How can osteopenia be reduced?

How to Reduce Osteopenia

For osteopenia, start with calcium 1,000-1,200 mg daily plus vitamin D 600-800 IU daily combined with weight-bearing exercise, smoking cessation, and alcohol limitation; add oral bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) only if you have prior fragility fracture OR FRAX shows ≥20% 10-year major osteoporotic fracture risk OR ≥3% hip fracture risk. 1, 2

Risk Stratification Determines Whether You Need Medication

Osteopenia alone is NOT a disease and does NOT automatically require drug therapy. 1, 3 The T-score between -1.0 and -2.5 represents a wide spectrum of fracture risk that must be individualized. 2, 4

When to Start Pharmacologic Treatment

You need medication if ANY of the following apply:

• History of fragility fracture (low-trauma fracture from standing height or less) – this triggers immediate treatment regardless of FRAX score 1, 2
• FRAX calculation shows ≥20% 10-year risk of major osteoporotic fracture 1, 2
• FRAX shows ≥3% 10-year risk of hip fracture 1, 2
• T-score approaching -2.5 (especially <-2.0) in patients ≥65 years 1, 2
• Height loss with suspected vertebral fracture – obtain spine X-rays; silent vertebral fractures mandate treatment 2

When Medication is NOT Needed

• Mild osteopenia (T-score -1.0 to -1.5) in women <65 years without other risk factors derives minimal benefit from treatment 2
• Low FRAX scores (<20% major fracture risk and <3% hip fracture risk) – focus on lifestyle measures only 1, 2

Universal Measures for ALL Patients (With or Without Medication)

Calcium and Vitamin D Supplementation

• Calcium 1,000-1,200 mg daily from diet plus supplements 5, 1
• Vitamin D 600-800 IU daily (some guidelines recommend 800 IU) 5, 1
• Target serum 25-hydroxyvitamin D ≥20 ng/mL (some experts prefer ≥30 ng/mL) 1, 2
• For documented deficiency (<20 ng/mL): vitamin D₂ 50,000 IU weekly for 8-12 weeks, then monthly maintenance OR vitamin D₃ 2,000 IU daily for 12 weeks then 1,000-2,000 IU daily 1

Critical point: Pharmacologic therapy is significantly less effective without adequate calcium and vitamin D supplementation. 1

Lifestyle Modifications

• Weight-bearing exercise (walking, jogging) ≥30 minutes on ≥3 days per week 1
• Resistance training to improve muscle strength and reduce fall risk 1
• Balance training especially for older adults to prevent falls 1
• Smoking cessation – tobacco accelerates bone loss 5, 1
• Limit alcohol to 1-2 drinks per day maximum 5, 1
• Maintain healthy body weight – low BMI (<19 kg/m²) is a risk factor 5, 1
• Fall prevention: address vision problems, review medications causing dizziness, remove home hazards 2

Pharmacologic Treatment When Indicated

First-Line: Oral Bisphosphonates

Oral bisphosphonates are mandatory first-line therapy based on the most favorable balance of efficacy, safety, and cost. 5, 1

Specific options:

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

Efficacy: Bisphosphonates reduce hip fractures by 50% and vertebral fractures by 47-56% over 3 years. 1 In women with severe osteopenia (T-score <-2.0), risedronate reduced fracture risk by 73%. 1, 2

Administration: Take oral bisphosphonates on empty stomach in morning, 0.5-2 hours before food and other drugs, at a different time than calcium supplements (calcium inactivates bisphosphonates). 5

Second-Line: Denosumab

• Denosumab 60 mg subcutaneously every 6 months for patients with contraindications to or intolerance of bisphosphonates 5, 1
• Also use denosumab if eGFR <35 mL/min (bisphosphonates contraindicated) 2
• Critical warning: Never discontinue denosumab abruptly without transitioning to bisphosphonate therapy – abrupt discontinuation causes rebound bone loss and multiple vertebral fractures 1, 2

Treatment Duration and Monitoring

• Initial treatment duration: 5 years with bisphosphonates 5, 1
• Do NOT monitor bone density during the initial 5-year treatment period – no clinical benefit demonstrated 1
• After 5 years: Reassess fracture risk to determine if continued therapy is warranted 5, 1
• Bisphosphonates reduce fractures even when BMD does not increase or actually decreases 1

Adverse Effects to Monitor

Common (not serious):

• Mild upper GI symptoms (bisphosphonates, denosumab) 5
• Influenza-like symptoms, myalgias, arthralgias, headaches (especially zoledronic acid) 5, 1
• Rash/eczema (denosumab) 5, 1

Rare but serious:

• Osteonecrosis of the jaw 5
• Atypical subtrochanteric femoral fractures 5
• High-quality evidence shows no difference in serious adverse events compared to placebo at 2-3 years 1

Agents to AVOID

The American College of Physicians strongly recommends AGAINST:

• Menopausal estrogen therapy (increased stroke, VTE, breast cancer risk) 5, 1
• Estrogen plus progestogen therapy (increased invasive breast cancer, node-positive tumors, breast cancer deaths) 5
• Raloxifene (increased thromboembolic events, pulmonary embolism, cerebrovascular death, hot flashes) 5, 1

These agents have unfavorable benefit-harm balance for osteopenia/osteoporosis treatment. 1

Evaluate and Treat Secondary Causes

Perform comprehensive workup in ALL osteopenic patients – secondary causes are found in 30-50% of cases. 1, 2

Laboratory Screening Panel

• Complete blood count 2
• Serum calcium and phosphate 2
• Creatinine with eGFR 2
• Total alkaline phosphatase 2
• TSH 2
• 25-hydroxyvitamin D level 2
• Serum protein electrophoresis with immunofixation (patients ≥50 years to rule out multiple myeloma) 2

Key Secondary Causes to Address

• Vitamin D deficiency 5, 1, 2
• Hypogonadism/premature menopause (age <45 years) 5, 1
• Glucocorticoid exposure (prednisone ≥5 mg/day for ≥3 months) 5, 1
• Malabsorption disorders 1, 2
• Hyperparathyroidism 1, 2
• Hyperthyroidism 1, 2
• Chronic alcohol use (≥3 units/day) 5, 1
• Smoking 5, 1

When a reversible secondary cause is identified, initiate targeted therapy for that condition before or concurrently with anti-osteoporotic pharmacotherapy. 1

Common Pitfalls to Avoid

• Do NOT treat based on T-score alone – osteopenia requires fracture risk assessment via FRAX 1, 2
• Do NOT delay calcium and vitamin D supplementation while completing evaluation 2
• Do NOT apply FRAX to patients with T-score ≤-2.5 (already meet osteoporosis criteria) 2
• Do NOT overlook secondary causes – untreated underlying conditions undermine therapy effectiveness 2
• Do NOT use anabolic steroids in patients with liver disease 5