Osteopenia Treatment and Management

Assessment and Risk Stratification

The American College of Rheumatology recommends that fracture risk should be calculated using the FRAX tool, which should be adjusted by 1.15 for major osteoporotic fracture risk and 1.2 for hip fracture risk if prednisone dose is >7.5 mg/day 2
The American College of Rheumatology suggests that pharmacological treatment should be considered when FRAX calculation shows a 10-year risk of hip fracture ≥3% or 10-year risk of major osteoporotic fracture ≥20% 1
For patients on glucocorticoids, the American College of Rheumatology recommends clinical fracture risk reassessment should be performed every 12 months 3

The American College of Rheumatology recommends that calcium intake should be optimized to 1,000-1,200 mg/day for all adults 3, 1
The American College of Rheumatology suggests that vitamin D intake should be 600-800 IU/day (with a target serum level ≥20 ng/ml) 3, 1
Regular weight-bearing and resistance training exercises are recommended to improve bone density, according to the American College of Rheumatology and other guidelines 4, 1
Lifestyle modifications include maintaining weight in recommended range, smoking cessation, and limiting alcohol intake to 1-2 alcoholic beverages per day, as recommended by the American College of Rheumatology 3, 1

The American College of Rheumatology recommends oral bisphosphonates (such as alendronate) as first-line therapy due to safety, cost, and efficacy for adults ≥40 years at moderate-to-high fracture risk 2
Alternative therapies if oral bisphosphonates are not appropriate (in order of preference) include IV bisphosphonates, teriparatide, denosumab, and raloxifene, according to the American College of Rheumatology 2

The American College of Rheumatology recommends that repeat DEXA should be performed every 2 years or as clinically indicated to monitor treatment response 1
Bone mineral density assessment should not be conducted more than annually, as recommended by the American College of Rheumatology 1

Even with appropriate recommendations, adherence to preventive therapies for bone health is often poor, with only 5-62% of patients on glucocorticoid therapy receiving appropriate preventive therapies, according to the Journal of Hepatology 5
Secondary causes of osteopenia (vitamin D deficiency, hypogonadism, alcoholism, glucocorticoid exposure) should be identified and treated, as recommended by the Clinical Infectious Diseases journal 4