What is the appropriate treatment for a 74-year-old man with osteoporosis diagnosed by DXA?

Treatment for Osteoporosis in a 74-Year-Old Male

Yes, this 74-year-old man with osteoporosis requires treatment, starting with oral bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) combined with calcium and vitamin D supplementation, plus structured exercise. 1, 2

Risk Stratification First

Before initiating treatment, you must calculate his 10-year fracture risk using FRAX (Fracture Risk Assessment Tool), which is the appropriate tool for assessing fracture risk and setting intervention thresholds in men with osteoporosis. 1, 2 The treatment intensity should be adapted to his baseline fracture risk—whether he is at high risk or very high risk will determine the specific regimen. 1

Critical question to answer immediately: Does he have a prior fragility fracture? If yes, he should be strongly considered for treatment regardless of other factors, as prior fracture is the strongest predictor of future fracture. 1

First-Line Pharmacologic Treatment

Oral bisphosphonates are the first-line treatment for men at high risk of fracture. 1, 2

• Alendronate 70 mg once weekly reduces radiographic vertebral fractures by approximately 140 fewer per 1000 treated patients over 2-3 years and significantly improves BMD at the lumbar spine, total hip, and femoral neck. 2, 3, 4
• Risedronate 35 mg once weekly is an equally effective alternative, improving BMD at the lumbar spine, total hip, and femoral neck. 1, 2, 3

Administration Details for Bisphosphonates

Alendronate must be taken after an overnight fast, at least 30 minutes before the first food or beverage of the day, with plain water only, and the patient must remain upright for at least 30 minutes to minimize esophageal irritation. 4 Bioavailability decreases by approximately 40% if taken with food. 4

Essential Baseline Supplementation

All men above age 65 years require vitamin D and calcium repletion—this is a strong recommendation. 1, 2

• Calcium: 1000-1200 mg daily 2, 3, 5
• Vitamin D: 800-1000 IU daily 2, 3, 5

Adequate vitamin D and calcium are necessary for bisphosphonates to work effectively. 2 These should be started immediately, even before pharmacologic therapy is initiated. 1

Second-Line Options

If oral bisphosphonates are contraindicated, cause adverse effects (such as esophageal irritation or gastrointestinal intolerance), or if adherence is a concern, use: 1, 2

• Denosumab 60 mg subcutaneously every 6 months, which improves BMD at the lumbar spine, femoral neck, and total hip 2, 3
• Zoledronic acid 5 mg intravenously annually, particularly useful when oral medication adherence is problematic, which significantly improves lumbar spine BMD, femoral neck BMD, and total hip BMD 2, 3

Important caveat: Up to 64% of men are non-adherent to oral bisphosphonate therapy by 12 months, so consider parenteral options early if adherence concerns exist. 1, 6, 3

Very High-Risk Patients Require Different Approach

If this patient has any of the following, he is at very high risk and should start with anabolic therapy followed by bisphosphonate consolidation: 1, 2, 6

• Recent vertebral fracture
• Hip fracture with T-score ≤-2.5
• Multiple fractures
• Very high FRAX score

For very high-risk patients, sequential therapy starting with a bone-forming agent followed by an anti-resorptive agent should be considered. 1, 6, 3 Options include:

• Abaloparatide (supported by the strongest BMD data for men at very high risk) 1, 6, 3
• Teriparatide, which significantly improves BMD at the lumbar spine and femoral neck 6, 3
• Romosozumab 5, 7

After completing anabolic therapy, transition to bisphosphonate to maintain gains. 2

Non-Pharmacologic Interventions (Mandatory)

Physical exercise and a balanced diet should be recommended to all men with osteoporosis—this is a strong recommendation. 1, 3

Specific exercises to prescribe: 2, 3

• Muscle resistance exercises: squats, push-ups, resistance bands
• Balance exercises: heel raises, standing on one foot, tai chi

These reduce fall risk and improve bone strength independently of medication. 2

Pre-Treatment Assessment Required

Check serum total testosterone level as part of the pre-treatment assessment. 1, 6, 3 If low levels of total or free serum testosterone are found, appropriate hormone replacement therapy should be considered. 1, 6 However, testosterone therapy has shown significant increases in lumbar spine trabecular volumetric BMD and cortical volumetric BMD, but anti-osteoporosis medications should be prescribed regardless of whether testosterone therapy is instituted, as testosterone alone does not adequately reduce fracture risk. 6, 3

Treatment Duration and Monitoring

• Reassess after 5 years of continuous bisphosphonate treatment. 2
• After 5 years, consider a drug holiday unless the patient has very high fracture risk. 2
• Use biochemical markers of bone turnover to assess adherence to anti-resorptive therapy, measuring at baseline and at 3 months. 1, 6, 3

Common Pitfalls to Avoid

1. Do not dismiss osteoporosis as a "female disease"—men have twice the 1-year mortality rate after hip fracture compared to women. 1, 5
2. Do not skip testosterone assessment—secondary causes are more common in elderly men than younger men. 1, 6, 8
3. Do not forget patient education about adherence—poor adherence is a significant issue with oral bisphosphonates. 1, 6, 3
4. Do not use male reference database for DXA diagnosis—a female reference database should be used for the densitometric diagnosis of osteoporosis in men. 1, 6, 3