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For further information, see CMDT Part 26-17: Osteopenia

Key Features

Essentials of Diagnosis

  • Patients are typically asymptomatic

  • Bone mineral density (BMD) below that for young normal adults, but less severe than osteoporosis

  • Diagnosis is by dual energy x-ray absorptiometry (DXA)

  • Fracture risk determined with FRAX tool

General Considerations

  • There is no absolute fracture threshold for BMD

  • Most patients with bone fractures are found to have osteopenia, rather than osteoporosis

  • Patients who are identified as osteopenic require an evaluation for causes of osteoporosis or osteomalacia and surveillance for worsening BMD

Clinical Findings

  • Patients are typically asymptomatic

  • However, bone pain can be present, particularly with osteomalacia

  • Osteopenia predisposes to low-impact and pathological fractures of

    • Vertebrae

    • Hips

    • Wrists

    • Metatarsals

    • Ribs

Diagnosis

Laboratory Findings

  • Moderate to severe osteopenia

    • T scores between –1.5 and –1.4 require an evaluation for underlying causes of osteoporosis and osteomalacia

    • Testing should include a serum blood urea nitrogen, creatinine, albumin, calcium, phosphate, alkaline phosphatase, and 25-OH vitamin D; a complete blood count is also recommended

    • A serum PTH is obtained if the serum calcium is abnormal

DXA Bone Densitometry & FRAX

  • T scores of –1.0 to –2.4 are diagnostic

  • The frequency of surveillance DXA testing for postmenopausal women and elderly men should be based on the T scores: obtain DXA testing

    • Every 5 years for T scores –1.0 to –1.5

    • Every 3–5 years for T scores –1.5 to –2.0

    • Every 1–2 years for T scores below –2.0

  • Patients requiring high-dose long-term prednisone therapy should have DXA surveillance every 1–2 years

  • FRAX score should be determined with each DXA BMD determination

Treatment

  • Pharmacologic therapy is not usually required; exceptions include

    • Patients who require long term high dose prednisone or

    • Patients whose FRAX score indicates a 10-year risk for fracture above 20% or hip fracture risk above 3%

Outcome

Prevention

  • Adequate vitamin D intake is required to achieve serum 25-OH vitamin D levels above 30 ng/mL (75 nmol/L)

  • Calcium supplementatation is not usually required, except for patients with unusually low dietary calcium intake

  • Lifestyle modifications may be required, including smoking cessation, alcohol moderation, strength training and weight-bearing exercise

  • Measures that may prevent falls

    • Balance exercises, such as tai chi

    • Reduction of tranquilizer and alcohol consumption

    • Visual or walking aids when warranted

    • Removal of home tripping hazards

    • Adequate night lighting

References

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Grossman  DC  et al. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Apr 17;319(15):1592–9.
[PubMed: 29677309]
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