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MEN’S
                                                                                                     HEALTH

                                                                     • Markers of bone formation and resorption – only confirm
                                                                      accelerated bone loss may be useful in monitoring response
                                                                      to therapy

                                                                     Treatment
                                                                       Includes life style measures and drug / hormone therapy
                                                                       Lifestyle measures
                                                                       • Weight–bearing exercises
                                                                       • Limit /Avoid smoking and excess alcohol use
                                                                       • Adequate Calcium intake: 1000 to 1200mg /day and Vitamin
                                                                         D 600–800 IU /day
                                                                       Treatment of secondary causes and avoiding offending agents

                                                                     where possible: glucocorticoids, smoking and alcohol

                                                                     Candidates for pharmacotherapy:
                                                                       • Men with osteoporosis ( T–score ≤ –2.5 or fragility fracture )

                                                                         without symptomatic hypogonadism or when testosterone ther-

                                                                         apy contraindicated

                                                                       • High risk men with low bone mass T–score –1.0 to –2.5 based

                                                                         on Fracture Risk Assessment Tool (FRAX) with a 10–year prob-

                                                                         ability of hip fracture or combined major osteoporotic fracture
                                                                         of ≥3.0 or ≥205 respectively. www.shef.ac.uk/FRAX/

                                                                     Choice of therapy

                                                                     BISPHOSPHONATES

                                                                     • Oral weekly alendronate or risedronate are initial therapy of

                                                                     choice based on efficacy cost and longterm safety data and an-

                                                                     nual IV Zolendronic acid for those intolerant or with con-

                                                                     traindication to oral therapy.

                                                                     • Effective in reducing risk of vertebral fractures

                                                                     • Administration first thing in the morning, fasting improves

Evaluation                                                           bioavailability. Calcium and Vitamin D that can interfere
  • Hypogonadism, Glucocorticoid excess may be apparent in the
    initial history and physical examination.                        with absorption should be delayed at least one hour.
  • Routine biochemical evaluation should include
      • Hepatic and renal function                                   • Should be taken alone on an empty stomach first thing in
      • Complete blood count
      • Serum testosterone                                           the morning with at least eight ounces of water
      • Calcium/albumin
      • Phosphorus and Alkaline phosphatase                          • Should remain upright and not eat any food or drink for at
      • 25 OH Vitamin D
      • 24hr urine calcium and creatinine                            least 30 min to an hour
  • Additional testing guided by abnormal results or unexplained
    bone loss                                                        • Enteric coated delayed risedronate is taken immediately after
      • Parathyroid hormone
      • Estradiol                                                    breakfast with four ounces of water
      • Tissue transglutaminase antibodies, especially if Vitamin D
        or Urinary calcium levels are low)                           Side effects and precautions
      • Serum and urine electrophoresis prompted by anemia or
        vertebral fractures                                          • Reflux, esophagitis and ulcer if improperly administered
      • 24hr urine free cortisol
      • Serum Tryptase to rule out Mastocytosis                      • Should not be given to patients with active Upper GI disease

                                                                     • Should be stopped if patients develop symptoms of

                                                                     esophagitis

                                                                     • Esophageal cancer – conflicting data

                                                                     • Follow up of 46,000 bisphosphonate uses in a case co-

                                                                     hort study did not find an increased risk of esophageal

                                                                     or gastric cancer

                                                                     • Nested Case control analysis of 15,000 adults with GI

                                                                     cancer, found an increased risk esophageal cancer with

                                                                     bisphosphonate use at 1.3 relative risk.

                                                                     • FDA recommendation to not use in patients with Bar-

                                                                     rett’s esophagus

                                                                                                             continued on page 24

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