What is the best treatment approach for an elderly postmenopausal female patient with osteopenia?

Treatment of Osteopenia in Elderly Postmenopausal Women

For elderly postmenopausal women with osteopenia (T-score between -1.0 and -2.5), treatment decisions should be based on individualized fracture risk assessment using FRAX or similar tools, with pharmacologic therapy recommended when 10-year risk of major osteoporotic fracture is ≥20% or hip fracture risk is ≥3%, prioritizing bisphosphonates as first-line therapy. 1

Risk Stratification and Treatment Thresholds

The diagnosis of osteopenia alone is not an indication for treatment or reassurance—it must be incorporated into quantitative fracture risk calculation. 2

• Women ≥65 years with osteopenia and high fracture risk should receive pharmacologic treatment when FRAX scores meet thresholds (≥20% for major osteoporotic fracture or ≥3% for hip fracture). 1

• For women with severe osteopenia (T-score <-2.0), treatment benefits are greater than for those with mild osteopenia (T-score -1.0 to -1.5). 1

• Additional risk factors that increase fracture risk include: low body weight (<70 kg), smoking, weight loss, family history of fractures, decreased physical activity, alcohol or caffeine use, low calcium and vitamin D intake, and history of height loss. 1

• Consider thoracic and lumbar spine radiographs or DXA with vertebral fracture assessment in osteopenic patients with height loss, as clinically silent vertebral fractures would trigger pharmacologic therapy regardless of FRAX score. 1

First-Line Pharmacologic Treatment

Bisphosphonates (alendronate, risedronate, zoledronic acid) are the recommended first-line therapy based on high-quality evidence showing cost-effective fracture reduction in older osteopenic women. 1, 3, 2

• Evidence from trials demonstrates that oral and intravenous bisphosphonates cost-effectively reduce fractures in older osteopenic women. 2

• Post hoc analysis of risedronate in women with advanced osteopenia (near T-score of -2.5) showed 73% reduction in fragility fracture risk compared to placebo. 1

• The fracture reduction benefit in osteopenic women with severe disease is similar to that seen in women with osteoporosis. 1

• Generic bisphosphonates are more cost-effective than denosumab for initial therapy. 4

Second-Line Options

Denosumab should be reserved as second-line therapy for patients with contraindications to bisphosphonates or who experience adverse effects. 3, 4

• Denosumab carries risk of rebound bone turnover and multiple vertebral fractures upon discontinuation, requiring transition to bisphosphonate if stopped. 3, 5

• Very high-risk patients (history of osteoporotic fracture, multiple risk factors, or bisphosphonate failure) may require anabolic agents like romosozumab or teriparatide as third-line therapy. 6

Essential Non-Pharmacologic Interventions

All elderly women with osteopenia require calcium and vitamin D supplementation regardless of pharmacologic treatment decisions. 1, 3

• Recommended daily intake: 1,000-1,500 mg calcium and 800-1,000 IU vitamin D. 1, 3

• Weight-bearing exercise for 30 minutes at least 3 days per week (including jogging or walking) improves bone mineral density and reduces fracture risk. 1

• Combination exercise programs including multiple exercise types and resistance training show greater effects on bone health. 1

• Programs should be undertaken for 60+ minutes, 2-3 times per week for 7+ months minimum for optimal bone health benefits. 1

• Smoking cessation and limitation of alcohol intake are strongly recommended. 1, 3

Evaluation for Secondary Causes

Before initiating treatment, evaluate for secondary causes of low bone density, as these are present in 35-40% of postmenopausal women with osteoporosis. 1

• Most common secondary causes in postmenopausal women: premenopausal estrogen deficiency and glucocorticoid exposure. 1

• Other important causes include: hypogonadism, malabsorption, tobacco use, alcohol abuse, low body weight, and various medications. 1

• Laboratory evaluation should include: serum calcium, phosphorus, 25-hydroxyvitamin D, alkaline phosphatase, and parathyroid hormone levels. 1

• Specific treatment of identified secondary causes is essential before or concurrent with osteoporosis therapy. 1

Treatment Duration and Monitoring

Initial bisphosphonate therapy duration should be 5 years, with reassessment of fracture risk to determine if continued therapy is warranted. 3

• Bone density monitoring is not recommended during the initial 5-year treatment period. 3

• After 5 years, reassess fracture risk using clinical factors and consider drug holiday for lower-risk patients or continuation for high-risk patients. 3

Important Caveats

The FRAX tool has not been validated in certain populations (such as HIV-infected persons) and may underestimate fracture risk in these groups. 1

Most fractures occur in osteopenic individuals rather than those with osteoporosis due to the larger number of people with osteopenia, making appropriate treatment of high-risk osteopenic patients crucial. 2

Avoid estrogen or estrogen plus progestogen therapy for osteoporosis treatment due to lack of fracture reduction benefit in established osteoporosis and association with serious harms. 1