Osteopenia Medications and Treatment

Medication Options for Osteopenia (Low Bone Density)

doctor talking with elderly male patient about osteopenia
What treatment options are available for osteopenia?. Getty Images Credit: PeopleImages

If you've been diagnosed with osteopenia (low bone density) your doctor may have recommended treatment. What medication options are available if you don't yet have "full blown" osteoporosis, and when is it advantageous to consider treatment?

Osteopenia: Low Bone Density

Osteopenia means low bone density, but what exactly does this mean? It's easiest to understand osteopenia when we compare it to both normal bone density and osteoporosis (very low bone density).

Normal bone density means that the density and architecture of your bones is normal. On a bone density test, the number you would see if your bone density were normal would be higher than -1.0. In other words, your bone density would be at or better than one standard deviation below normal.

Osteoporosis is condition in which bones have become brittle and are more likely to break, even with mild injuries. A bone density test with osteoporosis gives a T-score of -2.5 or worse, meaning that a person's bone density is 2.5 standard deviations below the average bone density of a healthy young adult or worse.

Osteopenia lies between these numbers, with a T-score of better than -2.5 but worse than -0.1. The chance that osteopenia will progress to osteoporosis depends on your age, other medical conditions you have, medications you are taking, and much more.

Treating Osteopenia

There are many factors to consider before treating osteopenia, and this is currently a controversial and hot topic.

If osteopenia is combined with fractures, it's likely that treatment can make a difference. It's less clear whether treating osteopenia without fractures is beneficial.

There are FDA-approved medications for the prevention of osteoporosis (and therefore for osteopenia). These medications are effective but some of them have serious side effects.

Some doctors are hesitant to prescribe osteoporosis medications for osteopenia while others are aggressive in trying to slow bone loss. The real goal in treating both osteopenia and osteoporosis is preventing fractures, especially of the hip and spine. Doctors can calculate your 10-year fracture risk based on your current bone mineral density and other risk factors. That 10-year risk is the biggest consideration when thinking about taking medications for osteopenia.

A side note, though important, is that many health insurance companies do not recognize osteopenia as a condition that requires treatment and therefore may not cover the cost (sometimes substantial) of these drugs.

When Should Osteopenia Be Treated?

As noted earlier, the treatment of osteopenia is controversial. That said, when treatment is begun at this stage in people who are expected to progress to osteoporosis, or have other underlying conditions, treating osteopenia may prevent the development of osteoporosis and fractures. Conditions in which osteopenia may be more serious include:

  • Osteopenia found in a young person, for example, a person who is only 50 years old.
  • People with cancer, especially those with breast cancer or prostate cancer who will be using hormonal therapies.
  • People who have been on long-term steroids for conditions such as asthma, COPD, or inflammatory arthritis.
  • Those who have conditions associated with an increased risk of osteoporosis such as lupus, rheumatoid arthritis, and many others.
  • Those who are more likely to fall due to medical conditions such as a seizure disorder or other neurological diseases.
  • Those who have a strong family history of osteoporosis.
  • Those who have suffered fractures and have low bone density.

Medications to Prevent Osteoporosis (Treatment of Osteopenia)

There are a number of different medications approved for the treatment of osteoporosis, but only a few are approved for prevention including Actonel and Evista.

We will list options for osteoporosis treatment, as sometimes medications other than those approved for osteopenia (prevention of osteoporosis) may be indicated. The different categories of medications are listed below.

Bisphosphates

Bisphosphonates are medications which work by slowing the rate of bone loss and improve bone density. Most of these reduce the risk of spine fractures, but not all have been shown to reduce the risk of hip fractures. Some of these medications are taken orally while other are given by injection. Actonel, specifically, has been approved for the prevention of osteoporosis. Zometa has now been approved to use along with an aromatase inhibitor for the treatment of postmenopausal breast cancer.

Medications in this category include:

  • Fosomax (alendronate): Fosomax appears to reduce both hip and spine fractures.
  • Actonel (resedronate): Actonel may reduce the risk of both hip and spine fractures.
  • Boniva (ibandronate): Boniva reduces the risk of spine fractures but not hip fractures.
  • Zometa or Reclast (zoledronic acid): Given by injection, Zometa reduces the risk of both hip and spine fractures.

Side effects of bisphosphonates vary based on whether they are used orally or by injection. With oral bisphosphonates, people are asked to take the medication with a full glass of water and remain upright for 30 to 60 minutes. These drugs may cause heartburn or esophageal irritation. Injectable medications may cause flu-like symptoms for a day or two after injection and may also cause muscle and joint pain.

A uncommon but severe side effect is osteonecrosis of the jaw. People who have gum disease or dental hygiene, have a dental device, or require procedures such as a tooth extraction are at greatest risk. Other uncommon side effects include atrial fibrillation and atypical femur fractures.

Selective Estrogen Receptor Modulators (Evista and Tamoxifen)

Selective estrogen receptor modulators (SERMS) are medications can have both estrogen like and anti-estrogen effects depending on the part of the body they act on. Evista (raloxifene) is approved for the prevention of osteoporosis in postmenopausal women and is thought to reduce the risk of breast cancer as well. Tamoxifen is used for women with premenopausal breast cancers which are estrogen receptor positive in order to reduce the risk of recurrence. Tamoxifen may also be used to reduce the risk of developing breast cancer.

