Osteopenia Treatment
Treatment decisions for osteopenia should be based on fracture risk stratification, with bisphosphonates recommended as first-line therapy for women aged 65 or older with severe osteopenia (T-score < -2.0), while younger women or those with mild osteopenia (T-score -1.0 to -1.5) should focus on lifestyle modifications and calcium/vitamin D supplementation. 1, 2
Risk Stratification Framework
The critical distinction is that osteopenia is not a treatment indication by itself—it is a risk factor that must be incorporated into fracture risk assessment. 3 The approach differs dramatically based on age and T-score severity:
High-Risk Osteopenia (Treat with Bisphosphonates)
- Women ≥65 years with T-score < -2.0 should receive bisphosphonate therapy 1, 2
- Post hoc analysis of risedronate trials showed 73% reduction in fragility fractures in women with advanced osteopenia near the osteoporosis threshold 1
- This fracture reduction is similar to that seen in women with frank osteoporosis 1
Low-Risk Osteopenia (Lifestyle Modifications Only)
- Women <65 years with any osteopenia 1, 2
- Women ≥65 years with mild osteopenia (T-score -1.0 to -1.5) 1, 2
- These groups have unfavorable benefit-harm balance from bisphosphonates given lower baseline fracture risk and potential for prolonged drug exposure 1
Additional Risk Factors to Consider
Beyond age and T-score, assess for factors that increase fracture risk and may shift treatment decisions: 1
- Previous fracture as an adult
- Family history of hip fracture
- Low body weight
- Smoking
- Corticosteroid use
- Excessive alcohol or caffeine consumption
- Low calcium and vitamin D intake
- Decreased physical activity
Note: While FRAX scores are widely used, no RCT evidence demonstrates that using FRAX for treatment decisions improves fracture outcomes. 1
First-Line Pharmacologic Treatment (When Indicated)
Bisphosphonates are the first-line agents with the most favorable benefit-harm-cost profile: 1, 4
Specific Bisphosphonate Options
- Alendronate 70 mg once weekly (oral) 4
- Risedronate 35 mg once weekly (oral) 4
- Zoledronic acid 5 mg once yearly (IV)—ideal for patients with GI intolerance or compliance concerns 4
Treatment Duration and Monitoring
- Treat for 5 years initially, then reassess fracture risk to determine if continuation is warranted 2, 4
- Do not routinely monitor BMD during the initial 5-year treatment period—fracture reduction occurs even without BMD increases 4
- The risk for severe adverse effects increases with prolonged bisphosphonate use 1
Essential Non-Pharmacologic Interventions (For All Patients)
Calcium and Vitamin D Supplementation
- Calcium: 1,000-1,200 mg daily 2, 4
- Vitamin D: 600-800 IU daily (higher doses up to 2,000 IU may be needed in certain populations) 2, 4
- These are mandatory adjuncts to any pharmacologic therapy and insufficient as monotherapy 4
Exercise Program
- Combination programs are most effective: weight-bearing activities plus progressive resistance training 2
- Include balance training to reduce fall risk 2
Lifestyle Modifications
Monitoring for Untreated Patients
Women not receiving pharmacologic therapy should have BMD monitored every 2 years and be reconsidered for bisphosphonate therapy if T-score declines to ≤-2.5 (osteoporosis threshold). 2
Common Pitfalls to Avoid
- Do not treat all osteopenia uniformly—most fractures occur in osteopenic individuals due to their greater numbers, but individual fracture risk varies widely 3
- Avoid raloxifene—it increases venous thromboembolism, pulmonary embolism, and fatal stroke risk with an unfavorable benefit-harm profile 4
- Avoid menopausal estrogen therapy for osteoporosis treatment—unfavorable benefit-harm profile 4
- Do not use calcium or vitamin D alone as primary fracture prevention—uncertain efficacy as monotherapy 4
- Recognize that denosumab causes rapid rebound bone loss with multiple vertebral fracture risk upon discontinuation 4