What is the recommended treatment for a patient with hip fracture and testosterone deficiency?

Management of Hip Fracture in Patients with Testosterone Deficiency

For patients with hip fracture and testosterone deficiency, testosterone replacement therapy should be initiated alongside standard osteoporosis treatments, as testosterone deficiency is a significant risk factor for hip fractures in men and testosterone therapy improves bone mineral density. 1

Diagnostic Assessment

• Measure serum free or total testosterone levels as part of the investigatory work-up for osteoporosis in men with hip fracture 2
• Assess fracture risk using FRAX to guide treatment decisions 2
• Consider that testosterone levels may be transiently decreased immediately after acute fracture, with 43% of men showing recovery to normal levels after 6 months 3
• Defer final evaluation for testosterone deficiency until recovery from the acute fracture event to avoid overdiagnosis 3

Treatment Algorithm

First-Line Treatment:

• Oral bisphosphonates (alendronate or risedronate) as the primary anti-osteoporotic medication for men with hip fracture and testosterone deficiency 4, 2
• Testosterone replacement therapy should be initiated concurrently in men with confirmed testosterone deficiency 1
• Ensure adequate calcium intake (1,000-1,200 mg daily) and vitamin D supplementation (800-1,000 IU daily) 2

Second-Line Treatment (if oral bisphosphonates are not tolerated or contraindicated):

• Intravenous bisphosphonates (zoledronate) 4, 2
• Denosumab 60 mg subcutaneously every 6 months 4, 5

For Very High Fracture Risk:

• Consider sequential therapy starting with a bone-forming agent (teriparatide) followed by an anti-resorptive agent 2

Evidence Supporting Testosterone Replacement in Hip Fracture

• Low testosterone levels are significantly associated with increased hip fracture risk in men, with studies showing 71% of men with hip fractures have testosterone deficiency compared to 32% of controls (odds ratio 5.3) 6
• Testosterone therapy significantly increases bone mineral density in hypogonadal men, particularly at the lumbar spine, with improvements in both trabecular and cortical bone density 1
• Bioavailable testosterone levels are significantly lower in patients with hip fracture (2.69 nmol/L versus 3.89 nmol/L in controls), making it an independent predictor for osteoporotic hip fracture in elderly men 7

Important Clinical Considerations

• Anti-osteoporosis medications should be prescribed regardless of whether testosterone therapy is instituted, as testosterone alone does not adequately reduce fracture risk 2
• Monitor for potential side effects of both anti-osteoporosis medications and hormone replacement therapy 2
• For patients with advanced chronic kidney disease (eGFR < 30 mL/min/1.73 m²), evaluate for chronic kidney disease-mineral bone disorder before initiating treatments like denosumab 5
• Poor adherence is a significant issue with oral bisphosphonates, with up to 64% of men being non-adherent by 12 months 2

Non-Pharmacological Interventions

• Recommend regular physical activity, particularly weight-bearing exercise, as it is an important factor for BMD maintenance 4
• Counsel patients to avoid smoking, alcohol, cannabis, and excessive caffeine consumption 4
• Implement balance training, flexibility exercises, and resistance training to reduce fall risk 2

Monitoring

• Measure bone turnover markers at baseline and at 3 months to monitor treatment response 2
• Repeat BMD measurement approximately 2 years after initiating treatment 1
• Monitor testosterone levels to ensure they remain in the therapeutic range 1