What is the appropriate treatment and management plan for a patient with osteopenia?

Osteopenia Treatment: A Risk-Stratified Approach

For patients with osteopenia, treatment decisions must be driven by absolute fracture risk calculated using the FRAX tool, not by the T-score alone—pharmacological therapy is indicated only when 10-year hip fracture risk reaches ≥3% or major osteoporotic fracture risk reaches ≥20%, while all patients regardless of risk require calcium, vitamin D, and lifestyle modifications. 1, 2

Risk Stratification: The Critical First Step

Calculate fracture risk using FRAX (www.sheffield.ac.uk/FRAX), which integrates BMD with clinical risk factors including age, prior fracture, parental hip fracture, smoking, glucocorticoid use, and other factors. 1, 2 This calculation determines whether you observe or treat pharmacologically.

Key thresholds for pharmacological intervention: 1, 2

• 10-year hip fracture risk ≥3%, OR
• 10-year major osteoporotic fracture risk ≥20%

Special adjustment for glucocorticoid users (≥7.5 mg/day prednisone): Multiply major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2 before applying treatment thresholds. 1, 2

Universal Non-Pharmacological Management (All Patients)

Every patient with osteopenia requires these foundational interventions regardless of fracture risk: 1, 2

Calcium supplementation:

• Ages 19-50: 1,000 mg daily 1, 2
• Ages ≥51: 1,200 mg daily 1, 2
• Calcium citrate formulations taken between meals optimize absorption and minimize gastrointestinal side effects 3

Vitamin D supplementation:

• Ages 19-70: 600 IU daily 1, 2
• Ages ≥71: 800 IU daily 1, 2
• Target serum 25-hydroxyvitamin D level ≥20 ng/mL (some guidelines recommend ≥30 ng/mL) 1
• Doses of 800 IU/day combined with adequate calcium reduce non-vertebral fractures by 15-20% 4

Exercise prescription:

• Weight-bearing exercises (walking, jogging, stair climbing) 1, 2
• Muscle-strengthening/resistance training 1, 2
• Balance training (tai chi, physical therapy, dancing) to reduce fall risk 1, 2
• Minimum 30 minutes of moderate physical activity daily 2

Lifestyle modifications:

• Smoking cessation (mandatory) 1, 2
• Limit alcohol to 1-2 drinks per day maximum 1, 2
• Maintain weight in recommended range (low BMI is an independent risk factor) 1, 2

Fall prevention strategies:

• Vision and hearing assessment 1, 2
• Medication review (sedatives, antihypertensives causing orthostasis) 1, 2
• Home safety evaluation (remove tripping hazards, improve lighting, install grab bars) 1, 2

Pharmacological Treatment (High-Risk Patients Only)

First-line therapy: Oral bisphosphonates 1, 2

• Alendronate 10 mg daily or 70 mg weekly 1
• Risedronate 5 mg daily, 35 mg weekly, or 150 mg monthly 1
• Preferred due to proven efficacy in reducing vertebral, non-vertebral, and hip fractures, favorable safety profile, low cost (generics available), and extensive clinical experience 4, 1

Second-line alternatives when oral bisphosphonates are inappropriate (due to esophageal disorders, inability to remain upright ≥30 minutes post-dose, malabsorption, non-compliance, or patient preference): 1

1. IV zoledronic acid 5 mg once yearly 1

   • For patients with oral intolerance, dementia, malabsorption, or adherence concerns 4
   • Contraindicated if creatinine clearance <35 mL/min 1

2. Denosumab 60 mg subcutaneously every 6 months 1

   • Alternative for patients intolerant to bisphosphonates 4, 1
   • Critical warning: Requires careful discontinuation planning—stopping denosumab causes rebound bone loss and increased vertebral fracture risk; must transition to another agent 1

3. Teriparatide (anabolic agent) 1

   • Reserved for very severe osteoporosis or patients who have failed bisphosphonates 4, 1
   • Higher cost and burden of daily injections 4

4. Raloxifene 60 mg daily (postmenopausal women only) 1

   • Selective estrogen receptor modulator 1
   • Not used in men or premenopausal women 4

Critical Pre-Treatment Evaluation

Before initiating any pharmacological therapy, you must identify and correct secondary causes of low bone density: 1, 2

• Vitamin D deficiency (measure serum 25-hydroxyvitamin D) 1
• Hypogonadism 1, 2
• Excessive alcohol use 1, 2
• Glucocorticoid exposure 1, 2
• Hyperparathyroidism 1
• Thyroid disease 1

Excluding osteomalacia is mandatory before prescribing bisphosphonates—treating osteomalacia (commonly from vitamin D deficiency) with anti-resorptive agents increases bone fragility and fracture risk. 1

Special Populations Requiring Modified Approach

Cancer survivors (especially on aromatase inhibitors or causing hypogonadism): 4, 1, 2

• Obtain baseline DEXA and repeat every 2 years 4
• Bisphosphonates or denosumab are preferred agents for high fracture risk 4, 1, 2
• Perform dental screening before initiating bone-modifying agents to reduce osteonecrosis of jaw risk 2

Glucocorticoid users (≥2.5 mg/day prednisone for ≥3 months): 4, 1

• Fracture risk assessment within 6 months of starting therapy 1
• Apply FRAX dose adjustment (multiply risks by 1.15 and 1.2 as noted above) 1, 2
• Annual clinical fracture risk reassessment mandatory 1, 2
• More aggressive treatment thresholds apply 4

Liver transplant recipients: 1, 2

• Calcium and vitamin D supplementation plus weight-bearing exercise 1, 2
• Initiate bisphosphonates for established osteoporosis or recurrent fractures 1

Women of childbearing potential: 4

• If not planning pregnancy and using effective contraception: oral bisphosphonates preferred 4
• If oral bisphosphonates unsuitable: teriparatide second-line 4
• Denosumab and IV bisphosphonates only after discussion of potential fetal harm in unplanned pregnancy 4

Monitoring Strategy

For patients NOT on pharmacological therapy (low fracture risk): 1, 2

• Repeat DEXA every 2-3 years depending on risk factors 1
• Annual clinical fracture risk reassessment 1

For patients ON pharmacological therapy: 1, 2

• Repeat DEXA every 2 years to evaluate treatment response 1, 2
• Do not perform BMD assessment more frequently than annually 4, 1
• Monitor adherence systematically—poor adherence is extremely common 4, 1
• Consider discontinuation of bone-modifying agent when T-scores improve, followed by periodic DEXA surveillance 2

Common Pitfalls to Avoid

Over-treating low-risk patients: Osteopenia is not a disease—it encompasses a wide range of fracture risks. 5 The T-score alone does not justify pharmacological treatment; absolute fracture risk calculated by FRAX determines intervention. 1, 2, 5

Under-treating high-risk patients: Only 5-62% of patients who meet treatment criteria actually receive appropriate therapy. 1, 2 Systematic identification and treatment of high-risk patients is essential.

Failing to address secondary causes: Treating with bisphosphonates without correcting vitamin D deficiency, hypogonadism, or other reversible contributors renders therapy ineffective or harmful. 1

Ignoring adherence: Long-term adherence to osteoporosis medications is notoriously poor. 4 Structured follow-up, patient education, risk communication, and shared decision-making substantially improve adherence (up to 90% in fracture liaison services). 4

Stopping denosumab without transition therapy: This causes rapid bone loss and vertebral fracture risk elevation—always plan sequential therapy. 1