Treatment of Osteopenia with Fragility Fracture
Patients with osteopenia and a history of fragility fracture should be treated with pharmacologic therapy using oral bisphosphonates (alendronate or risedronate) as first-line agents, combined with calcium and vitamin D supplementation. 1
Rationale for Treatment
The presence of a fragility fracture fundamentally changes the risk-benefit calculation, even when bone mineral density is only in the osteopenic range:
Treatment should be initiated in patients with a history of low-trauma fracture, even if DXA does not indicate osteoporosis. 1 This represents a critical clinical decision point that many providers miss—the fracture itself is the strongest predictor of future fractures, independent of BMD measurements.
Post-hoc analysis demonstrates that risedronate reduces fragility fracture risk by 73% in postmenopausal women with osteopenia (femoral neck T-score between -1.0 and -2.5) who have no prevalent vertebral fractures. 2 This magnitude of benefit is comparable to that seen in patients with frank osteoporosis.
More recent evidence shows zoledronate reduces the risk of nonvertebral or vertebral fragility fractures by 37% (hazard ratio 0.63) in women with osteopenia over 6 years, with a number needed to treat of only 15. 3
First-Line Pharmacologic Treatment
Initiate oral bisphosphonates as the primary therapeutic intervention:
Alendronate or risedronate are first-choice agents because they are well-tolerated, have low cost (generic forms available), reduce vertebral fractures by 47-48%, non-vertebral fractures by 26-53%, and hip fractures by 51%. 1, 4
These medications should be prescribed for 3-5 years initially, with continuation in patients who remain at high risk. 1
For patients with oral intolerance, dementia, malabsorption, or non-compliance, use zoledronic acid (intravenous every 18 months) or denosumab (subcutaneous every 6 months) as alternatives. 1
Essential Adjunctive Therapy
All patients must receive calcium and vitamin D supplementation concurrently:
Calcium 1000-1200 mg daily and vitamin D 800 IU daily should be prescribed, as this combination reduces non-vertebral fractures by 15-20% and falls by 20%. 1, 4, 5
Avoid high pulse doses of vitamin D, which paradoxically increase fall risk. 1
A serum vitamin D level of at least 20 ng/mL (50 nmol/L) is recommended for optimal bone health. 1
Non-Pharmacologic Interventions
Implement comprehensive fall prevention and lifestyle modifications:
Conduct multidimensional fall risk assessment and prescribe supervised weight-bearing exercise programs (30 minutes at least 3 days per week), which improve BMD, muscle strength, balance, and reduce fall frequency by approximately 20%. 1, 4, 5
Counsel on smoking cessation and limiting alcohol intake, as these lifestyle factors directly affect bone quality and fracture risk. 1
Monitoring and Follow-Up
Systematic follow-up is critical for treatment success:
Monitor for medication adherence, tolerance, and adverse effects through regular clinical visits, as long-term adherence to oral bisphosphonates is notoriously poor outside of structured fracture liaison services. 1
Order DXA scan of lumbar spine and hip to quantify baseline BMD and identify any undiagnosed vertebral fractures, as only one-third of vertebral fragility fractures are symptomatic. 4, 5
Risk communication and shared decision-making significantly improve adherence rates, which can reach up to 90% in fracture liaison services compared to much lower rates in usual care. 1
Common Pitfalls to Avoid
Do not withhold treatment based solely on BMD T-scores in the osteopenic range when a fragility fracture has occurred. The American College of Physicians recommends treatment decisions for osteopenic women 65 years or older at high fracture risk should be based on discussion of patient preferences, fracture risk profile, and medication benefits/harms—but the presence of a fragility fracture already establishes high risk. 1
Do not delay treatment while waiting for extensive secondary osteoporosis workup. While evaluation for secondary causes is appropriate (hypogonadism, vitamin D deficiency, malabsorption, glucocorticoid use), pharmacologic treatment should be initiated promptly in patients with fragility fractures. 1
Do not prescribe calcium supplementation alone without bisphosphonates in patients with fragility fractures. Calcium alone has no demonstrated effect on fracture reduction and is associated with gastrointestinal side effects. 1