Is a man with osteoporosis (lumbar T-score of -2.5) and given FRAX scores a candidate for bisphosphonate treatment?

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Indication pour traitement par bisphosphonate chez cet homme

Oui, ce patient a une indication claire pour un traitement par bisphosphonate, car il présente un score T lombaire de -2.5 (diagnostic d'ostéoporose selon l'OMS) et il est un homme de plus de 50 ans. 1

Critères diagnostiques confirmés

  • Score T de -2.5 au rachis lombaire = ostéoporose confirmée selon les critères de l'OMS, qui définissent l'ostéoporose comme un score T ≤ -2.5 au rachis lombaire, col fémoral ou hanche totale 1
  • Chez les hommes de plus de 50 ans, les scores T (et non les scores Z) sont utilisés pour le diagnostic, avec la même base de référence que pour les femmes 1

Recommandations thérapeutiques

La National Osteoporosis Foundation recommande un traitement pharmacologique pour tous les hommes de plus de 50 ans avec un score T ≤ -2.5 1

Traitement de première ligne

  • Bisphosphonates oraux (alendronate 70 mg/semaine) constituent le traitement de première intention 2
  • L'alendronate a démontré son efficacité chez les hommes avec ostéoporose, augmentant significativement la DMO au rachis lombaire (+5.3% à 2 ans avec 10 mg/jour, +2.8% à 1 an avec 70 mg/semaine) 3

Alternatives thérapeutiques

Si les bisphosphonates oraux sont contre-indiqués ou non tolérés:

  • Denosumab 60 mg SC tous les 6 mois, particulièrement si insuffisance rénale (DFG <35 mL/min) 2
  • Bisphosphonates intraveineux comme alternative 2

Rôle du score FRAX dans ce cas

Le score FRAX n'est PAS nécessaire pour décider du traitement chez ce patient, car il a déjà un score T ≤ -2.5 1

  • Le FRAX est utilisé principalement pour les patients avec ostéopénie (score T entre -1.0 et -2.5) afin d'identifier ceux nécessitant un traitement 1
  • Les seuils d'intervention FRAX sont: risque de fracture majeure ≥20% OU risque de fracture de hanche ≥3% sur 10 ans 1
  • Avec un diagnostic d'ostéoporose confirmé (T-score -2.5), le traitement est indiqué indépendamment du score FRAX 1

Évaluation biologique recommandée avant traitement

Avant d'initier les bisphosphonates, effectuer un bilan pour exclure les causes secondaires d'ostéoporose 2:

  • Numération formule sanguine
  • Calcium, phosphate, créatinine (DFG)
  • Phosphatase alcaline totale
  • TSH
  • 25-hydroxyvitamine D (cible ≥30 ng/mL)
  • Électrophorèse des protéines sériques avec immunofixation (surtout >50 ans)

Supplémentation concomitante obligatoire

  • Calcium 1000-1200 mg/jour 1
  • Vitamine D 600-800 UI/jour (ou dose nécessaire pour maintenir 25-OH vitamine D ≥20-30 ng/mL) 1, 2

Mise en garde importante

Ne pas retarder le traitement en attendant les résultats biologiques complets - initier immédiatement la supplémentation en calcium et vitamine D 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Osteoporosis Diagnosis and Treatment

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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