What are the treatment options for osteopenia in a 65-year-old black female?

From the Guidelines

For a 65-year-old Black woman with osteopenia, I recommend an individualized approach to determine whether to start pharmacologic treatment with bisphosphonate to reduce the risk of fractures, considering her baseline risk for fracture and balancing benefits with harms and costs, as suggested by the American College of Physicians 1.

Lifestyle Modifications

To manage osteopenia, it is essential to start with lifestyle modifications, including:

• Weight-bearing exercise for 30 minutes most days of the week
• Ensuring adequate calcium intake of 1,200 mg daily through diet or supplements
• Vitamin D supplementation of 1,000-2,000 IU daily to maintain blood levels above 30 ng/mL
• Implementing fall prevention strategies, such as removing tripping hazards at home and having regular vision checks

Pharmacological Therapy

Pharmacological therapy is not typically first-line for osteopenia alone but may be considered if her FRAX score indicates a high risk for fracture.

• If medication is warranted, oral bisphosphonates like alendronate 70 mg weekly would be the initial choice, taken on an empty stomach with a full glass of water while remaining upright for 30-60 minutes afterward, as recommended by the American College of Physicians 1.
• It is crucial to consider that Black women often have higher bone mineral density than other racial groups, which should be taken into account when interpreting DXA results and making treatment decisions.

Monitoring and Treatment Effectiveness

Regular monitoring with repeat bone density testing every 2-3 years is recommended to assess disease progression and treatment effectiveness.

• The decision to treat should be based on a discussion of patient preferences, fracture risk profile, and benefits, harms, and costs of medications, as suggested by the American College of Physicians 1.

From the FDA Drug Label

Osteoporosis in Postmenopausal Women Osteoporosis is characterized by low bone mass that leads to an increased risk of fracture. The diagnosis can be confirmed by the finding of low bone mass, evidence of fracture on x-ray, a history of osteoporotic fracture, or height loss or kyphosis, indicative of vertebral (spinal) fracture Osteoporosis occurs in both males and females but is most common among women following the menopause, when bone turnover increases and the rate of bone resorption exceeds that of bone formation. These changes result in progressive bone loss and lead to osteoporosis in a significant proportion of women over age 50. Fractures, usually of the spine, hip, and wrist, are the common consequences From age 50 to age 90, the risk of hip fracture in white women increases 50-fold and the risk of vertebral fracture 15-to 30-fold. It is estimated that approximately 40% of 50-year-old women will sustain one or more osteoporosis-related fractures of the spine, hip, or wrist during their remaining lifetimes Hip fractures, in particular, are associated with substantial morbidity, disability, and mortality Daily oral doses of alendronate (5,20, and 40 mg for six weeks) in postmenopausal women produced biochemical changes indicative of dose-dependent inhibition of bone resorption, including decreases in urinary calcium and urinary markers of bone collagen degradation (such as deoxypyridinoline and crosslinked N-telopeptides of type I collagen) These biochemical changes tended to return toward baseline values as early as 3 weeks following the discontinuation of therapy with alendronate and did not differ from placebo after 7 months Long-term treatment of osteoporosis with alendronate sodium 10 mg/day (for up to five years) reduced urinary excretion of markers of bone resorption, deoxypyridinoline and cross-linked N-telopeptides of type I collagen, by approximately 50% and 70%, respectively, to reach levels similar to those seen in healthy premenopausal women Similar decreases were seen in patients in osteoporosis prevention studies who received alendronate sodium 5 mg/day. The decrease in the rate of bone resorption indicated by these markers was evident as early as one month and at three to six months reached a plateau that was maintained for the entire duration of treatment with alendronate sodium In osteoporosis treatment studies alendronate sodium 10 mg/day decreased the markers of bone formation, osteocalcin and bone specific alkaline phosphatase by approximately 50%, and total serum alkaline phosphatase by approximately 25 to 30% to reach a plateau after 6 to 12 months In osteoporosis prevention studies alendronate sodium 5 mg/day decreased osteocalcin and total serum alkaline phosphatase by approximately 40% and 15%, respectively Similar reductions in the rate of bone turnover were observed in postmenopausal women during one-year studies with once weekly alendronate sodium 70 mg for the treatment of osteoporosis and once weekly alendronate sodium 35 mg for the prevention of osteoporosis These data indicate that the rate of bone turnover reached a new steady-state, despite the progressive increase in the total amount of alendronate deposited within bone. As a result of inhibition of bone resorption, asymptomatic reductions in serum calcium and phosphate concentrations were also observed following treatment with alendronate sodium In the long-term studies, reductions from baseline in serum calcium (approximately 2%) and phosphate (approximately 4 to 6%) were evident the first month after the initiation of alendronate sodium 10 mg. No further decreases in serum calcium were observed for the five-year duration of treatment; however, serum phosphate returned toward prestudy levels during years three through five Similar reductions were observed with alendronate sodium 5 mg/day. In one-year studies with once weekly alendronate sodium 35 and 70 mg, similar reductions were observed at 6 and 12 months. The reduction in serum phosphate may reflect not only the positive bone mineral balance due to alendronate sodium but also a decrease in renal phosphate reabsorption

The treatment for osteopenia in a 65-year-old black woman may involve the use of bisphosphonates such as alendronate.

• Alendronate has been shown to reduce bone resorption and increase bone mass in postmenopausal women with osteoporosis.
• The recommended dosage of alendronate for the treatment of osteoporosis in postmenopausal women is 10 mg/day or 70 mg once weekly.
• It is essential to note that alendronate should be taken with plenty of water and the patient should remain upright for at least 30 minutes after taking the medication to reduce the risk of esophageal irritation.
• Additionally, calcium and vitamin D supplementation should be considered to support bone health.
• The patient should be monitored for adverse reactions such as gastrointestinal symptoms, musculoskeletal pain, and hypocalcemia.
• It is crucial to follow the recommended treatment guidelines and consult with a healthcare professional to determine the best course of treatment for the patient's specific condition 2.

From the Research

Treatment Options for Osteopenia

• Lifestyle interventions, such as calcium and vitamin D supplementation, smoking cessation, and increased physical activity, can help enhance peak bone mass and decrease bone loss in African American women, including a 65-year-old black woman with osteopenia 3.
• Hormone replacement therapy, bisphosphonates, and selective estrogen receptor modulators may also be considered as treatment modalities for osteopenia in this population, although further study is needed to determine their effectiveness in African American women 3.

Denosumab as a Treatment Option

• Denosumab has been shown to be effective in improving bone mineral density (BMD) and reducing bone turnover markers in patients with osteoporosis who are unresponsive to bisphosphonates 4, 5, 6, 7.
• Denosumab may be a valuable treatment option for improving BMD in patients with osteopenia, including those with intestinal failure receiving home parenteral nutrition 6 and those with systemic rheumatic disease receiving glucocorticoids 7.
• Switching to denosumab from bisphosphonates has been shown to result in significant increases in BMD and improvements in patient satisfaction in some patient populations 7.

Considerations for Treatment

• The risk factors for osteoporosis in African American women are similar to those found in Caucasian women, and treatment should be tailored to the individual patient's needs and medical history 3.
• The choice of treatment for osteopenia in a 65-year-old black woman should take into account her overall health, medical history, and potential risks and benefits of each treatment option 3, 4, 5, 6, 7.