically studied in postmenopausal women with osteoporosis, and their effectiveness in women with osteopenia is not directly addressed in the provided drug labels. Therefore, the use of these interventions in postmenopausal women with osteopenia should be approached with caution and considered on a case-by-case basis 2, 3.
From the Research
Recommended Interventions for Postmenopausal Women with Osteopenia
The following interventions are recommended for postmenopausal women with osteopenia:
- Pharmacological interventions:
- Bisphosphonates (e.g. alendronate, risedronate) to reduce the risk of vertebral and non-vertebral fractures 4, 5
- Raloxifene to prevent bone loss and fracture 4, 6
- Hormone replacement therapy to prevent osteoporosis in early postmenopausal women 4, 6
- Denosumab to treat osteoporosis 6
- Teriparatide (anabolic therapy) for women at high risk of fracture 6
- Non-pharmacological interventions:
- Regular weight-bearing exercise to decrease risk of fracture 7
- A balanced diet with adequate calcium and vitamin D intake 4, 7
- Avoidance of smoking, excessive alcohol intake, and fall risks at home 7
- Maintenance of a healthy body weight 7
- Reduction of other risk factors for osteoporotic fractures (e.g. immobilization, impaired vision) 8
Considerations for Treatment
Treatment decisions should be based on:
- Age of the patient 4, 8
- Presence or absence of prevalent fractures, especially at the spine 4
- Degree of bone mineral density measured at the spine and hip 4, 8
- Absolute fracture risk, which increases with the presence of multiple risk factors 8
- Cost-effectiveness of anti-resorptive therapy, which increases with the absolute fracture risk 8