SLR - July 2009 - Eric S. Trathen
Reference:
Ebeling, P.R. (2008). Osteoporosis in Men. New England Journal of Medicine, 358, 1474-1482.
Scientific Literature Reviews
Reviewed by: Eric S. Trathen, DPM
Residency Program: Miami VA Medical Center
Podiatric Relevance:
This review article examines the occurrence rate and relative under-diagnosis of osteoporosis in men. The author recommends effective testing to assist in the diagnosis and associated treatment options.
Methods & Results:
The following review article discusses the differences between the etiology and onset of osteopenia and osteoporosis in men and women. Hip and vertebral fractures are common in patients with osteoporosis and osteopenia. 1/3rd of all hip fractures world wide occur in men and demonstrate a 37% mortality rate within oneyear of the fracture. Vertebral fractures are greater in men under the age of 65, but decline with age as compared to women. Osteoporosis in men is often due to secondary causes such as ETOH abuse, hypogonadism, corticosteroid use and vitamin D deficiency. A study of elderly nursing home patients with hip or vertebral fractures found that 66% and 20% had hypogonadism respectively. Secondary causes such as vitamin D deficiency are common in both sexes over the age of 65 years and are associated with an increased risk of hip fracture. Men experience a decrease in new bone formation after the age of 70 attributed to the decrease in testosterone levels.
Diagnosis is performed through routine assessment of risk factors (>70 years of age, corticosteroid use, excessive daily ETOH use, hypogonadism, smoking, family Hx, hypercalciuria, hyperparathyroidism, hyperthyroidism, BMI < 20, celiac sprue), and the use of diagnostic tests including bone density scan ( t and z score), radiography, labs (used to r/o secondary causes for elevated z score), serum calcium and creatinine levels, liver-function tests, measurement of the thyrotropin level, complete blood count, Bence Jones protein, and anti–tissue transglutaminase antibodies (celiac sprue). Ultimately low vit-D and testosterone levels are good predictors for future fracture.
Treatments: Nonpharmacologic treatments such as proper diet and dietary supplement (vit D 800 IU and calcium 1200 mg Qd) have been shown to reduce fractures due to osteoporosis by 12%. In addition, weightbearing exercises and resistance training reduce the risk of fracture.
Pharmacologic therapy is indicated in patients with t scores less that 2.5 or those that have experienced previous fracture due to osteoporosis or osteopenia. Bisphosphonates demonstrate benefits in patients who have not experienced a previous hip or vertebral fracture. Follow-up bone scans are recommended every 2 years in
patients who are managed with or without pharmacotherapy and in patients who are older than 70 years of age. Bone scans are recommended earlier in patients whose bone mineral density is in the osteoporotic range, men over the age of 50 who have had fractures, T score below –1.5, osteopenia, corticosteroids use > = 3 months or
with those who have hypogonadism.
Conclusions:
Patients who are at risk of fracture include those with t scores less than 1.5, z scores less than 1.5, and those 70 years of age with a diagnosis of osteoporosis. Therapies should include calcium, vitamin D supplements, and bisphosphonates.