What is the appropriate work-up for secondary causes of osteoporosis in men?

From the Guidelines

The appropriate work-up for secondary causes of osteoporosis in men should include a comprehensive medical history, physical examination, and laboratory testing, with a focus on assessing serum total or free testosterone levels, as recommended by recent guidelines 1. The work-up should consist of initial laboratory evaluation including complete blood count, comprehensive metabolic panel (including calcium, phosphorus, creatinine, liver function tests), 25-hydroxyvitamin D level, total testosterone, thyroid-stimulating hormone, parathyroid hormone, and 24-hour urinary calcium excretion. Additional tests to consider include:

• Serum protein electrophoresis
• Tissue transglutaminase antibodies (to screen for celiac disease)
• 24-hour urinary free cortisol if Cushing's syndrome is suspected
• Bone turnover markers such as serum C-telopeptide or N-telopeptide to assess bone resorption Radiographic studies should include:
• Dual-energy X-ray absorptiometry (DXA) scan for bone mineral density measurement
• Vertebral imaging to identify existing fractures In men with significant bone loss without obvious cause, bone marrow examination may be necessary to rule out multiple myeloma or other malignancies. This comprehensive evaluation is crucial because secondary causes are identified in approximately 40-60% of men with osteoporosis, with hypogonadism, glucocorticoid use, alcohol abuse, vitamin D deficiency, hyperparathyroidism, and malabsorption syndromes being the most common contributing factors, as noted in recent studies 1. Early identification of these underlying conditions allows for targeted treatment that addresses both the secondary cause and the resulting bone loss, and may include hormone replacement therapy for men with low levels of total or free serum testosterone, as suggested by recent guidelines 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Work-up for Secondary Causes of Osteoporosis in Men

The work-up for secondary causes of osteoporosis in men involves a comprehensive evaluation to identify underlying conditions that may be contributing to bone loss.

• A thorough history and physical examination are essential to reveal secondary causes of osteoporosis 2, 3, 4.
• Laboratory tests can be helpful in identifying secondary causes, including:
  • Measurement of 25-hydroxyvitamin D 2, 5, 6
  • Testosterone levels in men 5, 6
  • Thyroid-stimulating hormone (TSH) 6
  • Parathyroid hormone (PTH) 6
  • Serum and urine calcium, phosphate, and creatinine 6
  • Liver function tests 6
  • Complete blood count (CBC) 6
• Dual-energy X-ray absorptiometry (DXA) is the preferred diagnostic test for osteoporosis in men, and it should be performed on every new patient with newly diagnosed osteoporosis 2, 3, 4.
• A careful search for undiagnosed conditions such as hyperthyroidism, hypogonadism, and vitamin D deficiency is crucial in the evaluation of secondary osteoporosis in men 5, 4, 6.
• The evaluation should also include an assessment of risk factors for osteoporosis, such as age, smoking, and prior fracture 5, 4.

Common Secondary Causes of Osteoporosis in Men

Some common secondary causes of osteoporosis in men include:

• Hypogonadism 5, 4
• Vitamin D deficiency 5, 4, 6
• Hyperthyroidism 4
• Hyperparathyroidism 5
• Glucocorticoid therapy 2
• Androgen deprivation therapy for prostate cancer 2, 3, 6
• Excessive alcohol consumption 4
• Malabsorption or history of surgery for peptic ulcer disease 2