Osteopenia Medications

How is osteopenia treated?

Having osteopenia means that your bones have weaker than normal bone density, but it has not progressed to a low enough bone mass to be diagnosed with osteoporosis. Osteopenia can progress to osteoporosis over time and in the setting of other factors (e.g. medications that cause bone loss, such as steroids and certain breast cancer medications), but it can also stabilize after menopause.

The goal after a diagnosis of osteopenia is to preserve as much bone density as possible. An important way to do this is with lifestyle strategies such as incorporating resistance, weight-bearing and balance exercises, a healthy diet, and getting enough calcium and vitamin D (Cleveland Clinic, 2021). For postmenopausal women, it is important to get a total of 1,200 mg of calcium daily through diet and supplement combined (AACE 2020 Osteoporosis Clinical Practice Guidelines, 2020). Avoid the use of tobacco and excessive use of alcohol, and include fall prevention strategies such as eliminating risk factors for falling and ensuring a safe environment.

You might be able to prevent osteopenia from progressing to osteoporosis through lifestyle changes, but people with an increased risk of the condition may need osteopenia medication to counter bone loss and protect their bone mineral density. Whether you might also benefit from osteopenia medications depends on your bone density score (often called a T-score), your history of prior fractures, and other risk factors. If you've already had a fragility fracture (a low-trauma bone fracture that would not have occurred in healthy bone), you may be at higher risk of fracture and can be diagnosed with osteoporosis despite findings on a bone density scan that may be in an osteopenia range. 

What is osteopenia?

The word osteoporosis literally means “porous bones.” Imagine that your bones are like the wooden beams supporting your home. Tiny mice are constantly eating away at the old, worn wood. Cells called osteoclasts do the same thing in your body by breaking down old bone in a process called bone resorption.

Meanwhile, tiny construction workers constantly rebuild the beams to strengthen them. In bones, cells called osteoblasts rebuild collagen and minerals like calcium (also known as bone formation) that keep bones strong (Johns Hopkins Medicine, 2022).  

When bone breaks down faster than it is being rebuilt, tiny holes form inside your bones and weaken them. Osteoporosis happens when the bones become so porous that they fracture easily (Johns Hopkins Medicine, 2022).  

Osteopenia happens earlier in this process. Your bones start to lose some minerals and density, but not enough for you to be diagnosed with osteoporosis. And your fracture risk isn't as high as it would be with osteoporosis.

Both men and women can develop osteopenia, but it affects women more often because they have lower bone mass to begin with. Postmenopausal women are at the highest risk for ongoing bone loss. Before menopause, estrogen promotes the action of bone-building osteoblasts. When estrogen production drops during menopause, that protective effect lessens and bone loss accelerates (Endocrine Society, 2022).

How is osteopenia diagnosed?

There are a few ways your doctor can determine if you have osteopenia or osteoporosis. One way is by obtaining a bone density test or scan. Dual x-ray absorptiometry (DEXA or DXA) scans are a type of imaging test that shows how dense your bones are compared to those of a healthy younger person. This scan will also give you a bone mineral density score, which can help you determine your degree of bone loss. The second way osteoporosis can be diagnosed is based on an osteoporotic fracture. An osteoporotic fracture is a type of fracture that is, in and of itself, an indication of osteoporosis regardless of what your bone density test shows) (Bone Health and Osteoporosis Foundation, 2022).

DXA scan results are represented as a T-score, as shown below.

Medications for osteopenia

Deciding whether to take medication for osteopenia is an individualized decision tailored to your bone density as measured by your bone density scan (DEXA scan and T-score), bone fracture history, and risk of future fractures (Varacallo, 2022). If your bone density scan is in an osteopenia range (T-score between -1 and -2.5) your doctor will calculate your risk for breaking a bone over the next 10 years and if the risk of a hip and/or major fracture is greater than a certain threshold, they may recommend medication.

Your doctor might prescribe medication for osteopenia if you're age 50 or older and:

• You've had a fragility fracture in the past
• Your T-score is between -1 and -2.5 and you're at high risk for a fracture
• Your T-score is -2.5 or higher (Iqbal, 2019)

It's important to weigh the pros of taking medication against cons like potential side effects and cost. Your personal preferences should also factor into the decision.

If your doctor does recommend medication, the same classes of treatment used for osteoporosis are also used to treat osteopenia. Below are some of these options.

Bisphosphonates

Bisphosphonates are typically the first treatment for osteopenia, and the most commonly prescribed medication for the condition. These medications work by slowing the breakdown of bone by osteoclasts, which helps to preserve bone strength (Varacallo, 2022).

How long will you have to stay on bisphosphonates? 

If you're initially at very high risk for fracture and remain at high risk, you might keep taking one of these medications for up to 10 years. For patients at “high fracture risk”, a “drug holiday” from bisphosphonates may be considered after 5 years of stability on oral bisphosphonates (AACE 2020 Osteoporosis Clinical Practice Guideline). 

