Men With Osteoporosis Often Fall Through the Cracks

Osteoporosis and its associated fractures are as devastating in men as they are in women, yet the rates of osteoporosis detection and treatment in men are dismal, Dr. Eric Orwoll said at the annual meeting of the International Society for Clinical Densitometry.

In a study of 110 men and 253 women admitted to the hospital with atraumatic hip fractures, the mean age was about 80 years. At discharge, 27% of the women but only 4.5% of the men were receiving treatment of any kind for osteoporosis. Up to 5 years later, 27% of the men and 71% of the women were being treated. The 12-month mortality rate was 32% in men and 17% in women (Arch. Intern. Med. 162[19]:2217-22, 2002).

Fracture risk factors in men include advanced age, a history of falls or previous fractures, low body weight, a calcium or vitamin D deficiency, cigarette smoking, a history of medical conditions associated with low bone mineral density (BMD), alcohol abuse, and a family history of osteoporosis or fractures, said Dr. Orwoll of Oregon Health and Science University, Portland.

The International Society for Clinical Densitometry recommends regular BMD assessments for men who are aged 70 years or older or have a history of fragility fractures or have a medical condition known to increase the risk of bone loss, such as hypogonadism or hyperparathyroidism.

Men with a T score <�2, especially if they are elderly or have other risk factors, should be considered potential candidates for treatment, he said, but often it's a judgment call. Dr. Orwoll said he might delay treating a 50-year-old patient with a T score <�2 but no other risk factors, but would prescribe treatment for a 30-year-old with a similar T score who smoked, drank heavily, and had a family history of fractures.

Treatment consists of vitamin D 600-800 IU/day, calcium 1,200 mg/day, and a bisphosphonate or parathyroid hormone 20 �g/day. Other treatments, such as testosterone for a patient with hypogonadism, may be prescribed as needed. These approaches build bone density and decrease fracture risk in men, but have been underused, Dr. Orwoll said.

About one-third of men aged 75-79 years have vertebral deformities. At age 60, the lifetime fracture risk is 26% in a white male and 56% in women. Men aged 50-64 years have a greater risk of vertebral fracture than women in the same age group. After age 64, women's fracture rate increases sharply, outpacing that of men.

�Vertebral deformities herald lower bone density and skeletal fragility, so if you see a vertebral deformity on a chest x-ray, that has some implications for that person's risk of subsequent fracture,� he said.

Of men who sustain a hip fracture, one-third will develop another fracture within 3 years. In one study of a Medicare population, men who sustained a hip fracture had 2-year mortality of about 50%.

The etiology of osteoporosis in men hasn't been studied as extensively as it has in women, he said. In one study of 47 men with vertebral and appendicular fractures or osteopenia referred to a metabolic bone center, 30 had osteoporosis secondary to factors such as glucocorticoid treatment, excessive alcohol consumption, or severe hyperthyroidism. The others were presumed to have primary osteoporosis (Ann. Intern. Med. 123[6]:452-60, 1995).