osteoporosis

Osteoporosis in Men

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While low bone mass, or osteoporosis, is less common in men than in women, over 8 million men in the US are affected by it. The mortality rate in hip and spine fractures is higher in men than women, furthermore, due to the older age and the greater number of chronic diseases present in men at the time of fracture.

There is no routine recommendation for screening of men for osteoporosis.  DEXA scanning is suggested when fragility fractures occur and if men have high risk conditions as outlined below.  Once osteoporosis is identified, regular DEXA screening every 2 years is recommended.

The treatment of osteoporosis in men is composed of lifestyle measures, hormonal therapy, and/or non-hormonal drug therapy.

Lifestyle measures:

  • Practicing a weight-bearing exercise regimen

  • Tobacco cessation

  • Avoidance of excessive alcohol use

  • Maintaining a daily calcium intake of 1000-1200 mg per day.  

  • Measuring Vitamin D levels and adding supplementary Vitamin D3 if indicated

Hormonal therapy 

  • A Low testosterone level (LowT) is among the most common causes of osteoporosis in men.  Replacement therapy with testosterone provides skeletal benefits by increasing bone mineral density (BMD) and thereby reducing osteoporosis and the risk of fractures.   Men with LowT should also be treated with a bisphosphonate if fracture risk remains high.  There is no known benefit from taking testosterone if baseline testosterone levels are normal.  

  • Glucocorticoids, also known as steroids, can induce bone loss.  The doses of these medications should be reduced to the lowest effective dose, and stopped if possible.  Glucocorticoid-induced bone loss should be treated aggressively.

  • Androgen-deprivation therapy, administered to men with prostate cancer, increases the risk of clinical fractures by lowering testosterone levels.  If BMD is diminished, as soon as justified, this hormonal therapy should be discontinued.

  • Gastrointestinal disorders can contribute to osteoporosis due to malabsorption of Vitamin D, resulting at times in severely low Vitamin D levels.  Most often, providing adequate Vitamin D replacement and supplemental calcium can lead to marked increases in BMD.

Non-hormonal medical therapy

  • Men with normal testosterone levels

  1. In men with a history of osteoporosis (fragility fracture and/or t-score <-2.5), bisphosphonates are indicated.

  2. Men > age 50 with t-scores of -1.0 to -2.5 and at high risk of fracture, bisphosphonates are indicated.

  • In men with low testosterone levels

  1. Testosterone replacement is recommended unless a contraindication is present.

  2. Bisphosphonates are recommended if the patient also:

  • Takes high-dose glucocorticoids

  • Has frequent falls

  • Has had a recent fragility fracture

  • Has a t-score below -3.0

  • Has a t-score less than 2.5 two years after having received adequate testosterone replacement therapy.

As with women, there is no consensus on low long men should continue medication for osteoporosis.  Some experts recommend discontinuing bisphosphonates after 5 years’ use.

For men with contraindications to the use of oral bisphosphonates, Intravenous bisphosphonates and Reclast can be used, as well as Prolia and Forteo/Tymlos.  There is no reason to combine any two non-hormonal therapies.

Osteoporosis in Women

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Your bones are in a constant state of renewal, with new bone forming while old bone is being recycled by your body.  Before the age of 30, your body makes new bone faster than old, but as you age bone mass is usually lost faster than it is created.  This imbalance can weaken your bones.

Osteoporosis, which occurs when the formation of new bone doesn’t keep up with the loss of old bone, can cause bones to be brittle and can often lead to fractures after falls and such simple actions as coughing and bending over.  

Osteoporosis is usually asymptomatic in its early stages, so you may not know that there is a problem.  As the disease progresses symptoms such as back pain, height loss, stooped posture and bone fractures that occur more easily than expected can all occur.

Factors that increase the risk of osteoporosis in females include:

  • Female sex

  • Age—the older you are the greater the risk, especially after age 65

  • White and Asian race

  • Positive family history, if osteoporosis is present in either parents or any siblings

  • Small body frame

  • Certain abnormal hormone levels

  1. Lowered sex hormones

  2. Elevated thyroid hormone levels

  3. Overactive adrenal and parathyroid glands

  • Diet issues

  1. Low calcium intake

  2. Eating disorders, such as anorexia

  3. Previous gastrointestinal surgery, especially gastric by-pass

  • Certain medications

  1. Steroids

  2. Some anti-seizure drugs

  3. Proton-pumps inhibitors (e.g. Prilosec) used for heartburn and reflux

  4. Anti-cancer drugs

  5. Drugs to prevent transplant rejection

  • Certain medical conditions

  1. Inflammatory bowel disease

  2. Celiac disease

  3. Kidney and liver diseases

  4. Cancer 

  5. Lupus

  6. Multiple myeloma

  7. Rheumatoid arthritis

  • Lifestyle choices

  1. Sedentary lifestyle

  2. Tobacco use

  3. Excessive alcohol consumption

Osteoporosis Diagnosis and Treatment for Women

Lifestyle measures that should be adopted by every woman include:

  • Adequate calcium and Vitamin D

  • Regular weight-bearing exercise

  • Smoking cessation

  • Avoidance of excessive alcohol

  • Counseling for fall prevention, including advice on balance training

At age 65 in usual-risk women, and sooner if high-risk conditions are present, dual-energy xray assessment, or DEXA, scan should be performed to establish a baseline.  This test measures bone density at the spine and hip, producing a t-score value that is the most accurate assessment of bone density.  Normal t-score is -1.0 to 0.0, osteopenia (some thinning of bones) is defined as a t-score of -2.5 to 1.0 and osteoporosis (significant thinning of bones) is present when the t-score is < -2.5.  A t-score above 0.0 indicates stronger-than-usual bones.

The probabilty of fracture can be estimated by calculating the FRAX score, which utilizes the t-score and history of osteoporosis risk factors.  Most DEXA reports include a FRAX score.

Medication is indicated for women who have a history of fragility fracture and/or whose bone density measurements via DEXA show a t-score that is less than -2.5.  Medication is also appropriate for women whose t-score is -1.0 to 2.5 and who have a 10-year fracture risk assessment risk of > 3 at the hip or 20% overall as calculated using the FRAX.

The choice of drug is patient-specific.  The bisphosphonates alendronate (Fosamax) and risendronate (Actonel) are the drugs of choice for most patients, unless there is a history of esophageal disorders, chronic kidney disease and/or some types of weight loss surgery.  

Prolia, a drug injected twice a year, or Reclast, given by intravenous infusion once a year, are indicated for osteoporosis patients if bisphosphates should not be used.  Patients at very high risk should receive either Forteo or Tymlos.  However, these two drugs must be injected just beneath the skin every day and are very expensive.

Once diagnosed, osteoporosis and osteopenia should be monitored for progression by performing a DEXA scan every two years, regardless of what treatment has been started.

There is controversy about the length of treatment, but many authorities suggest a drug holiday after 5 years of bisphosphonate use and 3 years of Reclast infusions, and the drugs can be discontinued indefinitely if the t-score is stable and there have been no fractures.  Patients at very high risk should probably continue bisphosphonates for 10 years.  Forteo and Tymlos must be stopped after 2 years, when bisphosphonates can then be substituted.  There is no time limit for Prolia.