From the Guidelines
The patient likely has Cushing's syndrome causing secondary osteoporosis, which led to his vertebral compression fracture, and urgent endocrinology referral for evaluation of hypercortisolism is necessary. The diagnosis is suggested by his constellation of symptoms: recent weight gain despite diet adherence, hypertension, abdominal striae (stretch marks), and severe osteoporosis at a young age for a male 1. Initial management should include pain control with acetaminophen or NSAIDs, possible short-term bracing for the vertebral fracture.
Key Considerations
- Laboratory testing should include 24-hour urinary free cortisol, overnight dexamethasone suppression test, and late-night salivary cortisol to confirm the diagnosis of Cushing's syndrome.
- If Cushing's syndrome is confirmed, imaging (MRI of the pituitary or CT of the adrenal glands) would be needed to determine the source of excess cortisol 1.
- Treatment depends on the cause but may include surgical removal of a pituitary or adrenal tumor, or withdrawal of exogenous steroids if that's the cause.
- Addressing the underlying hypercortisolism is essential to prevent further bone loss and fractures.
- Calcium and vitamin D supplementation should be initiated, and bisphosphonate therapy may be needed to treat the established osteoporosis once the primary condition is addressed, as recommended by the evidence-based guideline for the management of osteoporosis in men 1.
Management of Osteoporosis
- The management of osteoporosis in men is crucial to prevent further fractures and mortality, with men being at a substantially higher risk of death following a fracture than women 1.
- The Endocrine Society guideline recommends treatment for men ‘at high risk of fracture’, including those with a history of fragility fracture of the hip or vertebra, men with a BMD 2.5 (or more) standard deviations below the mean value for normal young white men 1.
From the Research
Patient Presentation
The patient is a 45-year-old man presenting with acute onset of back pain, specifically in the midline just below the shoulder blades, which started 48 hours ago. He has no history of similar pain and no difficulty with urination or defecation. The pain does not radiate to the lower back or lower extremities.
Medical History
In the past 12 months, the patient has gained about 40 pounds. He was found to have mild high blood pressure during a physical examination four months ago, and despite efforts to lose weight and exercise, his blood pressure has remained elevated at around 150/95. Two months ago, he noticed stretch marks on his abdomen, which he attributed to weight gain.
Physical Examination and Diagnostic Findings
The physical examination revealed tenderness over the twelfth thoracic vertebral body, but the neurologic exam was intact. A radiograph of the thoracic spine showed a compression fracture of T12, and a bone mineral density scan indicated marked osteoporosis, well below age-matched controls and below the threshold for risk of fracture after minimal trauma.
Treatment Considerations
Given the patient's osteoporosis diagnosis, treatment options may include bisphosphonates, which have been shown to reduce the risk of fracture by suppressing bone resorption and increasing bone strength 2. Patient preference for once-weekly versus once-daily dosing with alendronate, a type of bisphosphonate, has been studied, with most patients preferring the once-weekly dosing regimen due to its convenience and potential for better long-term compliance 3. Other treatment options, such as calcium and vitamin D3, denosumab, teriparatide, raloxifene, and strontium ranelate, may also be considered 4.
Bisphosphonate Therapy
Bisphosphonates are widely used in the treatment of osteoporosis, and their effectiveness in reducing fractures has been demonstrated in clinical trials 5. A comparison of the effects of three oral bisphosphonate therapies (alendronate, ibandronate, and risedronate) on the peripheral skeleton in postmenopausal osteoporosis found differences in effect on the central skeleton but not on the peripheral skeleton 6. The choice of bisphosphonate therapy may depend on various factors, including patient preference, potential side effects, and the specific characteristics of the patient's osteoporosis.