What is the management plan for osteoporosis in men?

Management of Osteoporosis in Men

Oral bisphosphonates (alendronate or risedronate) are the first-line treatments for men at high risk of fracture, with denosumab or zoledronate as second-line options. 1

Risk Assessment and Diagnosis

• Use a female reference database for densitometric diagnosis of osteoporosis in men (strong recommendation) 1
• FRAX is the appropriate tool for fracture risk assessment and setting age-dependent intervention thresholds 1
• Trabecular bone score, used with BMD and FRAX, provides additional information for risk assessment 1
• All men with prior fragility fracture should be considered for treatment 1

Treatment Algorithm

First-Line Assessment:

1. Identify high-risk men:

   • Men aged ≥70 years
   • Men aged 50-69 with risk factors (prior fracture, low body weight, smoking)
   • Men with T-scores ≤-2.5
   • Men with prior fragility fractures

2. Laboratory testing:

   • Assess serum total testosterone (weak recommendation) 1
   • Consider other secondary causes of osteoporosis

Non-Pharmacological Interventions:

• Calcium and vitamin D:

  • Ensure vitamin D and calcium repletion in all men above 65 years 1
  • Dietary calcium intake of 800-1200 mg daily
  • Vitamin D supplementation (800 IU) for those with insufficiency 1

• Lifestyle modifications:

  • Regular weight-bearing and resistance exercise 1
  • Balanced diet with adequate protein intake 1
  • Smoking cessation
  • Limit alcohol consumption
  • Fall prevention strategies

Pharmacological Treatment:

For Men at High Risk of Fracture:

• First-line: Oral bisphosphonates - alendronate or risedronate 1

  • Alendronate reduces bone resorption markers by 60% and bone formation markers by 40% 2
  • Improves BMD and reduces fracture risk

• Second-line: Denosumab or zoledronate 1

  • Consider if oral bisphosphonates are not tolerated or contraindicated
  • Denosumab is administered subcutaneously every 6 months 3
  • Zoledronate is given as an intravenous infusion

For Men at Very High Risk of Fracture:

• Sequential therapy: Start with a bone-forming agent followed by an anti-resorptive agent 1
• Abaloparatide can be considered as first-line treatment (weak recommendation) 1

For Men with Low Testosterone:

• Consider appropriate hormone replacement therapy (weak recommendation) 1

Monitoring Treatment

• Use biochemical markers of bone turnover to assess adherence to anti-resorptive therapy 1
• Continue monitoring with serial dual-energy x-ray absorptiometry testing
• Be aware that up to 64% of men may be non-adherent to bisphosphonate therapy by 12 months 1

Special Considerations and Pitfalls

Potential Side Effects to Monitor:

• Bisphosphonates: Gastrointestinal issues (acid regurgitation, dyspepsia, abdominal pain) 2
• Denosumab: Risk of serious infections, skin problems, hypocalcemia, osteonecrosis of the jaw, and atypical femur fractures 3
• Increased fracture risk after discontinuation: Particularly with denosumab, which requires careful transition planning 3

Common Pitfalls:

1. Underdiagnosis and undertreatment: Most men with osteoporosis are not diagnosed or treated
2. Poor medication adherence: Provide education and consider monitoring adherence
3. Stigma: Address potential perception that osteoporosis is a "female condition"
4. Inadequate calcium/vitamin D: Ensure proper supplementation before and during treatment
5. Failure to identify secondary causes: Always assess for underlying conditions

Remember that osteoporosis treatment does not cure the disease but effectively reduces fracture risk. Even if normal BMD is achieved, the diagnosis persists and ongoing monitoring with strategic interventions remains necessary.