Osteoporosis Underdiagnosed in Older Men With Fracture

Marcia Frellick

November 08, 2020

Osteoporosis is frequently underdiagnosed and undertreated in men before and even after they have experienced a fracture, according to research presented at ACR Convergence 2020 on Saturday.

Dr Jeffrey Curtis

"This is an important public health concern," as fractures contribute significantly to morbidity and mortality, said Jeffrey Curtis, MD, MS, MPH, professor of medicine in the Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham.

Men are often overlooked, he said, "because it's misconstrued as a disease that mainly, if not only, affects Caucasian women," despite the fact that 20%-25% of fractures occur in men.

Emerging evidence suggests that men who have bone fractures have worse outcomes than women, Curtis said.

Guidelines Lacking

Consistent guidelines for osteoporosis screening among men are also lacking, leading to ambiguity and increased disease burden.

Researchers studied records for a 5% random sample of male Medicare fee-for-service beneficiaries (n = 9876) at least 65 years old with a closed fragility fracture between January 2010 and September 2014. Average age for the men with fractures was 77.9 years, and the most common sites of the fracture were the spine, hip, and ankle.

They looked back to see whether these men had been effectively screened and treated.

Very few had.

"We found that 92.8% of them did not have any diagnosis or treatment of osteoporosis at baseline," Curtis said. On top of that, less than 6% of men had undergone any dual energy x-ray absorptiometry [DEXA] or bone mineral testing in the 2 years prior to their fracture.

Even men who had high-risk factors for falls, such as those using beta-blockers, mobility impairment, or a history of opioid use, were unlikely to be screened, he said.

Curtis's data show there was actually a decline in DEXA scans from 2012 to 2014, and that decline was particularly high in men 75 years and older who are more likely to be at risk for fracture.

In addition to underscreening and undertreating before the fracture, Curtis said, "The treatment patterns after the fracture were not much better." In the year after the fracture, "only about 10% of these men had BMD [bone mineral density] testing. Only 9% were treated with an osteoporosis medication."

"Importantly, about 7% of the men in this large cohort went on to have one or more fractures in the next year," he added.

Reasons for Undertreatment

Reasons for the poor rates of diagnosis and treatment may begin with patients not having symptoms. Therefore, they aren't coming into doctors' offices asking to be screened. "Even if they break bones, they may not know enough to ask how to prevent the next fracture," Curtis said.

There's a financial obstacle as well, Curtis explained. "US legislation that provides population screening for Medicare patients really, for men, is quite dissimilar to the near-universal coverage for women. So many clinicians worry they won't get reimbursed if they order DEXA in men for screening."

Additionally, post-fracture quality-of-care guidelines that are reimbursed as part of the MACRA and the MIPS program specifically exclude men, he noted.

Better management of male osteoporosis, including early identification of at-risk individuals is clearly warranted, he said, so they can be screened and put on effective therapy.

Sonali Khandelwal, MD, a rheumatologist with Rush University Medical Center in Chicago, who was not part of the research, agrees.

She told Medscape Medical News that part of the problem is that diagnosis and treatment could come from a variety of specialists — endocrinologists, rheumatologists, orthopedists, primary care physicians — and each may think it falls in another's realm.

At Rush and some other sites nationally, she said, an alert is registered in electronic medical records flagging any patient who may need bone density screening based on age, medications, or history.

Rush University also has a fracture liaison service under which everyone hospitalized at Rush who may have had a history of a fracture or is admitted with a fracture gets followed up with screening and treatment, "to capture those patients who may not have come through the system otherwise."

She said guidelines have called for DEXA screening for men at age 70, but she said clinical screening should start younger — as young as 50 — for patients with conditions such as lupus, rheumatoid arthritis, hypogonadism, or those on chronic steroids.

Khandelwal said even when an insurance company doesn't typically cover bone density screening for men, physicians can often make a case for reimbursement if the patient has a history of falls or fractures.

"In the long run, preventing a fracture is saving so much more money than when you get a fracture and end up in a hospital and have to go to a nursing home," she said.

Curtis reported relationships with AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Gilead Sciences Inc, and Sanofi. Khandelwal reported no relevant financial relationships.

American College of Rheumatology (ACR) 2020 Annual Meeting: Abstract 0533. Presented November 7, 2020.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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