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MEN’S
HEALTH
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Osteoporosis in Men
• Flu–like symptoms • Previous or current treatment with bisphosphonate “blunts” re-
• Seen as acute–phase reaction (low grade fever, myalgia’s , sponse to PTH
arthralgia) 24 to 72 hrs after IV bisphosphonates, responsive
to ibuprofen or acetaminophen and decreasing occurrence • Baseline and periodic monitoring with s calcium renal profile
with subsequent infusions • Treatment duration for no longer than 24 months
• BMD improvement s of 2 percent and 6 percent and fracture
• Clinically significant hypocalcemia only with IV bisphospho-
nate or in the setting of VIT D or PTH deficiency relative risk of 0.35 and 0.45 at vertebral and non–vertebral
sites respectively
• Rare but persistent severe musculoskeletal pain
• Renal – contraindicated with Creatinine clearance below 35 DENOSUMAB
An option in the setting of intolerance to bisphosphonate or im-
ml/min
• Osteonecrosis of the jaw paired renal function. Fracture prevention data in men available
only for use with androgen deprivation therapy
• Risk 1 in 10,000 to 100,000 patient– years
• IV bisphosphonate, cancer, anti–cancer therapy, duration of Hypogonadism
• Testosterone therapy: In the absence of contraindications, for
exposure (>4 years), dental extractions and implants, poor individual with clinical features of androgen deficiency and truly
fitting dentures, glucocorticoid therapy and smoking are low testosterone levels and those with unequivocal diagnoses
risk factors like Klinefelter and gonadotrophin deficiency. Treatment may
• Discussion of risk, dental hygiene and regular dental visits improve BMD by 5 to 10 percent and occurs primarily in cor-
are encouraged tical bone.
• The American Association of Oral and Maxillofacial Sur- • For high risk patients with hypogonadism; that are not respond-
geons recommends stopping bisphosphonate therapy for ing to testosterone replacement, fracture or therapy, are on con-
two months in patient s requiring dental extraction or im- comitant glucocorticoids, or T score below –3, additional
plants if they have received therapy for >4 years or use con- treatment with bisphosphonates recommended.
comitant glucocorticoids. No restrictions for less than four
years use Glucocorticoid induced osteoporosis
• Atrial Fibrillation • Doses of Prednisone or equivalent as low as 2.5–5 mg/day can
• Risk is small if any, seen with IV Zolendronic acid increase fracture risk within 3–6 months of therapy
• Atypical Femur Fractures • All individuals receiving any dose of glucocorticoids for ≥3
• Related to decrease in bone turnover with prolonger therapy month should receive Calcium and Vitamin D supplementa-
leading to adynamic /frozen bone tion 12000mg/dal and 800 IU /day respectively
• Long term use (~7 years ) increases the relative risk though • Treatment recommendations are guided by age, FRAX score,
absolute risk is low 3.2–>50 cases per 100,000 person years) prednisone dose
• Risk declines with stoppage of bisphosphonates • Men ≥ 50 yrs. with established osteoporosis should receive phar-
• Typical presentation is mid–thigh or groin pain, plain ra- macologic therapy.
diograph may show cortical thickening, to be confirmed on • Men ≥ 50 yrs. with T–score –1 to –2.5, treatment based on
MRI FRAX score
• Pharmacotherapy if 10–year probability of hip or combined
Duration of therapy major osteoporotic fracture of ≥3 percent or 20 percent re-
• Drug holiday after five years of oral alendronate or three years spectively
• If 10 year risk less than above, pharmacotherapy only if
of annual Zolendronic acid in in the setting of stable BMD, no prednisone dose >7.5mg for ≥3 months
h/o fragility fracture. Treatment resumption if significant reduc- • Men ≤ 50 years with fragility fracture while on >7.5mg pred-
tion in follow up at two yearly BMD or new fragility fracture nisone for>3 months, pharmacotherapy recommended
• Should probably receive pharmacotherapy if there is evi-
PARATHYROID HORMONE dence of accelerated bone loss(>4 percent/year)
PTH 1–34 Teriparatide is an anti–resorpitive anabolic agent that • Weekly Alendronate and Risedronate are the bisphosphonates
of choice and IV Zolendronic acid for those intolerant to oral
stimulates bone formation and bone remodeling. agents
• Administered subcutaneously as daily injections
• Indication: T score ≤ –2.5 and at least one fragility fracture and
continue to fracture after one year of bisphosphonate or unable
to tolerate any other therapy
24 San Antonio Medicine • December 2015
