What is the appropriate management for a patient with osteopenia (T‑score –1.1 at total left hip and –1.7 at left femoral neck)?

Management of Osteopenia (T-score -1.1 Total Hip, -1.7 Femoral Neck)

For this patient with osteopenia (T-scores between -1.0 and -2.5), pharmacologic treatment is NOT routinely indicated based on bone density alone—instead, perform a comprehensive fracture risk assessment using FRAX, and initiate treatment only if the 10-year major osteoporotic fracture risk is ≥20% or hip fracture risk is ≥3%. 1, 2

Risk Stratification Approach

Your patient falls into the osteopenic range, which encompasses a wide spectrum of fracture risk 1. The critical next step is risk stratification:

• Calculate FRAX score incorporating age, BMD, and clinical risk factors (prior fracture, parental hip fracture, smoking, glucocorticoid use, rheumatoid arthritis, alcohol consumption) 1, 2, 3
• Treatment thresholds: Initiate pharmacologic therapy if FRAX shows major fracture risk ≥20% OR hip fracture risk ≥3% over 10 years 2, 3
• Special consideration: The femoral neck T-score of -1.7 approaches the threshold where fracture risk increases more substantially, particularly if the patient is ≥65 years old 1

Evidence for Treatment in Osteopenia

The decision to treat osteopenia is nuanced:

• Post hoc analysis data shows risedronate reduces fracture risk by 73% in women with advanced osteopenia (T-score near -2.5) and no prevalent vertebral fractures 1
• Most fractures occur in osteopenic patients despite lower individual risk, because this population is so large 4
• Number needed to treat (NNT) is much higher in osteopenia (NNT >100) compared to osteoporosis (NNT 10-20), making universal treatment cost-ineffective 5
• Women younger than 65 years with mild osteopenia (T-score -1.0 to -1.5) benefit less than older women with severe osteopenia (T-score <-2.0) 1

Baseline Evaluation Before Treatment Decisions

Perform these laboratory tests to exclude secondary causes of bone loss (present in 30-50% of patients) 3:

• Complete blood count (to detect malignant hemopathies or anemia) 3
• Serum calcium and phosphate (to identify hyperparathyroidism or phosphocalcic disorders) 3
• Creatinine with eGFR (affects bisphosphonate choice) 3
• Total alkaline phosphatase (to detect Paget's disease, osteomalacia, or bone metastases) 3
• TSH (to exclude hyperthyroidism causing accelerated bone loss) 3
• 25-hydroxyvitamin D level (target ≥30 ng/mL) 2, 3
• Serum protein electrophoresis with immunofixation if age ≥50 years (to exclude multiple myeloma) 3

Universal Interventions (Regardless of Treatment Decision)

Initiate these measures immediately for all patients with osteopenia 2, 3:

• Calcium supplementation: 1000-1200 mg daily 2, 3
• Vitamin D supplementation: 600-800 IU daily (or dose necessary to maintain 25-OH vitamin D ≥20-30 ng/mL) 2, 3
• Weight-bearing exercise: Regular physical activity reduces hip fracture risk independent of BMD 6
• Fall prevention strategies: Address modifiable risk factors including vision, medications causing dizziness, home hazards 1

Pharmacologic Treatment (If FRAX Thresholds Met)

If fracture risk assessment indicates treatment:

• First-line: Oral bisphosphonates (alendronate 70 mg weekly) 2, 3
• Alternative if bisphosphonates contraindicated or eGFR <35 mL/min: Denosumab 60 mg subcutaneously every 6 months 2, 3, 7
• Ensure vitamin D sufficiency (≥30 ng/mL) before initiating bisphosphonates 2, 3

Critical Pitfalls to Avoid

• Do not treat based on T-score alone: Osteopenia is not a disease diagnosis but a risk factor requiring contextualization 6, 5
• Do not delay calcium/vitamin D supplementation: Start immediately while completing the evaluation 2, 3
• Do not use FRAX if osteoporosis is present (T-score ≤-2.5): FRAX is specifically for osteopenia risk stratification 2
• Do not ignore secondary causes: Failure to identify and treat underlying conditions (vitamin D deficiency, hyperparathyroidism, hyperthyroidism) will undermine any treatment 3
• If denosumab is ever started and then stopped: Must transition to bisphosphonate to prevent rebound bone loss and multiple vertebral fractures 3

Age and Gender Considerations

• For men: Use the same T-score definitions and treatment thresholds as women 1, 2
• For patients <50 years: Use Z-score (not T-score), and consider osteopenia abnormal only if Z-score ≤-2.0; do not diagnose osteoporosis on BMD alone in this age group 1
• For patients ≥65 years with T-score <-2.0: The benefit-to-harm ratio favors treatment more strongly than in younger patients with milder osteopenia 1