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Endocrine Society clinical practice guidelines address osteoporosis in men
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The Endocrine Society published a set of clinical guidelines for the assessment and treatment of osteoporosis in men. Bone mineral density should be tested, particularly in men older than 70 years. Men aged 50 to 69 years may be tested if the physician detects additional risk factors, including a history of fracture after age 50 years.
DXA of the spine and hip should be the first step taken to measure BMD in men at risk for osteoporosis, according to the guidelines. If this result is inconclusive, or the patient has hyperparathyroidism or is receiving androgen deprivation therapy for prostate cancer, the same X-ray may be used to measure the forearm.
The authors recommend obtaining a complete history of the potential patient that includes medications used, chronic diseases, alcohol or tobacco use, history of falls or fractures as an adult and history of osteoporosis in the family. Patient height, mobility and other measures of balance and frailty should be assessed along with evidence of testicular atrophy or chronic obstructive pulmonary disease. Serum calcium, phosphate, creatinine, 25-hydroxyvitamin D, total testosterone, complete blood count and other biomarkers should be assessed. If these measures are inconclusive, urine protein electrophoresis or thyroid function tests may be performed, along with vertebral fracture assessment or lateral spine radiographs. Clinicians should view the full document for specific instances when each of these assessment measures should be used.
Lifestyle changes and treatment
Men at risk for osteoporosis should consume 1,000 mg to 1,200 mg calcium daily, perform weight-bearing activities in 30- to 40-minute sessions three to four times per week, reduce alcohol intake if they consume three or more units per day and quit smoking. For men with low vitamin D levels, supplementation may be considered to reach a level of at least 30 ng/mL.
Eligibility criteria for pharmacotherapy includes men who have had a hip or vertebral fracture without major trauma; those who have not experienced these fractures but who have low BMD according to prespecified thresholds; those with a T-score between –1.0 and –2.5 in the spine, femoral neck, or total hip plus 10-year risks for certain fractures; or those who are receiving long-term glucocorticoid therapy, according to the recommendations.
Approved pharmacotherapies for osteoporosis in men include alendronate, risedronate, zoledronic acid and teriparatide (Forteo, Lilly), according to the authors. Denosumab may be used for men receiving androgen deprivation therapy for prostate cancer. Clinicians should assess for the aforementioned clinical and lifestyle factors when selecting medications. A bisphosphonate, teriparatide or another proven anti-fracture agent may be used to treat hypogonadal men receiving testosterone. Testosterone therapy may be preferable to a bone drug in men with increased fracture risk who have serum testosterone levels below 200 ng/dL and accompanying clinical indicators of androgen deficiency or organic hypogonadism; or in men with these factors and contraindications to approved osteoporosis medications. Men receiving androgen deprivation therapy who have a high fracture risk may receive pharmacological osteoporosis treatment.
BMD as assessed by DXA of the spine and hip every 1 to 2 years is recommended as a measure to monitor patients. The frequency of measurements may be reduced if BMD reaches a plateau. Clinicians also may use a bone resorption marker to measure bone turnover markers 3 to 6 months after treatment initiation. This may aid in determining anti-responsive therapy.
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