What is the recommended treatment plan for a woman with osteopenia on a DEXA scan?

Treatment Plan for Women with Osteopenia on DEXA

For women with osteopenia, treatment decisions must be based on comprehensive fracture risk assessment using the FRAX tool, not bone density alone—initiate oral bisphosphonates combined with calcium 1,200 mg daily and vitamin D 800 IU daily if FRAX shows ≥20% risk of major osteoporotic fracture OR ≥3% risk of hip fracture, or if there is any history of fragility fracture. 1, 2

Risk Stratification Determines Treatment Threshold

High-risk osteopenia requiring immediate pharmacologic therapy includes:

• Any history of fragility fracture (hip, vertebral, or other minimal trauma fracture), which mandates treatment independent of FRAX calculations 2
• FRAX-calculated 10-year probability ≥20% for major osteoporotic fracture OR ≥3% for hip fracture 1, 2, 3
• Severe osteopenia with T-score <-2.0 in patients ≥65 years with additional risk factors 2, 4
• Height loss suggesting silent vertebral fractures—obtain spine radiographs or vertebral fracture assessment; presence of vertebral fractures mandates treatment regardless of FRAX score 2

Additional high-risk features that lower treatment threshold:

• Family history of hip fracture in a parent 2
• Body weight <127 lb (58 kg) 2
• Current use of medications causing bone loss (glucocorticoids ≥7.5 mg/day prednisone for ≥3 months, aromatase inhibitors, androgen deprivation therapy) 1, 2
• Current smoking 2

First-Line Pharmacologic Treatment for High-Risk Osteopenia

Oral bisphosphonates are 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

• Alendronate 70 mg once weekly (preferred for cost and efficacy) 2
• Risedronate 35 mg once weekly (alternative with similar efficacy; evidence shows 73% lower fragility fracture risk in severe osteopenia) 2, 4
• Zoledronic acid 5 mg IV annually (for patients unable to tolerate oral formulations due to GI contraindications or concerns about adherence) 2

Essential Supplementation (Universal Requirement)

All osteopenic patients must receive calcium and vitamin D supplementation, as pharmacologic therapy is significantly less effective without adequate supplementation: 2

• Calcium 1,200 mg daily (from diet plus supplements) 1, 2
• Vitamin D 800 IU daily (target serum 25-hydroxyvitamin D ≥20 ng/mL) 1, 2
• For documented vitamin D deficiency (<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

Mandatory Lifestyle Modifications (All Patients)

These interventions are required for all osteopenic women regardless of whether they receive pharmacologic therapy: 1, 2

• Weight-bearing aerobic exercise (walking, jogging) for at least 30 minutes on ≥3 days per week to improve bone density 1, 2
• Resistance and muscle-strengthening exercises to reduce fall risk 2
• Balance-training programs to further diminish fall likelihood, especially in older adults 2
• Smoking cessation (tobacco accelerates bone loss and increases fracture incidence) 1, 2
• Limit alcohol consumption to no more than 1-2 standard drinks per day 1, 2
• Maintain healthy body weight within recommended range 1, 2

Evaluation for Secondary Causes of Bone Loss

Perform comprehensive workup for secondary contributors in every osteopenic patient before or concurrent with initiating pharmacologic therapy: 2

Key secondary causes to assess:

• Vitamin D deficiency 2
• Hypogonadism/estrogen deficiency 2
• Glucocorticoid exposure 2
• Malabsorption syndromes (celiac disease, inflammatory bowel disease) 2
• Hyperparathyroidism 2
• Hyperthyroidism 2
• Chronic alcohol or opioid misuse 2

Laboratory screening panel (detects secondary causes with ~92% sensitivity): 2

• Serum calcium
• Phosphorus
• 25-hydroxyvitamin D
• Alkaline phosphatase
• Parathyroid hormone (PTH)

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 with bisphosphonates is 5 years: 1, 2

• Do NOT monitor bone density during the initial 5-year treatment period—bisphosphonates reduce fractures even when BMD does not increase or actually decreases, and routine monitoring provides no clinical benefit 1, 2
• After 5 years, reassess fracture risk using FRAX to determine if continued therapy is warranted 1, 2
• Patients at low risk for fracture after 5 years can be considered for drug discontinuation 2

For patients NOT meeting treatment thresholds (low-risk osteopenia):

• Repeat DEXA scan every 2 years to monitor bone density 1
• Reassess fracture risk annually using clinical risk factors 1
• Earlier reassessment warranted if new risk factors develop 1

Second-Line Pharmacologic Options

For patients with contraindications to or intolerance of oral bisphosphonates (e.g., esophageal disorders, severe GERD, inability to remain upright for 30 minutes): 2

• Denosumab 60 mg subcutaneously every 6 months is the recommended alternative 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 in Osteopenia

The American College of Physicians strongly recommends AGAINST the following therapies due to unfavorable benefit-harm balance: 2

• Menopausal estrogen therapy 2
• Estrogen plus progestogen therapy 2
• Raloxifene 2
• Teriparatide and romosozumab (reserved for very high-risk osteoporosis, not osteopenia) 2

Safety Profile and Adverse Effects

High-certainty evidence shows bisphosphonates cause no difference in serious adverse events compared to placebo at 2-3 years: 2

Common mild adverse effects:

• Mild upper GI symptoms (dyspepsia, nausea) 2
• Influenza-like symptoms (with IV zoledronic acid) 2
• Myalgias, arthralgias, headaches 2

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

• Osteonecrosis of the jaw (risk increases with dental procedures) 2
• Atypical femoral fractures 2

This is why treatment duration is limited to 5 years with mandatory reassessment—the risk of severe adverse effects increases with prolonged bisphosphonate use. 2

Common Pitfalls to Avoid

• Do not treat based on bone density alone—osteopenia diagnosis is not an indication for treatment; fracture risk assessment using FRAX is mandatory 1, 2, 4
• Do not undertreat high-risk patients—any history of fragility fracture mandates treatment even with osteopenia 2
• Do not overtreat low-risk patients—FRAX <20% major osteoporotic fracture and <3% hip fracture without other high-risk features does not warrant pharmacologic therapy 1, 2
• Do not monitor BMD during active treatment—it provides no clinical benefit and bisphosphonates work regardless of BMD changes 1, 2
• Do not use estrogen, raloxifene, or teriparatide for osteopenia—these have unfavorable risk-benefit profiles for this indication 2