ESSENTIALS OF DIAGNOSIS
Patients are typically asymptomatic.
Bone density below that for young normal adults but less severe than osteoporosis.
Diagnosis is by DXA.
Fracture risk determined with FRAX tool.
Osteopenia is less severe than osteoporosis, with T scores between –1.0 and –2.4 (see above). There is no absolute fracture threshold for BMD, and 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 monitoring for worsening BMD.
Patients with osteopenia 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, and ribs.
Patients with 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 BUN, 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.
C. DXA Bone Densitometry and FRAX
Osteopenia is diagnosed by DXA bone densitometry with T scores of –1.0 to –2.4. 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, and 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 (see above) should be determined with each DXA BMD determination.
Patients with osteopenia require adequate vitamin D intake to achieve serum 25-OH vitamin D levels above 30 ng/mL (75 nmol/L). Calcium supplementation 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. Balance exercises such as tai chi may help prevent falls. Other fall prevention measures include reduction of tranquilizer and alcohol consumption, visual or walking aids when warranted, removal of home tripping hazards, and adequate night lighting.
Pharmacologic therapy is not usually required for patients with osteopenia. However, pharmacologic intervention treatments (see osteoporosis) may be required for patients who require long-term high-dose prednisone, for patients with fragility fractures, and for those whose FRAX score indicates a 10-year risk for fracture above 20% or hip fracture risk above 3%.
et al. Role of bisphosphonate therapy in patients with osteopenia: a systemic review. Cureus. 2019;11:e4146.