Common bisphosphonate drugs include: (Varacallo, 2022; American College of Rheumatology, 2023)

• Alendronate (Fosamax): A pill that you take once a day or weekly. It can reduce the risk of hip, spine, and wrist fractures by 50%.
• Ibandronate (Boniva): A pill that you take once a month. It may reduce the risk for vertebral, but not hip fractures and alendronate and risedronate are often used instead. 
• Risedronate (Actonel): A pill you take once a month, week or day. It may reduce the risk of spine and hip fractures.
• Zoledronic acid (Reclast): An intravenous (IV) infusion that you get into your arm once a year. It can reduce the risk of new spinal fractures and hip fractures significantly, by ~70% and 40% respectively

The most common side effects with bisphosphonates include: 

• Upset stomach
• Heartburn
• Flu-like symptoms (intravenous form of bisphosphonates)

Most people do not experience any severe side effects. Very rarely, people who take these medications can develop a break in the front of the thigh bone, called an atypical femoral fracture. Osteonecrosis (death of the bone) of the jaw is another rare side effect that can happen after an invasive dental procedure. It's more common in people who have cancer and are on more frequent dosing of these medications (Mayo Clinic, 2022).

Denosumab (Xgeva, Prolia)

Denosumab is a medication with a different mechanism of action than the bisphosphonates, called a RANKL inhibitor. It preserves bone mineral density by blocking a substance that helps osteoclasts mature and survive and as a result reduces bone loss (Hildebrand, 2022).

Denosumab is given as a subcutaneous  injection into the upper arm, thigh, or belly every six months. The most common side effects from this medication include mild symptoms such as fatigue, joint pains and headaches. Rare complications such as skin rashes, osteonecrosis of the jaw and an atypical femoral fracture have been reported (Hildebrand, 2022).

It is very important with denosumab to stay on schedule with dosing every six months and not miss a dose, which can result in significant bone loss and a potential for fractures. Once your bone density has been improved and your fracture risk is better, your doctor will switch you off of denosumab usually onto a bisphosphonate. There is no “drug holiday” on denosumab due to how it works and it is always followed by another bone medication. You can be on denosumab for up to 10 years with continued improvement in your bone density.

Hormone replacement therapy

Hormone replacement therapy or hormone therapy (HRT) is a treatment for menopause. This was previously considered a treatment of choice for postmenopausal osteoporosis although never specifically approved for this use. The FDA has approved estrogen for the prevention of postmenopausal osteoporosis if a woman is at increased risk for osteoporosis and not a candidate for other non-estrogen medications (AACE 2020 Osteoporosis Clinical Practice Guideline).

As the name indicates, hormone replacement therapy replaces the hormone estrogen. Progestin should also be given in patients with an intact uterus to protect against endometrial stimulation. Along with relieving menopause symptoms like hot flashes and vaginal dryness, hormone replacement therapy also helps prevent bone loss in women with osteopenia and osteoporosis (Thacker, 2018).

This treatment also comes with potential side effects, such as blood clots, and controversy regarding heart and breast cancer risks which is why current recommendations are to use the lowest possible dose of estrogen for relief of menopausal symptoms for the shortest period of time (The North American Menopause Society, 2023).

It may not be worth using this medication solely to protect your bones, but if you are going through menopause and hormone replacement therapy helps with those symptoms, your healthcare provider may keep you on it for the bone benefits.

Raloxifene (Evista)

Raloxifene is part of a group of medications called selective estrogen receptor modulators (SERMs). It acts like estrogen in helping to protect your bones but also carries a 3-times increase in risk of clotting (similar to estrogen) (Royal Osteoporosis Society, 2022).

Raloxifene may be appropriate initial therapy in some cases for patients requiring drugs with spine-specific protection (but not hip). Since raloxifene has not been shown to reduce hip or non-spine fractures, it may not be the best treatment choice for many people with osteoporosis. When raloxifene is discontinued, the benefits on bone are lost quickly during the following 1-2 years. Raloxifene has been found to  decrease the risk of breast cancer in women who are at higher-than-usual risk for the disease and is taken as a tablet once daily (BreastCancer.org, 2022). Thus this may be an attractive choice to use in patients at high breast cancer risk and bone loss in the spine but not hip.

Teriparatide (Forteo)/Abaloparatide (Tymlos)

AACE 2020 Osteoporosis Clinical Practice Guidelines recommend the use of bone-building (anabolic medications) if you are at a very high risk for fractures or have prior osteoporotic fractures.

Teriparatide and abaloparatide are PTH (parathyroid hormone) agonists, which means they naturally help stimulate new bone formation and build bone mineral density. It comes as an injection that you take once a day (Johns Hopkins, 2023). Teriparatide requires refrigeration and abaloparatide does not. These medications can be used for 2 years and then followed by a bisphosphonate or Prolia. These medications should not be used if you have had prior radiation.

Romosozumab (Evenity)

Romosozumab is a bone-building medication that is a monoclonal antibody against sclerostin, given once a month as a shot in your doctor's office for a year. It is also recommended for people who are at very high risk for fractures. After treatment for one year this medication must be followed by a bisphosphonate or Prolia for long-term treatment. There is a black-box warning for romosozumab that states that it should not be used in patients at high risk for cardiovascular events or who have had recent myocardial infarction or stroke.

