How should I manage a 69-year-old female diagnosed with osteopenia (bone mineral density T-score –1.0 to –2.5)?

Management of Osteopenia in a 69-Year-Old Female

For a 69-year-old woman with osteopenia (T-score -1.0 to -2.5), treatment decisions should be based on calculated 10-year fracture risk using FRAX, not the T-score alone, with pharmacological therapy reserved for those meeting specific high-risk criteria. 1

Initial Risk Stratification

Calculate the patient's 10-year fracture risk using FRAX immediately to determine whether pharmacological intervention is warranted. 1, 2 The diagnosis of osteopenia alone does not constitute a treatment imperative, as the number needed to treat exceeds 100 in this population compared to 10-20 in patients with established osteoporosis. 2

Key Risk Factors to Assess

• Personal history of fragility fracture after age 50 (strongest indicator for treatment) 1
• Family history of hip fracture (particularly maternal hip fracture after age 50) 3, 1
• Current smoking status 3, 1
• Low body weight (BMI <24 or weight <127 lbs) 3, 1
• History of prolonged glucocorticoid use (>6 months) 1
• Height loss >4 cm (suggests vertebral compression fractures) 3

Non-Pharmacological Management (First-Line for All Patients)

All osteopenic patients should receive comprehensive lifestyle interventions regardless of fracture risk: 1

• Calcium supplementation: 1,000-1,200 mg daily (through diet or supplements) 4, 1
• Vitamin D supplementation: 800-1,000 IU daily 4, 1
• Weight-bearing and resistance exercise regimen 4, 1
• Smoking cessation and alcohol limitation 4, 1

These interventions may reduce hip fracture risk independent of bone density and should be implemented before considering pharmacological therapy. 3, 5

Indications for Pharmacological Therapy

Initiate bisphosphonate therapy if the patient meets ANY of the following criteria: 1, 2

• 10-year major osteoporotic fracture risk ≥20% (based on FRAX calculation) 6
• 10-year hip fracture risk ≥3% 6
• History of fragility fracture after age 50 (hip, vertebral, proximal humerus, or pelvis) 1, 6
• Two or more additional risk factors (family history of hip fracture, current smoking, BMI <24, glucocorticoid use >6 months) 1

A 2024 Lancet review supports that major osteoporotic fracture risks of 10-15% could be acceptable indications for treatment with generic bisphosphonates in motivated patients older than 65 years, as most fractures occur in osteopenic individuals due to their greater numbers. 7

Pharmacological Treatment Options

If treatment is indicated, oral bisphosphonates are first-line therapy: 1, 2

• Alendronate 70 mg once weekly 4
• Risedronate 35 mg once weekly or 150 mg once monthly 4, 1
• Ibandronate 150 mg once monthly 4, 1

Alternative Options

• Zoledronic acid 5 mg IV every 2 years (for patients unable to tolerate oral bisphosphonates or with adherence concerns) 1
• Denosumab 60 mg subcutaneously every 6 months (particularly for patients who cannot tolerate bisphosphonates) 1

Critical Administration Requirements for Oral Bisphosphonates

Patients must meet ALL of the following criteria to safely use oral bisphosphonates: 4

• Ability to stand or sit upright for at least 30 minutes after taking medication 4
• Take medication on an empty stomach with plain water only 4
• No esophageal abnormalities or swallowing difficulties 4

The American Geriatrics Society case example illustrates that patients with hiatal hernia or poor medication adherence may not be suitable candidates for oral bisphosphonates. 3

Monitoring Strategy

Repeat BMD measurement in 1-2 years to assess for progression or treatment response. 4, 1 Ensure measurements are conducted at the same facility using the same DXA system for accurate comparison, as a significant change is considered 1.1% or greater. 1

Evaluate for secondary causes of osteoporosis if initiating treatment, including serum calcium, phosphate, 25-hydroxyvitamin D, parathyroid hormone, thyroid function, and renal function. 4

Treatment Duration

Bisphosphonate therapy typically continues for 3-5 years, then reassess the need for continuation based on fracture risk and BMD response. 4 Evidence shows benefits begin after 9-12 months of treatment in high-risk patients. 3

Critical Pitfalls to Avoid

• Do not initiate pharmacologic therapy based solely on T-score without calculating fracture risk, as osteopenia encompasses a wide range of fracture risks. 5, 2
• Address calcium and vitamin D deficiency before initiating pharmacologic therapy to optimize treatment response. 1
• If denosumab is used, never discontinue without transitioning to another antiresorptive agent due to risk of rebound bone loss and increased fracture risk. 1
• Proton pump inhibitors decrease calcium absorption and increase fracture risk, which should be considered in the overall risk assessment. 3
• Degenerative changes in the lumbar spine may artificially elevate BMD measurements, potentially masking true bone loss. 1

Special Consideration for Vertebral Fractures

Consider DXA vertebral fracture assessment (VFA) if the patient has: 3

• Age ≥70 years with T-score <-1.0 3
• Historical height loss >4 cm 3
• Self-reported but undocumented prior vertebral fracture 3
• Glucocorticoid use ≥5 mg prednisone daily for ≥3 months 3

Vertebral fractures are diagnostic of osteoporosis even with osteopenic BMD values and significantly elevate future fracture risk. 8, 6