Should a 65-year-old patient with osteopenia, a FRAX (Fracture Risk Assessment Tool) score of 8.9% for major osteoporotic fractures and 0.9% for hip fractures, and T scores of -1.3 in the lumbar spine and -1.6 in the femoral neck be started on a bisphosphonate, such as alendronate (alendronic acid) or risedronate, to reduce her risk of osteoporotic fractures?

Should You Start a Bisphosphonate for This Patient?

No, you should not start a bisphosphonate for this 65-year-old patient with osteopenia (T-scores of -1.3 lumbar spine, -1.6 femoral neck) and FRAX scores of 8.9% for major osteoporotic fracture and 0.9% for hip fracture, as her fracture risk falls well below the treatment thresholds established by current guidelines. 1, 2

Treatment Thresholds for Osteopenia

The American College of Physicians establishes clear treatment thresholds that your patient does not meet:

• Initiate bisphosphonates if 10-year FRAX risk is ≥20% for major osteoporotic fracture OR ≥3% for hip fracture 1, 2
• Your patient's scores (8.9% major, 0.9% hip) are substantially below both thresholds 1, 2
• Her T-scores (-1.3 and -1.6) place her in the mild osteopenia range, not the severe osteopenia (T-score < -2.0) where treatment benefit is more favorable 1

Why Treatment Is Not Indicated

The number needed to treat (NNT) in osteopenia is much higher (>100) compared to patients with osteoporosis (NNT 10-20), making widespread treatment in this population inadvisable 3:

• The absolute benefit of bisphosphonate therapy is low in women without baseline vertebral fractures and mild osteopenia 4
• Treatment efficacy in the osteopenic range is less well established than in patients with T-scores below -2.5 3
• The balance of benefits versus harms (including rare but serious adverse events like osteonecrosis of the jaw and atypical femoral fractures) is unfavorable at this low fracture risk 1

Evidence Supporting Conservative Management

The 2025 USPSTF guideline demonstrates that screening programs target much higher-risk populations:

• Studies showing fracture reduction benefit enrolled patients with mean 10-year FRAX scores of 19-24.6% for major osteoporotic fractures and 6.7-11.6% for hip fractures 1
• These are 2-3 times higher than your patient's current risk 1

The American College of Physicians specifically recommends an individualized approach for women over 65 with osteopenia, emphasizing that women with mild osteopenia (T-score between -1.0 and -1.5) benefit less than those with severe osteopenia 1.

What You Should Do Instead

Implement non-pharmacologic interventions and reassess fracture risk periodically 2, 5:

• Calcium supplementation: 1,000-1,200 mg daily 2, 5
• Vitamin D supplementation: 600-800 IU daily (target serum level ≥20 ng/mL) 2, 5
• Weight-bearing exercise: 30 minutes at least 3 times weekly 2, 5
• Smoking cessation and alcohol limitation: Both accelerate bone loss 2, 5
• Repeat FRAX calculation in 1-2 years or if clinical risk factors change 1

When to Reconsider Treatment

You should reconsider bisphosphonate therapy if any of the following develop 1, 2:

• Low-energy fracture occurs (treatment indicated regardless of FRAX score) 1, 2
• FRAX score increases to ≥20% for major osteoporotic fracture or ≥3% for hip fracture 1, 2
• T-score declines to < -2.0 (severe osteopenia threshold) 1
• Additional risk factors emerge: prolonged corticosteroid use, significant weight loss, family history of hip fracture 1

Common Pitfalls to Avoid

• Do not treat based on T-score alone in the osteopenic range - an osteopenic T-score does not constitute a treatment imperative 3
• Do not assume FRAX scores remain static - recalculate when clinical circumstances change, as age alone will increase fracture risk over time 1
• Do not overlook secondary causes of bone loss - ensure you've ruled out conditions like vitamin D deficiency, hyperparathyroidism, or celiac disease before attributing low bone density to primary osteoporosis 5