Like estrogen (as in hormone replacement therapy) their action on bone increases bone mineral density and reduces the risk of vertebral (spinal) fractures. Unlike HRT, however, Evista has anti-estrogen effects on breast cells and may reduce the risk of developing breast cancer. While SERMS do not increase bone density to the level that bisphosphonate do, they can reduce the risk of spine fractures (but not hip fractures) and improve bone density.

Side effects of SERMS include hot flashes, joint aches, and sweating. They may also increase the risk of blood clots such as deep vein thrombosis, pulmonary emboli (blood clots in the leg which break off and travel to the lungs), and retinal vein thrombosis.

Hormone Replacement Therapy (HRT)

While hormone replacement therapy (HRT) was once referred to as nearly a miracle drug to prevent osteoporosis in women, it is no longer approved for this indication. In addition, studies finding an increased risk of breast cancer, heart disease, and strokes in women taking HRT has resulted in these medications being used much less frequently.

Certainly there are still people who use HRT for menopausal symptoms, and it can work well for these symptoms. One significant cause of bone loss in menopausal women is the reduction in the amount of estrogen produced by the body. It makes sense then that hormone replacement therapy (HRT) would help reduce bone loss.

As with any medication, you must weigh the risks and benefits of any medication you use. For young women who have had surgical menopause and are suffering from life-limiting hot flashes, HRT may be a good option. Yet, even in this setting, the goal of treatment with HRT should not be a reduction in osteoporosis risk.

Denosumab (Prolia and Xgeva)

Used most often by people with cancer, denosumab is a monoclonal antibody which prevents the formation of osteoclasts, cells which cause the breakdown of bone.

For women who are on aromatase inhibitors (drugs for postmenopausal breast cancer) which increase the risk of osteoporosis, or men who are on androgen deprivation therapy for prostate cancer (which also increases the risk of osteoporosis), it can reduce the risk of fractures. Denosumab is also used for people with any type of cancer which has spread to their bones to reduce the risk of fractures.

Given by injection, denosumab has a side effect profile similar to bisphosphonates and may increase the risk of osteonecrosis of the jaw.

Calcitonin (Miacalcin, Fortical, Calcimar)

Calcitonin is a man-made version of a hormone in our bodies that regulates bone metabolism, and helps change the rate at which the body reabsorbs bone.  It is available both as a nasal spray and by injection and can reduce the risk of spine fractures. Miacalcin nasal spray, in particular, may be a option for postmenopausal women who can't tolerate the side effects of other medications.

Parathyroid Hormone and Derivatives

Forteno (teriparatide) is a man-made version of the body's natural parathyroid hormone, and is usually used only for people with severe osteoporosis who are at a high risk of fractures. It is the only medication which can actually stimulate the body to grow new bone. Use is currently restricted to only 2 years. Tymlos (abaloparatide) is similar and is a synthetic version of a portion of parathyroid hormone.

Drug Treatment Bottom Line

There is debate over the use of medications to treat osteopenia, and some argue that osteopenia is a natural part of aging. Yet we know that some people will be at a greater risk of suffering fractures, and all that a fracture might mean, if it is left untreated. If you have osteopenia, you and your doctor can estimate your 10-year risk of developing a hip or spine fracture using charts and tables available from the World Health Organization or the Osteoporosis Foundation.

Managing Osteopenia With or Without Drugs

Whether or not you choose to use medications for osteopenia, there are things you can do to reduce your risk of fractures. From making sure your stairs are free of clutter, to staying off of ladders, there are a number of simple ways you can reduce your chance of a fall.

Getting adequate calcium and vitamin D is important as well. Many people get ample calcium in their diet, but vitamin D is harder to come by, especially in Northern climates. Talk to your doctor about checking your vitamin D level (most people are deficient). If your level is low or in the lower part of the normal range, ask about whether or not you should take a vitamin D3 supplement.

Regular exercise and abstaining from smoking are also crucially important in the prevention of osteoporosis.

A Word From Verywell on the Treatment of Osteopenia

Unlike osteoporosis, there aren't clear guidelines on treating osteopenia, and each person must be evaluated carefully to decide whether medications may be of benefit. One major consideration is whether a person is expected to progress to having osteoporosis or is at an increased risk of suffering fractures as a result of other medical conditions.

There are several medications which can be effective in reducing bone loss, but these all come with the risk of side effects as well. Currently, the only drugs approved for osteopenia (osteoporosis prevention) are Actonel and Evista. Other medications, however, may be considered based on an individuals particular circumstances.

If you have been diagnosed with osteopenia have a careful discussion with your doctor. Talk about what may be expected in the years to come. Talk about your risk of fractures, and what fractures might mean with regard to your mobility and independence. Then talk about the potential side effects of any treatment and weigh these against any benefit you might predict. It's important to be your own advocate in your care, especially in a situation such as this in which treatment options must be carefully individualized.

Sources:

Eriksen, E. Treatment of Osteopenia. Reviews in Endocrinology and Metabolic Disorders. 2012. 13(3):209-223.

Kasper, Dennis L.., Anthony S. Fauci, and Stephen L.. Hauser. Harrison's Principles of Internal Medicine. New York: Mc Graw Hill education, 2015. Print.

Rosen, H. Patient education: Osteoporosis prevention and treatment (Beyond the Basics). UpToDate. Updated 03/26/17.

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