Osteopenia

Osteopenia - What is Osteopenia?

Osteopenia is a bone condition where the bone mineral density is lower than normal. Bones are made of minerals like calcium and phosphate. Osteopenia is considered to be a precursor of a similar bone condition called osteoporosis. But in many cases osteopenia may not lead to osteoporosis.

Definition of osteopenia

Osteopenia is defined as a bone mineral density T-score between -1.0 and -2.5. This definition was coined by the World Health Organization in June 1992. The expert group defined the condition that means bone density that was one standard deviation below that of an average 30-year-old white woman. According to the definition osteoporosis is bone density 2.5 standard deviations or more below that 30-year-old.

Pathology of osteopenia

Osteopenia is a condition in which the bones lose the minerals like calcium and phosphate. This results in weak bones that become prone to fractures. When bone loss becomes more severe, the condition is referred to as osteoporosis.

Symptoms of osteopenia

In the early stages of osteopenia and osteoporosis there may be no symptoms. With continued bone loss there may be a propensity for fractures. Common fractures include those of spine, wrists, or hips.

Before fractures there may be bone pain. Common symptoms include neck or low back pain, loss of height, stooped posture and tenderness over long bones.

Risk factors for osteopenia

Osteopenina and osteoporosis may occur commonly:

  • in females after menopause
  • those who take steroids or other medications like protease inhibitors used in HIV infection that cause bone loss
  • smokers
  • alcoholics
  • those who are underweight

In females after menopause, bone loss occurs due to declining female hormones that maintains normal bone structure. Premature babies are also at risk of osteopenia. Anti-HIV medications can cause negative side effects that may increase the risk of osteopenia and osteoporosis.

Diagnosis of osteopenia

Osteopenia can be diagnosed on a radiograph as a visual loss of bone density. Low bone density is detected using a dual energy x-ray absorptiometry (DEXA) scan. This can help in diagnosis of both osteopenia and osteoporosis. This is a painless, non-invasive procedure. The bone mineral density result that is obtained is compared to people of the same age and health to see if the bones are weaker than they should be.

Osteopenia treatment

Patients with bone loss need evaluation of the condition. Drugs that lead to bone loss if taken need to be changed or stopped. Treatment consists of dietary supplements like Calcium and Vitamin D.

Other medications include bisphosphonates like raloxifene. These are primarily use in osteoporosis. Calcitonin and hormone replacement therapy for postmenopausal women may also be prescribed to slow bone loss and reduce the risk of fractures.

In addition, assistance in the form of walker, canes and crutches may be used. Patient is counselled to prevent falls. Patient is advised to perform regular weight bearing exercise like walking, jogging, dancing, and other physical activities that help to make the bones stronger. They are advised to abstain from excess alcohol and quit smoking.

What Causes Osteopenia?

Osteopenia is loss of bone mineral density that is a common precursor of osteoporosis. These are some risk factors that increase the propensity for osteopenia and osteoporosis.

Some of the causes and risk factors for osteopenia include:

Post-menopausal women

During reproductive age women produce estrogen from their ovaries. After menopause decline of this hormone leads to bone loss.

Genetics

Many individuals are genetically predisposed to osteopenia and osteoporosis

Aging

Bone loss is a normal feature of aging.

Lifestyle factors:

  • Lack of exercise and sedentary lifestyle
  • Excess alcohol consumption
  • Excessive smoking
  • Excessive stress
  • Crash dieting and eating disorders
  • Excessive coffee, tea, soda, chocolate or sports and energy drinks
  • Young female athletes with eating disorders and amenorrhea. These women have lower body weight, lower fat percentage, and higher incidence of asthma. This increases the risk of osteopenia.
  • Teenage pregnancy

Drugs and medications and medical conditions:

  • Glucocorticoids – Individuals on long term steroids are at risk of bone mineral loss
  • Those treated for Chronic inflammatory diseases such as Arthritis, Leukemia, Lupus, Lymphoma, organ transplant, cancers are at risk of lowered bone density due to long term steroid use
  • Anorexia and bulimia
  • Asthma
  • Vitamin B 12 deficiency
  • Cancers
  • Celiac disease
  • Crohn’s disease, Ulcerative colitis and other inflammatory bowel diseases
  • Malabsorption syndromes
  • Chronic kidney disease or patients on dialysis
  • Cerebral palsy
  • Cushing’s syndrome leading to excess steroids
  • Diabetes
  • Drugs used in epilepsy
  • Those with hyperthyroidism and with hyperparathyroidism
  • Those with Hypogonadism
  • Liver disease, lactose intolerance
  • Patients with Multiple myeloma, Osteo-genesis imperfect, polio, Sickle Cell anemia, Skin disorders, Thalassemia.

