Men at Risk for Osteoporosis Should Have DXA Testing

June 20, 2012 — Men at increased risk for osteoporosis should undergo bone mineral density (BMD) testing using central dual-energy X-ray absorptiometry (DXA), according to newly released clinical practice guidelines (CPG) from the Endocrine Society. The new recommendations on the management of osteoporosis in men are published in the June issue of the Journal of Clinical Endocrinology and Metabolism.

In the United States, about one fifth of persons with osteoporosis or low bone density are male. Among men aged 50 to 69 years, those with osteoporosis have higher mortality than their counterparts without osteoporosis.

"For men age 50, one in 5 will experience an osteoporosis-related fracture in their lifetime," CPG Task Force Chair Nelson Watts, MD, from Mercy Health Osteoporosis and Bone Health Services in Cincinnati, Ohio, said in a news release. "Mortality after fracture is higher in men than in women. Of the 10 million Americans with osteoporosis, 2 million are men. Of the 2 million fractures due to osteoporosis that occur each year, 600,000 are in men."

The Endocrine Society convened a task force composed of a chair selected by the Clinical Guidelines Subcommittee, 5 additional experts, and a methodologist. To describe the strength of recommendations and evidence quality, the task force used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

To arrive at consensus recommendations, the task force relied on systematic evidence reviews, 1 in-person meeting, and multiple conference calls and emails. The Endocrine Society's Clinical Guidelines Subcommittee and Clinical Affairs Core Committee; representatives of the American Society for Bone and Mineral Research, European Calcified Tissue Society, the European Society of Endocrinology, and the International Society for Clinical Densitometry; and members at large reviewed and commented on successive task force drafts.

Risk factors for osteoporosis in men include age 70 years or older, low body weight, prior fracture as an adult, and smoking.

Specific recommendations in the CPG include the following:

Men at higher risk for osteoporosis should undergo bone density testing using DXA, as well as laboratory testing to detect contributing causes.
Recommended daily calcium intake for men who are at risk for osteoporosis is 1000 to 1200 mg. Ideally, dietary sources would suffice, but calcium supplements may be added if needed.
Men at higher risk for osteoporosis should be encouraged to participate in weight-bearing exercise and to avoid smoking and excessive alcohol.
Men with vitamin D levels lower than 30 ng/mL should receive vitamin D supplementation with a target level of 30 ng/mL or greater.
Pharmacotherapy for osteoporosis is indicated for men at least 50 years of age with a history of spine or hip fractures, and for men at high risk for fracture resulting from low BMD (T-scores of −2.5 or below) and/or clinical risk factors.
Appropriate medications may include alendronate, risedronate, zoledronic acid, or teriparatide, as well as denosumab for men receiving androgen deprivation therapy for prostate cancer).
Selection of therapeutic agent should be individualized based on patient-specific factors including fracture history, severity of osteoporosis (T-scores), risk for hip fracture, patterns of BMD, comorbid conditions (such as peptic ulcer disease, gastroesophageal reflux, malabsorption syndromes, malignancy), cost, and other factors.
To determine treatment response, clinicians should monitor BMD by serial DXA at the spine and hip every 1 to 2 years in men receiving pharmacotherapy for osteoporosis.