Osteopenia is a condition in which bone mineral density (BMD) is low but not as low as osteoporosis [1]. For measurement of BMD, dual energy X-ray absorptiometry (DXA) of the hip and spine is currently the test of “gold standard” [2]. According to the criteria of World Health Organization, osteopenia is diagnosed when T score is from -1 to -2.5 on DXA [1].

Low BMD is a strong predictor of further development of osteoporosis and osteoporotic fractures [3-5]. People with osteopenia may have a higher risk of fractures [5,6]. In 82% of postmenopausal women with fractures showed T scores higher than -2.5 [7].

Several studies have shown that anti-osteoporosis medication could decrease fracture risk and the economic burden of fracture in osteopenia patients [8]. But, pharmacological fracture prevention has been debated in osteopenia patients [9], because of concerns about cost-effectiveness and adverse events including osteonecrosis of the jaw (ONJ) and atypical femoral fractures (AFFs) after long-term use of bisphosphonate [9].

The recent the American College Physicians guidelines (2017) recommended that clinicians make the decision whether to treat osteopenic women 65 years of age or older who are at high risk for fracture based on a discussion of patient preference, fracture risk profile, and benefits, harms, and costs of medications [10]. Therefore, clinicians’ attitude is important in the treatment of osteopenia. Nevertheless, there has been no study on this issue.

The purpose of our survey was to evaluate the clinicians’ attitudes on the treatment of osteopenia by using a questionnaire.

A survey was conducted by using a questionnaire during 3 osteoporosis-related symposia, which were held from August 2019 to September 2019 in South Korea.

The questionnaire was made referring to the 2017 American College of Physicians clinical practice guideline on the treatment of low bone density or osteoporosis to prevent fractures [10].

The questionnaire was composed of 6 items: (1) do you think anti-osteoporosis medications are necessary in osteopenia patients?; (2) what is your preference to manage osteopenia patients (multiple choice), except for anti-osteoporosis medications?; (3) what is your indication for the anti-osteoporosis medication in osteopenia patients? (multiple choice); (4) what kind of anti-osteoporosis medication do you prefer to treat osteopenia patients? (multiple choice); (5) do you use bisphosphonates or not?; and (6) if not, what is the reason for not using bisphosphonates? (multiple choice; Table 1).

A total of 180 physicians to this survey 173 (96.1%) among them replied questionnaire. Specialties of the respondents were shown in Table 2.

Reportedly, the prevalence of osteopenia among the population aged 50 years and older was 46.5% in males and 48.7% in females in South Korea [11]. Our survey figured out the attitudes of South Korean physicians to manage osteopenia patients.

In this survey, most physicians (86.7%) advocated the use of anti-osteoporosis medications were necessary in osteopenia patients to prevent fracture. The most common indication for the use of anti-osteoporosis medication in osteopenia patients was a history of osteoporotic fracture.

In May 2015, South Korean health insurance started to reimburse the prescription of anti-osteoporosis medication for patients with osteoporotic fractures regardless of T-score [12]. This change of reimbursement guideline might explain the high advocating rate of anti-osteoporosis medications in our survey.

The use of FRAX^® has been popularized to guide the preventive treatment of patients at risk of osteoporotic fractures (https://www.sheffield.ac.uk/FRAX/). However, the FRAX^® is not reimbursed in South Korea, yet, and only 19.7% of our responders indicated the use FRAX^® for the anti-osteoporosis medication.

Bisphosphonates and SERM have been reported to reduce fracture risk in osteopenia patients [13-15]. HRT has been known to prevent or reverse bone loss in postmenopausal women [16]. In our study, the most preferred medication for osteopenia patients was bisphosphonates, followed by SERM and HRT.

Most responders (74.0%) prescribed bisphosphonates, while 17.9% of the responders did not prescribe bisphosphonates in osteopenia patients.

Major reason (77.4%, 24/31) for not prescribing bisphosphonates was restricted reimbursement from the health insurance. The reimbursement issue was a serious obstacle to osteoporosis treatment in Asia-Pacific region as well as in the United States [17,18]. In May 2015, the Korean Health Insurance Review and Assessment Service (HIRA) permitted the preventive use of osteoporosis medications in osteopenia patients, when they had a history of osteoporotic fracture [12]. Since October 2018, the HIRA has reimbursed the preventive use of bisphosphonates for patients who took glucocorticoids for more than 3 months [19]. The second common reason (61.3%, 19/31) for not using bisphosphonates was a concern of AFFs and bisphosphonate-related ONJ. However, recent studies have demonstrated that the benefit of the bisphosphonate treatment exceeded the risk of adverse events [20,21]. The HRT was unfavored probably due to the potential risk of breast cancer [22].

This study has limitations. This survey involved small number (173) of physicians, and our results might not represent the general opinion of physicians in South Korea. Furthermore, due to privacy issues, the age and gender of respondents were not analyzed, which could also be confounding factors.

Most South Korean physicians (86.7%) thought anti-osteoporosis medications were necessary in osteopenia patients. They favored bisphosphonates, SERM, and HRT for the treatment of osteopenia patients to prevent fractures. Restricted reimbursement by the national health insurance was the major obstacle against the use of bisphosphonates.