Osteoporosis: No gender gap for therapy

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Decreased bone density causes vertebral bones (orange) to appear wedge-shaped.
Decreased bone density causes vertebral bones (orange) to appear wedge-shaped.

Although commonly considered a disease of women, men can be affected too. New guidelines recommend risk assessment for men and treatment for both sexes.


The American College of Physicians (ACP) has issued two sets of clinical guidelines on osteoporosis—the organization's first to address the condition. One set focuses on osteoporosis screening in men and the other addresses pharmacologic therapy for both sexes. “Osteoporosis is an important public health issue and a primary-care problem,” says Amir Qaseem, MD, senior medical associate at the ACP and lead author of the Guidelines. “It's in primary care that issues like screening should be brought up and where drug treatment can be readily provided.”

An estimated 44 million people in the United States have osteoporosis—55% of Americans older than age 50 years—and another 34 million have low bone mass and are at increased risk for developing the disorder. A frequently overlooked minority of these individuals are men, in whom the condition is “substantially underdiagnosed, undertreated, and underreported and inadequately researched,” the authors say.  There are few other practice guidelines addressing osteoporosis in this population, Dr. Qaseem observes.

Men at risk

According to Screening for Osteoporosis in Men: a Clinical Practice Guideline from the American College of Physicians, a risk assessment should be considered for all older men. Just when to start, the authors concede, is “uncertain,” but they note that it should be well before a man reaches his 65th birthday (the age by which at least 6% of men have osteoporosis). Participants in most of the studies from which risk factors were derived have been older than 50, they say.

Age older than 70 is in itself a major risk factor. Weight is another consideration: Both low body weight (BMI <20) and weight loss (current weight >10% less than usual adult weight) have been linked to significantly increased risk in meta-analysis of reliable data. A lack of regular physical activity (i.e., walking, gardening, housework, climbing stairs) or a history of oral corticosteroid use, androgen deprivation therapy, and previous fragility fracture are similarly associated with higher risk.

The authors recommend that clinicians screen men who fall into any of these categories and are candidates for osteoporosis drug therapy. Men who choose not to be screened should be reassessed periodically.

Dual-energy x-ray absorptiometry (DEXA) is the only screening test recommended in the Guidelines. Little evidence has been gathered on most other modalities, and those most studied—calcaneal ultrasonography and a structured self-screening tool—are not sufficiently sensitive or specific, the authors say. 

Medication: When and for whom?

In both men and women, pharmacotherapy is the principal modality for treating and preventing osteoporosis. Pharmacological Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: a Clinical Practice Guideline from the American College of Physicians offers recommendations on choosing patients to whom therapy should be offered and what drugs to use. Candidates for drug treatment include all patients with known osteoporosis, i.e., women or men older than 50 who have experienced a fragility fracture or have a bone mineral density T-score of -2.5 SDs below the young female adult mean. A number of drugs have been shown to reduce further bone loss and the risk of fracture in this group. (See “Choosing among drugs,” page 19-20.)

The criteria for pharmacotherapy to prevent osteoporosis itself are more complex and ambiguous. The Guidelines recommend that preventive treatment be considered for those of either sex who are “at risk” of developing the condition. In the absence of a formal algorithm to quantify such risk (the authors note that groups, including the World Health Organization, are currently developing instruments toward this end), the determination must engage clinical judgment on a case-by-case basis.

Risk factors for men were cited previously; risk factors for women include low body weight, weight loss, smoking, family history, physical inactivity, alcohol or caffeine use, and low calcium and vitamin D intake. In some individuals, a single risk factor (e.g., androgen deprivation therapy in men) might justify considering pharmacologic treatment, the authors say. Generally, the case for chemoprophylaxis is strongest in individuals whose T-scores are below -1.5 or in those who are receiving glucocorticosteroids or are older than 62 years of age.

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