Endocrine Society vs Osteoporosis in Men

Guess what?  Men suffer from osteoporosis, too!  It's not just a disease of old women.  Men who had delayed puberty, hypogonadism (doesn't that seem like every guy these days?!?!), hyperparathyroidism, (iatrogenic) hyperthyroidism, chronic obstructive pulmonary disease (COPD) are all at increase risk of fractures, as are those men who sustained a fracture after 50yo.  Those men whose medical history required use of GnRH agonists or long term glucocorticoids are also at great risk as are those who smoke and/or consume alcohol to excess.  This doesn't take into account all the secondary causes of osteoporosis like multiple myeloma.  I mention this because the Endocrine Society just published their Clinical Practice Guideline regarding osteoporosis in men in this month's Journal of Clinical Endocrinology & Metabolism.

Several points were made in this guideline.  First, dual energy xray absorptiometry (DXA or DEXA) should be used for screening purposes, using both spine & hip, if appropriate, and forearm as well, if necessary.  Second, DXA screening should start at 70yo at latest, although those 50-69yo w/any of the aforementioned risk factors should also be screened.

Third, fracture risk calculators, such as FRAX, should also be used to determine who to treat more aggressively, eg pharmacologically.  Here in the States, those osteopenic men (and women) with a 10 year risk of any fracture >20% OR hip fracture >3% should consider medical management.  Obviously, any person who's suffered an osteoporotic fracture (either hip or vertebral) w/o major trauma as the cause warrants drug treatment.  Likewise, all those deemed osteoporotic by nature of any of their DXA T-scores falling 2.5 standard deviations or more below the mean for normal young white males.  And finally, those persons who receive chronic glucocorticoid therapy equivalent to >7.5mg/d of prednisone also warrant prophylaxis.

Fourth, the Endocrine Society left open the choice of pharmacologic therapy, including various bisphosphonates, recombinant PTH, RANKL inhibitor, and even testosterone in appropriate hypogonadal men.  Of course, everyone(?) should get 1,000-1,200mg dietary calcium daily w/vitamin D supplementation if 25OH vitamin D <30ng/mL.  Fascinating that we all look at the same evidence yet come away with different interpretations.  Reminds me again of the blind men and the elephant with the Endocrine Society and US Preventive Services Task Force examining roughly the same data.

So take a look at the Endocrine Society's recommendations.  And let me know what you think.

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