From the Guidelines
Initiation of Bisphosphonate Therapy
Yes, bisphosphonate therapy should be initiated in a 65-year-old male with osteoporosis, indicated by a DXA T-score of -2.3, especially since he is on testosterone therapy, which may further increase the risk of osteoporosis 1.
- The patient's T-score of -2.3 indicates a high risk of fracture, and according to the Endocrine Society guideline, treatment is recommended for men with a BMD 2.5 (or more) standard deviations below the mean value for normal young white men 1.
- Bisphosphonates are widely advocated as a first-line treatment for osteoporosis in men, with options such as alendronate 70mg weekly or risedronate 35mg weekly being suitable choices 1.
- It is also essential to ensure adequate calcium and vitamin D supplementation, with a target of 1,200mg of calcium and 800-1,000 IU of vitamin D per day, to support bone health and prevent further bone loss 1.
- Regular monitoring of bone density is crucial, and treatment should be adjusted as needed to prevent fractures and manage osteoporosis effectively 1.
From the FDA Drug Label
In both studies, BMD responses were similar regardless of age (greater than or equal to 65 years vs. less than 65 years), gonadal function (baseline testosterone less than 9 ng/dL vs. greater than or equal to 9 ng/dL), or baseline BMD (femoral neck and lumbar spine T-score less than or equal to -2. 5 vs. greater than -2.5).
Bisphosphonate therapy can be initiated in a 65-year-old male with osteoporosis (indicated by a DXA T-score of -2.3) on testosterone therapy, as the drug label indicates that alendronate sodium is effective in men with hypogonadal or idiopathic osteoporosis, regardless of gonadal function or age.
- The studies showed significant increases in BMD at various sites, including the lumbar spine, femoral neck, and trochanter.
- The efficacy of alendronate sodium was demonstrated in two clinical studies, with daily and weekly dosing regimens.
- The drug label does not suggest any contraindications or precautions specific to patients on testosterone therapy 2.
From the Research
Patient Profile
- The patient is a 65-year-old male with osteoporosis, indicated by a DXA T-score of -2.3.
- The patient is currently on testosterone therapy.
Bisphosphonate Therapy Considerations
- According to 3, oral bisphosphonates are well-tolerated in elderly patients with varying degrees of kidney function, and there is no significant change in calculated creatinine clearance after initiation of therapy.
- A study by 4 found that age ≥65 years and male gender are associated with low persistence of treatment with bisphosphonates.
- 5 suggests that bisphosphonates can be discontinued in seniors after 3-7 years of use, but a risk of decreased bone mineral density and increased vertebral fractures remains.
- 6 found that 60% of seniors starting oral bisphosphonate therapy are exposed for 3 or more years, and studies are needed to examine the benefits and harms of continuing bisphosphonate therapy beyond 3 years.
Testosterone Therapy Considerations
- There is no direct evidence in the provided studies regarding the interaction between bisphosphonate therapy and testosterone therapy in patients with osteoporosis.
- However, 7 discusses the use of bisphosphonates in patients with multiple myeloma, and the benefits of bisphosphonate therapy in reducing skeletal-related events and improving survival.
Treatment Decision
- The decision to initiate bisphosphonate therapy in this patient should be based on individual factors, including the patient's overall health, kidney function, and potential benefits and risks of therapy.
- It is essential to weigh the potential benefits of bisphosphonate therapy in preventing fractures and improving bone density against the potential risks and side effects, particularly in elderly patients with kidney impairment or other comorbidities.
- Further research and consultation with a healthcare professional are necessary to determine the best course of treatment for this patient.