Drugs that lead to lowered bone density include:

  • Phenytoin
  • Depot provera
  • Drugs with Aluminum
  • Dilantin
  • Phenobarbital
  • Anticancer drugs
  • GNRH – agonsists like leuprolide
  • Aromatase inhibitors
  • Immunosuppressants like Cyclosporine A and FK506
  • Methotrexate
  • Proton pump inhibitors like omeprazole
  • Heparin
  • Lithium,
  • Thyroid hormone replacement,
  • Certain diuretics can all cause loss of bone mineral density and predispose to osteopenia

Osteopenia Treatment

Osteopenia is loss of bone mineral density and is often a precursor to more severe bone loss like osteoporosis. Bone loss in osteopenia may be reversed.

Treatment for osteopenia may be outlined as:

  • Diet and nutritional strategies
  • Exercises and physical activities
  • Prescription medication

The main question is whether or not to treat osteopenia. Currently, candidates for therapy include those at the highest risk of osteoporotic bone fracture. This is determined using bone mineral density and clinical risk factors. As of 2008, recommendations from the National Osteoporosis Foundation (NOF) are based on risk assessments from the World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX).

Who should therapy be offered to?

The recommendations suggest that therapy should be offered to postmenopausal women and men older than 50 years of age when present in addition to any of the following factors:

  • History of hip or vertebral (spinal) fracture (this identifies individuals for osteoporosis)
  • T-score of -2.5 at the femoral neck or spine. This is in absence of a secondary cause of bone loss like spread of cancers to the bone etc. (this identifies individuals for osteoporosis)
  • T-score between -1.0 and -2.5 at the femoral neck or spine AND a 10-year probability of hip fracture ≥3% OR a 10-year probability of major osteoporotic fracture ≥10%. (This identifies individuals with osteopenia)
  • Clinician’s judgement and patient preferences for treatment in people with 10-year fracture probabilities above or below these levels.

Bone mineral density test

A bone mineral density test using dual energy absorptiometry is advised at the age of 60 for all persons. If it is normal, it should be repeated ten years later.

On normal results of repeat tests, there is no need for further tests. If the test at age 60 shows osteopenia with a score of -1 to -1.7 standard deviations, a repeat test is advised at five years.

If initial cores in a woman is -1.8 to -2.4 (severe osteopenia) a repeat test in two years is advised.

If the score is -2.5 or less, the woman is osteoporotic and needs medical supervision and probably treatment with follow up bone mineral density measurements as medically appropriate.

Diet and nutritional strategies

Some foods need to be added to diet while yet others raise the risk of bone loss. Patients are advised to refrain from excessive alcohol, smoking and caffeine in diet (available from coffee, tea, soda, chocolate or sports and energy drinks).

In addition to dietary modification are the supplements. Dietary supplements useful for osteopenia include Calcium and Vitamin D. A calcium intake of 1,500 milligrams a day is recommended along with adequate vitamin D intake by diet or supplement along with a modest amount of sunlight exposure each day.

Exercise

Sedentary lifestyle is associated with a higher risk of osteopenia and osteoporosis. But not every form of exercise is good for those with bone loss. In fact, some forms of exercise can cause 'spontaneous fractures' and should be avoided. In addition, exercise programs should be designed in a manner that there is minimal risk of falls and injuries.

Patient is advised to perform regular weight bearing exercise like walking, jogging, dancing, and other physical activities. Tai chi for example has been found to have positive effect on bones. It is also stress reducing and helps with balance. Moderately vigorous activities for at least 30 minutes a day at least five days per week is advised generally.

Medical therapy

Medical therapy includes drugs like:

  • Bisphosphonates including alendronate (Fosamax), risedronate (Actonel), and ibandronate
  • Selective estrogen receptor modulators (SERMs) such as raloxifene (Evista)
  • Estrogen (Premarin, Estrace)
  • Calcitonin
  • Teriparatide.

Studies have shown that the actual benefits of these drugs may be marginal. Treatment with these drugs is usually begun after diagnosis of osteoporosis. Doctors are wary about overmedicating people with osteopenia.