What is the recommended management for an adult with osteopenia (T‑score –1.0 to –2.5)?

Management of Osteopenia in Adults

For adults with osteopenia (T-score –1.0 to –2.5), treatment decisions must be based on comprehensive fracture risk assessment using the FRAX tool, not bone density alone, with bisphosphonates initiated when 10-year major osteoporotic fracture risk ≥20% or hip fracture risk ≥3%, combined with mandatory calcium 1,200 mg daily and vitamin D 800 IU daily for all patients. 1, 2

Risk Stratification Determines Treatment Threshold

The diagnosis of osteopenia is not an indication for treatment—it simply identifies a population requiring fracture risk assessment. 3, 4 Most osteoporotic fractures actually occur in patients with osteopenia rather than osteoporosis, because the osteopenic population is much larger despite having individually lower risk. 5, 4

Initiate pharmacologic therapy immediately if any of the following are present:

• History of fragility fracture after age 50 (fracture from standing height or less)—this triggers treatment regardless of FRAX calculations 1, 2
• FRAX 10-year major osteoporotic fracture risk ≥20% 6, 1, 2
• FRAX 10-year hip fracture risk ≥3% 6, 1, 2
• T-score between –2.0 and –2.5 with additional risk factors (family history of hip fracture, current smoking, BMI <24, glucocorticoid use >6 months) 1, 2

For patients reporting height loss, obtain thoracic/lumbar spine radiographs or DXA with vertebral fracture assessment to detect silent vertebral fractures, as their presence mandates treatment irrespective of FRAX score. 2

First-Line Pharmacologic Treatment

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, with the most favorable balance of efficacy, safety, and cost. 1, 2

Specific bisphosphonate regimens:

• Alendronate 70 mg once weekly (most cost-effective option) 1, 2
• Risedronate 35 mg once weekly or 150 mg once monthly 6, 1
• Ibandronate 150 mg once monthly 6
• Zoledronic acid 5 mg IV annually (for patients unable to tolerate oral formulations) 1, 2

Essential Non-Pharmacologic Interventions for ALL Patients

Every patient with osteopenia requires the following, regardless of whether pharmacologic therapy is initiated:

• Calcium 1,000-1,200 mg daily (preferably through diet) 6, 1, 2
• Vitamin D 800-1,000 IU daily (target serum 25-OH-D ≥20 ng/mL) 6, 1, 2
• Weight-bearing exercise (walking, jogging) for ≥30 minutes on ≥3 days per week 2
• Resistance and muscle-strengthening exercises to reduce fall risk 2
• Balance-training programs especially in older adults 2
• Smoking cessation (tobacco accelerates bone loss) 6, 1, 2
• Limit alcohol to ≤1-2 drinks per day 6, 1, 2
• Fall prevention strategies 6, 1

For documented vitamin D deficiency (25-OH-D <20 ng/mL), prescribe high-dose repletion: vitamin D₂ 50,000 IU weekly for 8-12 weeks followed by monthly dosing, or vitamin D₃ 2,000 IU daily for 12 weeks then 1,000-2,000 IU daily for maintenance. 2

Evaluate and Treat Secondary Causes

All patients with osteopenia require workup for secondary causes of bone loss before or concurrent with treatment initiation. 1, 2 Laboratory screening should include serum calcium, phosphorus, 25-hydroxyvitamin D, alkaline phosphatase, and parathyroid hormone—this panel detects secondary causes with approximately 92% sensitivity. 2

Key secondary causes to assess:

• Vitamin D deficiency 1, 2
• Hypogonadism/estrogen deficiency 1, 2
• Glucocorticoid exposure 1, 2
• Malabsorption disorders 1, 2
• Hyperparathyroidism 1, 2
• Hyperthyroidism 1, 2
• Chronic alcohol or opioid misuse 2

When a reversible secondary cause is identified, initiate targeted therapy for that condition before or concurrently with anti-osteoporotic pharmacotherapy. 2

Treatment Duration and Monitoring

Initial treatment duration is 5 years with bisphosphonates. 1, 2 Do not monitor bone density during the initial 5-year treatment period—bisphosphonates reduce fractures even when bone density does not increase or actually decreases. 1, 2

After 5 years, reassess fracture risk to determine if continued therapy is warranted. 1, 2 Patients at low risk for fracture should be considered for drug discontinuation after 3-5 years. 2

For patients NOT receiving pharmacologic therapy: Repeat DXA scan in 1-2 years using the same facility and same DXA machine for accurate comparison, with a significant change defined as ≥1.1%. 1 Monitor for progression to osteoporosis (T-score ≤–2.5). 1

Second-Line Treatment Options

Denosumab 60 mg subcutaneously every 6 months is the recommended alternative for patients with contraindications to or intolerance of bisphosphonates. 1, 2

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

Agents to Avoid

Strongly avoid the following agents due to unfavorable benefit-harm balance:

• Menopausal estrogen therapy 1, 2
• Estrogen plus progestogen therapy 1, 2
• Raloxifene 1, 2

Teriparatide and romosozumab are reserved for very high-risk osteoporosis (not osteopenia) and should not be used as first-line therapy. 2

Common Pitfalls to Avoid

Lumbar spine measurements may be artificially elevated by degenerative changes (osteophytes, facet sclerosis), potentially masking true bone loss—rely more heavily on hip measurements in older adults with degenerative spine disease. 1

Bisphosphonates have high-certainty evidence showing no difference in serious adverse events compared to placebo at 2-3 years, but rare adverse effects include osteonecrosis of the jaw and atypical femoral fractures with prolonged use. 1, 2 Common adverse effects include mild upper GI symptoms, influenza-like symptoms, myalgias, arthralgias, and headaches. 2

The number needed to treat in osteopenia (NNT >100) is much higher than in patients with osteoporosis and prior fracture (NNT 10-20), which is why risk stratification is essential. 4