What are the treatment options for osteopenia in men?

Treatment Options for Osteopenia in Men

Oral bisphosphonates (alendronate or risedronate) are the first-line treatments for men at high risk of fracture, while lifestyle modifications including physical exercise and a balanced diet should be recommended to all men with osteopenia or osteoporosis. 1

Risk Assessment and Diagnosis

Before initiating treatment, proper risk assessment is essential:

• FRAX is the recommended tool for assessing fracture risk and determining intervention thresholds in men 1
• A female reference database should be used for densitometric diagnosis of osteoporosis in men 1
• Age-dependent FRAX-based intervention thresholds should guide treatment decisions 1
• Trabecular bone score, used with BMD and FRAX probability, provides additional information for fracture risk assessment 1

Treatment Algorithm for Men with Osteopenia

First-line interventions (for all men with osteopenia):

1. Non-pharmacological approaches:

   • Physical exercise (particularly weight-bearing and resistance training) 1
   • Balanced diet with adequate protein intake (800-1200 mg calcium daily) 1
   • Vitamin D and calcium repletion for all men above 65 years 1
   • Smoking cessation and limiting alcohol consumption 1

2. Laboratory assessment:

   • Serum total testosterone should be measured as part of pre-treatment assessment 1
   • Consider hormone replacement therapy for men with low testosterone levels 1

Pharmacological treatment (for men at high fracture risk):

1. First-line medications:

   • Oral bisphosphonates (alendronate or risedronate) 1

2. Second-line medications:

   • Denosumab or zoledronate 1

3. For men at very high fracture risk:

   • Sequential therapy starting with a bone-forming agent followed by an anti-resorptive agent 1
   • Abaloparatide can be considered as first-line treatment based on BMD data 1

Special Considerations

• Prior fragility fracture: All men with a prior fragility fracture should be considered for treatment with anti-osteoporosis medications 1
• Monitoring: Biochemical markers of bone turnover can assess adherence to anti-resorptive therapy 1
• Treatment adherence: Patient education is crucial as up to 64% of men are non-adherent to bisphosphonate therapy by 12 months 1
• Stigma awareness: Clinicians should be sensitive to potential stigma, as some men may view osteoporosis as a "female condition" 1

Nutritional Recommendations

• Ensure adequate protein intake (higher than recommended daily allowance may benefit skeletal health) 1
• Consume 800-1200 mg of calcium via diet daily; supplement if intake is below 800 mg 1
• Consider vitamin D supplementation (800 IU) for those at increased fracture risk or with insufficient levels 1
• Be aware that vegetarian/vegan diets may reduce BMD 1

Common Pitfalls to Avoid

• Underdiagnosis: Osteoporosis in men is often underdiagnosed and undertreated
• Inadequate evaluation: Failing to exclude secondary causes (30-60% of men with vertebral fractures have another illness contributing to bone disease) 2
• Premature discontinuation: All anti-fracture therapeutics treat but do not cure osteoporosis; skeletal deterioration resumes when medication is discontinued
• Overlooking testosterone: Failing to assess testosterone levels as hypogonadism is a common secondary cause of osteoporosis in men 2
• Inadequate monitoring: Not using bone turnover markers to assess treatment adherence 1

By following these evidence-based guidelines, clinicians can effectively manage osteopenia in men and reduce the risk of progression to osteoporosis and subsequent fractures.