Prevention and Treatment: Osteopenia

Women who have been diagnosed with osteoporosis are advised to take medication that can help them reduce bone loss. It would be easy to assume that women with osteopenia should be prescribed these medications as well. But that isn’t the case. In fact, osteopenia does not need to be treated with any drugs at all.

At first, this may not make sense. But the research has shown that the drugs most commonly used to treat osteoporosis—bisphosphonates, such as alendronate (brand name Fosamax), and the drug raloxifene (brand name Evista)—do not significantly reduce fracture risk in women with osteopenia. Why? Because women with osteopenia have had so little bone loss and have such a low risk for fracture there is very little for the drug to do.

Unlike osteoporosis osteopenia does not need drug treatments

So why are many women with osteopenia being prescribed medication? According to bone health expert Steve Cummings, MD, a former professor of medicine and epidemiology at the University of California, San Francisco School of Medicine, it is “because doctors have come to believe that osteopenia is a problem, and no one is disseminating information about the benefits or risks or worthwhileness of taking treatment if you have osteopenia.”

Doctors and their patients hear the word osteopenia, he continues, “and they get worried and think that they should do something.” But there’s no evidence that you should. If a woman with osteopenia starts taking a bisphosphonate, he says, all she would be doing is hoping that doing so “would mean that she would have a lower risk of fracture 10–15 years from now—and that is completely unproven.”

There are some unusual circumstances in which a woman with osteopenia should take drugs, but they are few and far between, Cummings says. These include a woman who has recently begun taking corticosteroid pills and has a T score of –2, “because you know the drugs will lead her bone density to go down and her risk of fractures to go up quickly.”

Further, when it comes to osteopenia, time really is on a woman’s side. “A woman who has osteopenia is likely to lose maybe seven percent of her bone density every 10 years,” explains bone health expert Bruce Ettinger, MD, a senior investigator at Kaiser Permanente in Oakland, California. “So 10 years later she will still have osteopenia, but 20 years later she will have osteoporosis.” And if she does develop osteoporosis, he continues, “we already have drugs that can put back six to eight percent of bone density and there are drugs coming that can put back 8–15%.” And in five or 10 years there will probably be even better drugs, “which means all the more reason to not [take medications] now.”

Note to Women with Breast Cancer:

Many women with hormone-sensitive tumors are now taking an aromatase inhibitor as part of their breast cancer treatment. These drugs—anastrozole (brand name Arimidex), letrozole (brand name Femara), and exemestane (brand name Aromasin)—reduce estrogen by blocking the aromatase enzyme and keeping it from converting androgens into estrogen. Clinical trials have found that these drugs, unlike the hormone therapy tamoxifen, increase bone fracture risk. For women who have osteoporosis and are on aromatase inhibitors, bisphosphonates should help reduce fracture risk.

Breast cancer treatment with aromatase inhibitors increase bone fracture risk

For women with osteopenia, though, it still makes more sense to wait until osteopenia has advanced to osteoporosis to begin taking these drugs. The exception would be a woman who is starting on an aromatase inhibitor and is already close to a –2.5 on her DEXA scan. In this case, she may want to start on a bisphosphonate while starting on the aromatase inhibitor.

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