Who needs medication for osteopenia?

The decision to take medication comes down to a few factors, including your bone mineral density score, your fracture history, and risk factors such as:

• Being age 50 or older
• Having a history of falls
• Having a condition such as rheumatoid arthritis that puts you at an increased risk of osteoporosis
• Strong family history of osteoporosis or fracture
• Taking certain medications long-term, such as prednisone 
• Smoking tobacco, which makes you more prone to get osteoporosis and fractures (Lewiecki, 2021)

Is medication enough to treat osteopenia?

Regardless of whether you require medication for osteopenia, it's worth adopting lifestyle habits that benefit your bone strength. Many osteoporosis risk factors are modifiable, including nutrition, smoking, and exercise. So even if you have a family history of the condition, you can lower your risk by making a few key changes to your daily routine (International Osteoporosis Foundation, 2023).

Proper nutrition for bone health

Eating a healthy diet has a big impact on your bone health. Calcium is a major structural component of bones. Vitamin D helps your body absorb calcium from your diet. When you don't get enough vitamin D, your body produces extra parathyroid hormone (PTH), which activates osteoclasts to break down bone (International Osteoporosis Foundation, 2023).

According to the AACE, the recommended calcium intake for adults over 50 is 1,200 mg/day. This includes calcium from milk and other dietary sources, plus calcium supplements if necessary when dietary intake is insufficient. AACE also recommends that you maintain your vitamin D intake and supplement with vitamin D3 if needed (daily dose of 1,000 to 2,000 IU, typically). 

If you don't get enough calcium and vitamin D from dietary sources such as milk and leafy green vegetables, your healthcare provider might recommend a supplement. Because the FDA does not regulate supplements closely, ask your healthcare provider or pharmacist for a recommendation before you buy anything off the shelf.

Don't smoke and drink less

Smoking is harmful to your body in many ways including bone health. The chemicals it contains reduce your body's ability to absorb calcium, which can contribute to low bone density. Nicotine slows the formation of new osteoblasts that remodel bone (Germany J, 2023). The exact mechanism of action is unclear but smokers should be counseled on tobacco cessation. For these and other reasons, current smokers are 25% more likely to fracture a bone than non-smokers (International Osteoporosis Foundation, 2023).

Alcohol in large quantities puts you at an increased risk of fracture. Postmenopausal women at risk for osteoporosis should be advised to limit excessive alcohol intake. Consuming more than 2 drinks daily is considered excessive.

Dial back your salt

Beyond its effects on blood pressure, salt in high quantities (sodium) can increase the amount of calcium your body removes in urine which can result in bone loss. Urine sodium levels can be measured if your doctor suspects you are losing calcium in your urine from too much daily sodium intake.   

Dial back your caffeine

Large amounts of caffeine can disrupt calcium absorption in the bones. Some observational studies have shown an increased association between high consumption of caffeinated beverages and fractures. To avoid getting too much of it in your diet, try to limit your caffeine intake to less than 1-2 servings (8-12 ounces/serving) of caffeinated drinks daily.

Exercises for bone health

Exercise does more than build muscle. It also maintains healthy bones by stimulating new bone formation and decreasing bone breakdown. Staying fit improves balance, too, which helps to prevent falls that might lead to a fracture (International Osteoporosis Foundation, 2023).

The best types of exercise for strengthening bones fall into three categories:

1. Weight-bearing exercise: Fast walking, stair climbing, high- or low-impact aerobics
2. Resistance training: Lifting weights or working out with resistance bands
3. Balance exercises: Tai Chi, standing on one leg

Looking for a way to incorporate these exercises into your life? An exercise program that targets the full body and incorporates these types of exercise, like Wellen, is a great starting point.

Osteopenia medications FAQs

What is the best medicine for osteopenia?

The best medicine for osteopenia depends on your individual health and risk factors. Bisphosphonates are a first-line treatment and the most commonly prescribed medicines for this condition because they slow bone loss, which can protect your bone density and reduce the risk of fractures. But other treatments are also effective if bisphosphonates aren't a good option for you.

Should osteopenia be treated with medication?

Not everyone will need to treat osteopenia with medication. The goal after diagnosis is to maintain bone density and slow bone loss to prevent osteoporosis. Your doctor will use your bone density score, your history of prior fractures, and other risk factors to decide if you should treat osteopenia with medication. Some people can protect their bone density through supportive lifestyle changes like including certain exercises and taking calcium and vitamin D supplements.

What medications are bad for osteopenia?

With osteopenia, the goal is to maintain bone density. Some medications prescribed for other reasons work against this goal and cause bone loss. The most common ones that cause bone loss are steroids and certain breast cancer medications. If your bone density is at risk, your doctor will evaluate all of your medical needs to suggest the best path forward for your bone mineral density and overall health. It's important that you don't stop these medications without consulting your doctor.

What meds are approved for osteopenia?

There are few FDA-approved medications to treat osteopenia (or to prevent osteoporosis). That list currently includes Actonel and Evista. But doctors are able to prescribe medications commonly used in osteoporosis treatment to some patients with osteopenia if they're the right choice for that individual.