What are the management options for an older adult or postmenopausal woman with osteopenia?

Management of Osteopenia in Older Adults and Postmenopausal Women

For postmenopausal women aged 65 or older with osteopenia (T-score between -1.0 and -2.5), treatment decisions must be based on individualized fracture risk assessment, with bisphosphonate therapy initiated for those at high risk (prior fragility fracture, FRAX ≥20% for major osteoporotic fracture or ≥3% for hip fracture, or T-score approaching -2.0), combined with calcium 1,200 mg daily and vitamin D 800 IU daily. 1, 2, 3

Risk Stratification Determines Treatment Threshold

The diagnosis of osteopenia alone does not automatically warrant pharmacologic treatment—fracture risk assessment is mandatory to guide management decisions. 2, 3

High-risk criteria requiring bisphosphonate therapy include: 2, 3

• Any history of fragility fracture (minimal trauma fracture), which triggers immediate pharmacologic therapy regardless of FRAX calculations
• FRAX 10-year risk ≥20% for major osteoporotic fracture OR ≥3% for hip fracture
• Severe osteopenia with T-score <-2.0, especially in women aged ≥65 years
• Family history of hip fracture in a parent combined with other risk factors
• Body weight <127 lb (58 kg) combined with other risk factors
• Current use of medications causing bone loss (glucocorticoids, aromatase inhibitors, anticonvulsants)

Low-risk patients with mild osteopenia (T-score -1.0 to -1.5) should focus on lifestyle modifications and supplementation only, as the balance of benefits and harms from bisphosphonates is less favorable in this population. 2

First-Line Pharmacologic Treatment for High-Risk Osteopenia

Oral bisphosphonates are the mandatory first-line therapy based on high-certainty evidence showing 50% reduction in hip fractures and 47-56% reduction in vertebral fractures over 3 years, with the most favorable balance of efficacy, safety, and cost. 1, 4, 2, 3

Specific bisphosphonate options include: 1, 2, 3, 5

• Alendronate 70 mg once weekly (preferred generic formulation)
• Risedronate 35 mg once weekly or 150 mg monthly
• Zoledronic acid 5 mg IV annually for patients unable to tolerate oral formulations due to gastrointestinal contraindications

Generic medications should be prescribed rather than expensive brand-name medications whenever possible. 1

Essential Supplementation (Non-Negotiable)

All patients with osteopenia—whether or not they receive bisphosphonates—must take calcium 1,200 mg daily and vitamin D 800 IU daily, as pharmacologic therapy is significantly less effective without adequate supplementation. 1, 4, 2, 3

Target serum vitamin D level ≥20 ng/mL, with higher doses (up to 2,000 IU daily) needed in certain populations with deficiency. 2

Critical caveat: Calcium and vitamin D alone are insufficient for fracture prevention in patients with established high fracture risk—they must be combined with bisphosphonates in high-risk patients. 4, 2, 3

Mandatory Lifestyle Modifications

All patients with osteopenia require the following non-pharmacologic interventions: 1, 2, 3, 6

• Weight-bearing exercise and progressive resistance training (most effective when combined)
• Balance training to reduce fall risk
• Smoking cessation
• Limit alcohol intake to <3 drinks daily
• Maintain healthy body weight (avoid excessive thinness)
• Fall prevention strategies at home (remove tripping hazards, improve lighting, install grab bars)

Evaluate and Treat Secondary Causes

All patients with osteopenia require workup for secondary causes of bone loss, including: 3

• Vitamin D deficiency (measure 25-hydroxyvitamin D level)
• Hypogonadism or premature ovarian failure
• Glucocorticoid exposure
• Malabsorption disorders (celiac disease, inflammatory bowel disease)
• Hyperparathyroidism
• Hyperthyroidism
• Excessive alcohol use

Treatment Duration and Monitoring

Initial treatment duration is 5 years with bisphosphonates. 1, 2, 3

Do not monitor bone density during the initial 5-year treatment period, as routine BMD monitoring during active treatment provides no clinical benefit. 1, 2, 3

After 5 years, reassess fracture risk to determine if continued therapy is warranted. 1, 2, 3 The decision for temporary bisphosphonate discontinuation (drug holiday) should be based on baseline fracture risk, type of medication and its half-life in bone, and benefits versus harms of discontinuation. 1

For patients not on pharmacologic therapy, monitor bone density every 2 years and initiate bisphosphonate therapy if T-score declines to ≤-2.5 (osteoporosis threshold). 2

Safety Profile and Adverse Effects

High-certainty evidence from randomized trials shows bisphosphonates cause no difference in serious adverse events compared to placebo at 2-3 years. 1, 3

Common mild adverse effects include: 3

• Mild upper gastrointestinal symptoms (dyspepsia, nausea)
• Influenza-like symptoms (with IV zoledronic acid)
• Myalgias and arthralgias
• Headaches

Rare but serious adverse effects with prolonged use (>5 years) include: 3

• Osteonecrosis of the jaw (very rare)
• Atypical femoral fractures (very rare)

This is why treatment duration is limited to 5 years initially with mandatory reassessment. 1, 2, 3

Second-Line Pharmacologic Options

For patients with contraindications to or intolerance of bisphosphonates, denosumab 60 mg subcutaneously every 6 months is the recommended second-line therapy. 1, 2, 3

Critical warning: Never discontinue denosumab abruptly without transitioning to bisphosphonate therapy—abrupt discontinuation causes rebound bone loss and multiple vertebral fractures in some patients. 1, 4, 3

Agents to Avoid in Osteopenia

The American College of Physicians strongly recommends against using menopausal estrogen therapy, estrogen plus progestogen therapy, or raloxifene for osteoporosis or osteopenia treatment due to unfavorable benefit-harm balance. 1, 3

Anabolic agents (teriparatide, abaloparatide, romosozumab) are reserved for very high-risk osteoporosis (not osteopenia) and should not be used as first-line therapy. 1, 3

Common Pitfalls to Avoid

Never use calcium and vitamin D alone as primary prevention in high-risk patients (prior fracture, FRAX ≥20% or ≥3%, T-score <-2.0)—these patients require bisphosphonates. 4, 2, 3

Never prescribe expensive brand-name bisphosphonates when generic alendronate or risedronate are equally effective. 1, 4

Never discontinue denosumab without transitioning to bisphosphonate. 1, 4, 3

Never monitor BMD during the initial 5-year treatment period—it provides no clinical benefit and does not change management. 1, 2, 3

Patient Education Priorities

Educate patients on: 1, 2

• Proper bisphosphonate administration (take on empty stomach with full glass of water, remain upright for 30-60 minutes)
• Expected duration of therapy (5 years initially)
• Importance of adherence to both medication and calcium/vitamin D supplementation
• Necessity of fall prevention strategies
• Osteopenia is asymptomatic until fracture occurs, making adherence critical