Osteoporosis in the aging male: Treatment options

Figures & data

Figure 1 The incidence of forearm, symptomatic vertebral and hip fractures in men and women from Cardiff (Johansen et al 1997).

Figure 2 The incidence of morphometric vertebral fractures in men and women in the European Prospective Osteoporosis Study (Roy et al 2003).

Figure 3 The Age-Standardised Mortality Ratio after fractures in men and women (Center et al 1999).

Figure 4 The relationship between femoral neck BMD and the incidence of hip fractures in 80 year old men and women in the Rotterdam Study (De Laet et al 1997).

Figure 5 The mean reduction in lumbar spine and femoral neck BMD in men with distal forearm (Tuck and Raj 2002), symptomatic vertebral (Scane et al 1999) and hip (Pande et al 2000) fractures compared with age-matched male control subjects. The statistical significance is indicated (** = p < 0.01, *** = p < 0.001).

Table 1 Causes of secondary oeteoporosis in men

Major causes with strong evidence	Hypogonadism
	Alcoholism
	Corticosteroids
	Transplantation
Other causes	Hormonal	- hyperparathyroidism
		- thyrotoxicosis
	Gastric surgery
	Gastrointestinal disorders	- celiac disease
		- inflammatory bowel disease
		- liver disease
	Drugs	- anticonvulsants
		- warfarin
	Idiopathic
	hypercalciuria
	Malignancy
	Chemotherapy

Table 2 Investigations for secondary osteoporosis in men

Investigation	Finding	Possible Cause
Full blood count	Anemia	Neoplasia or malabsorption
	Macrocytosis	Alcohol abuse or malabsorption
ESR	Raised ESR	Neoplasia
Biochemical profile	Hypercalcemia	Suppressed TSH; high T4 or T3
	Abnormal liver function	Alcohol abuse or liver disease
	Persistently high AP	Skeletal metastases
Thyroid function tests	Suppressed TSH; high T4 or T3	Hyperthyroidism
Serum and urine immunoelectrophoresis	Paraprotein band	Myeloma
Testosterone, SHBG, LH, FSH	Low testosterone or free testosterone index	Hypergonadotrophic hypogonadism with raised gonadotrophins
		Hypogonadotrophic hypogonadism with low gonadotrophins
Prostate specific antigen	Raised levels (often markedly so)	Skeletal metastases from prostate cancer
Vitamin D	Low	Osteomalacia
PTH	High	Primary or secondary hyperparathyroidism
Anti-endomysial antibodies	Positive	Celiac disease

Table 3 Summary of the available evidence for treatments of male osteoporosis (A = randomised controlled trials, B = other well designed studies, C = expert opinion/reports)

Treatment	Increase in BMD (spine and/or hip)	Reduction in vertebral fractures	Reduction in hip fractures	Reduction in non-vertebral fractures
Alendronate	A	A	None	None
Etidronate	B	None	None	None
Risedronate	C	None	None	None
Pamidronate	C	C	None	None
Ibandronate	C		None	None
Clodronate	A	A	None	None
Teriparatide	A	A	None	None
Calcium and vitamin D	A (older men)	None	None	None
Calcitonin	A	None	None	None
Strontium	C	None	None	None
Androgens	B	None	None	None

Table 4 Relative potencies of bisphosphonates

Bisphosphonates	Side Chains R1, R2	Relative Potency
Etidronate	R1= -OH	1
	R2= -CH3
Clodronate	R1= -Cl	10
	R2= -Cl
Pamidronate	R1= -OH	100
	R2= -C2H4NH2
Alendronate	R1= -OH	500
	R2= -C3H6NH2
Risedronate	R1= -OH	1000
	R2=
Ibandronate	R1= -OH	10000
	R2= -C2H4N(CH3)C5H11
Zoledronate	R1=	100000
	R2=

Figure 6 The change in lumbar spine and femoral neck BMD in men with osteoporosis treated with alendronate or placebo (Kurland et al 2000). The statistical significance between the two groups is indicated (*** = p < 0.001).

Figure 7 The change in lumbar spine and femoral neck BMD on treatment with subcutaneous Teriparatide 20 μg and 40 μg daily or placebo injections in men with osteoporosis. The statistical significance of differences from the placebo group is indicated (Kurland et al 2000: * = p < 0.05, *** = p < 0.001).

Figure 8 The change in lumbar spine BMD in men with osteoporosis treated with calcitonin or placebo (De Laet et al 1997). The statistical significance between the two groups is indicated.

Figure 9 Proposed flow chart for the treatment of men with osteoporosis.

JohansenAEvansRJStoneMD1997Fracture incidence in England and Wales: A study based on the population of CardiffInjury28655609624346

 PubMed Web of Science ®Google Scholar

RoyDKO’NeillTWFinnJD2003Determinants of incident vertebral fracture in men and women: results for the European Prospective Osteoporosis Study (EPOS)Osteoporosis Int141926

 PubMed Web of Science ®Google Scholar

CenterJRNguyenTVSchniederD1999Mortality after all major types of osteoporotic fracture in men and women: an observational studyLancet3538788210093980

 PubMed Web of Science ®Google Scholar

De LaetCEVan HoutBABurgerH1997Bone density and risk of hip fracture in men and women: cross-sectional analysisBMJ31522159253270

 PubMed Web of Science ®Google Scholar

TuckSPRajNSummersGD2002Is distal forearm fracture in men due to osteoporosis?Osteoporosis Int136306

 PubMed Web of Science ®Google Scholar

ScaneACFrancisRMSutcliffeAM1999Case-control study of the pathogenesis and sequelae of symptomatic vertebral fractures in menOsteoporosis Int9917

 PubMed Web of Science ®Google Scholar

PandeIO’NeillTWPritchardC2000Bone mineral density, hip axis length and risk of hip fractures in men: results from the Cornwall hip fracture studyOsteoporosis Int1186670

 Web of Science ®Google Scholar

KurlandESCosmanFMcMahonDJ2000Parathyroid hormone as a therapy for idiopathic osteoporosis in men: effects on bone mineral density and bone markersJ Clin Endocrinol Metabol85306976

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