From the Guidelines
The initial workup for osteoporosis in a healthy 49-year-old male should include a comprehensive history and physical examination, laboratory testing, and bone mineral density (BMD) testing, but only if risk factors are present, as the American College of Physicians recommends DXA for men who are at increased risk for osteoporosis and are candidates for drug therapy 1.
Initial Evaluation
The evaluation should start with a detailed medical history focusing on risk factors such as:
- Previous fractures
- Family history of osteoporosis
- Smoking
- Alcohol use
- Low body weight
- Medication use (particularly glucocorticoids)
- Age (>70 years), although the patient in question is 49
- Weight loss (>10% compared with the usual young or adult weight or weight loss in recent years)
- Physical inactivity
- Corticosteroid use
- Androgen deprivation therapy
- Previous fragility fracture
Laboratory Testing
Laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- 25-hydroxyvitamin D level
- Thyroid function tests
- Testosterone level
- 24-hour urinary calcium
Bone Mineral Density Testing
A dual-energy X-ray absorptiometry (DXA) scan of the hip and lumbar spine is the gold standard for measuring BMD, but it should only be considered if the patient has risk factors for osteoporosis, as recommended by the American College of Physicians 1.
Additional Tests
Additional tests to consider include:
- Serum protein electrophoresis if multiple myeloma is suspected
- Parathyroid hormone levels if hyperparathyroidism is a concern
This comprehensive evaluation is important because osteoporosis in men under 50 is uncommon without secondary causes, such as hypogonadism, glucocorticoid use, or other medical conditions. Early identification of underlying causes allows for targeted treatment approaches that address both the secondary cause and bone health, potentially preventing fractures and associated morbidity.
From the Research
Initial Workup for Osteoporosis
The initial workup for osteoporosis in a healthy 49-year-old male involves several steps:
- Screening for osteoporosis using dual energy x-ray absorptiometry (DXA) is not universally recommended for men of this age group, as the U.S. Preventive Services Task Force found insufficient evidence to recommend screening for osteoporosis in men 2.
- However, some organizations recommend screening all men 70 years and older, or men with clinical risk factors 2, 3.
- Laboratory tests to identify secondary causes of osteoporosis may include:
- Serum 25-hydroxyvitamin D
- Calcium
- Creatinine
- Thyroid-stimulating hormone 2
- Biochemical markers of bone turnover, such as serum procollagen type 1 amino-terminal propeptide and β-form of C-terminal cross-linked telopeptide of type I collagen (β-CTx-1/β-CrossLaps), may be used to monitor treatment and assess osteoporosis 4.
- A thorough medical history and physical examination to identify any underlying conditions that may contribute to osteoporosis, such as calcium and vitamin D deficiency, or inactivity 5.
Additional Considerations
- The World Health Organization's FRAX Fracture Risk Assessment Tool may be used to determine the patient's fracture risk 2.
- The patient's lifestyle and habits, such as smoking, alcohol intake, and exercise level, should be assessed and addressed as part of the overall management plan 2, 3.
- The use of pharmaceutical agents, such as bisphosphonates, denosumab, or anabolic agents, may be considered for treatment, depending on the patient's fracture risk and medical history 5, 2, 3.