What is the best treatment approach for a 67-year-old individual with osteopenia?

Treatment for Osteopenia in a 67-Year-Old

Treatment decisions for osteopenia must be based on comprehensive fracture risk assessment using FRAX, not bone density alone—initiate oral bisphosphonates combined with calcium 1,200 mg daily and vitamin D 800 IU daily only if the patient has prior fragility fracture OR FRAX shows ≥20% risk of major osteoporotic fracture OR ≥3% risk of hip fracture. 1, 2

Risk Stratification Determines Treatment Threshold

The diagnosis of osteopenia (T-score between -1.0 and -2.5) does not automatically warrant pharmacologic treatment. 1, 2 The decision hinges on calculating 10-year fracture risk:

• Calculate FRAX score immediately to determine 10-year probability of major osteoporotic fracture and hip fracture. 2, 3
• Initiate bisphosphonate therapy if FRAX shows ≥20% risk of major osteoporotic fracture OR ≥3% risk of hip fracture. 1, 2, 3
• Any history of fragility fracture (minimal trauma fracture) triggers immediate pharmacologic therapy regardless of FRAX score or T-score, as this represents high fracture risk that warrants treatment independent of calculations. 2, 4
• Severe osteopenia (T-score <-2.0) has significantly higher fracture risk than mild osteopenia (T-score -1.0 to -1.5), which influences treatment decisions. 4

Additional high-risk features that lower the treatment threshold include family history of hip fracture in a parent, body weight <127 lb (58 kg), and current use of medications causing bone loss. 3

First-Line Pharmacologic Treatment

Oral bisphosphonates are the mandatory first-line therapy based on high-certainty evidence showing 40-70% reduction in vertebral fractures and 40-53% reduction in hip fractures, with the most favorable balance of efficacy, safety, and cost. 2, 4

Specific bisphosphonate options include:

• Alendronate 70 mg once weekly (oral) 1, 2
• Risedronate 35 mg once weekly (oral) 1, 2
• Zoledronic acid 5 mg IV annually for patients unable to tolerate oral formulations or with compliance concerns 1, 2

Essential Supplementation (Mandatory for All Patients)

All patients must receive calcium 1,200 mg daily and vitamin D 800 IU daily, as pharmacologic therapy is significantly less effective without adequate supplementation. 2, 3, 4 Target serum vitamin D level ≥20 ng/mL. 2

Mandatory Lifestyle Modifications

Implement the following for all patients with osteopenia, regardless of whether pharmacologic treatment is initiated:

• Weight-bearing exercise 30 minutes at least 3 days per week 1, 3, 4
• Resistance training exercises 1, 2
• Smoking cessation 2, 3, 4
• Limit alcohol intake 2, 3
• Fall prevention strategies 2
• Maintain healthy body weight 2

Evaluate Secondary Causes of Bone Loss

All patients with osteopenia require workup for secondary causes, including:

• Vitamin D deficiency 2, 4
• Hypogonadism 2, 4
• Glucocorticoid exposure 2, 4
• Malabsorption disorders 2
• Hyperparathyroidism 2
• Hyperthyroidism 2
• Alcohol abuse 2

Patients with osteopenia due to glucocorticoid use (≥30 mg/day prednisone or equivalent) may benefit from earlier intervention with bisphosphonates. 3, 4

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 bisphosphonates reduce fractures even when bone density does not increase or actually decreases. 2, 3
• After 5 years, reassess fracture risk to determine if continued therapy is warranted. 1, 2, 3
• Patients at low risk for fracture should be considered for drug discontinuation after 3-5 years. 1, 2

Second-Line Treatment Options

Denosumab 60 mg subcutaneously every 6 months is the recommended alternative for patients with contraindications to or intolerance of bisphosphonates. 2, 3, 4

Critical warning: Never discontinue denosumab abruptly without transitioning to bisphosphonate therapy—abrupt discontinuation is associated with multiple vertebral fractures in some patients. 2, 4

Agents to Avoid

The American College of Physicians strongly recommends against using menopausal estrogen therapy, estrogen plus progestogen therapy, or raloxifene for osteopenia treatment due to unfavorable benefit-harm balance. 2, 4

Teriparatide and romosozumab are reserved for very high-risk osteoporosis (not osteopenia) and should not be used as first-line therapy. 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, 2 Common adverse effects include mild upper GI symptoms, influenza-like symptoms, myalgias, arthralgias, and headaches. 2 Rare adverse effects include osteonecrosis of the jaw and atypical femoral fractures, with risk increasing with prolonged use beyond 5 years. 2

Common Pitfalls to Avoid

• Do not treat based on T-score alone—most fractures occur in osteopenic individuals, but the number needed to treat is much higher (NNT>100) than in osteoporosis (NNT 10-20), making risk stratification essential. 5, 6
• Do not overtreat low-risk patients or undertreat high-risk patients—use FRAX systematically. 3
• Do not perform bone density scans more than annually or during the initial 5-year treatment period. 3