“Detailed Description of Osteoporosis Therapy in Men”
Screening
Bone density measurement should be performed in all men at increased risk for osteoporosis.
An age of 70 years or older is in itself a sufficient risk factor to justify bone density testing.
Younger men should be tested if they have additional risk factors.
A fracture after the age of 50 is an indication to evaluate for osteoporosis.
Men aged 50 to 69 should also be screened for osteoporosis if they have:
• Delayed puberty
• Hyperparathyroidism
• Hyperthyroidism
• COPD
• Long-term use of corticosteroids
• Or other risk factors for secondary osteoporosis
To assess fracture risk, online tools such as the FRAX calculator
(www.shef.ac.uk/FRAX) and the Garvan calculator
(www.fractureriskcalculator.com) are available.
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Which Men Should Be Treated?
Pharmacological treatment is recommended for men who:
• Have had a hip or vertebral fracture without major trauma
• Have no fracture but a bone density measurement (at the spine or femoral neck) with a T-score ≤ -2.5 (compared to healthy young white men)
• In the United States, men with a T-score between -1.0 and -2.5 at the spine or femoral neck and a:
o 10-year fracture risk >20%, or
o 10-year hip fracture risk ≥3%, calculated using FRAX
Outside the U.S., regional guidelines should be followed.
Treatment is also recommended for men receiving long-term glucocorticoid therapy (e.g. >7.5 mg/day of prednisolone), as per the American College of Rheumatology guidelines (2010).
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Which Medications Should Be Used for Men at High Fracture Risk?
The recommended medications are those approved by the U.S. FDA or the European Medicines Agency, including:
• Alendronate
• Risedronate
• Zoledronic acid
• Teriparatide
• Denosumab
(also for men receiving androgen-deprivation therapy (ADT) for prostate cancer)
The choice of drug should depend on:
• Fracture history
• Severity of osteoporosis
• Risk of hip fractures
• Whether bone mineral density is worse in cortical or trabecular bone
• Comorbidities (e.g., peptic ulcers, reflux, malabsorption syndromes, cancers)
Men with hip fractures should be treated with zoledronic acid.
Teriparatide should not be combined with antiresorptive therapy.
Medications not approved for use in men (e.g., calcitonin, ibandronate, strontium ranelate) should only be used when approved treatments are not suitable.
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Hypogonadal Men with High Fracture Risk
Men at high risk of fracture who are treated with testosterone should also receive a medication proven to reduce fracture risk (e.g., bisphosphonates or teriparatide).
Testosterone therapy for osteoporosis may be considered in men with:
• Testosterone levels below 200 ng/dL (6.9 nmol/L)
• And symptoms of testosterone deficiency (e.g., low libido, chronic fatigue, hair loss, hot flashes)
• Or a diagnosis of hypogonadism due to dysfunction of the hypothalamus, pituitary gland, or testes
Testosterone therapy may also be considered in men without a standard indication, if they are at high fracture risk and cannot take approved osteoporosis medications due to contraindications.
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Men with Prostate Cancer Undergoing Androgen-Deprivation Therapy (ADT)
Men with prostate cancer who are receiving ADT and are at high risk of fractures should be treated with osteoporosis medication.
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Monitoring Treatment Progress
Bone density should be measured using DXA at the spine and hip every 1–2 years to assess the response to treatment.
Once bone density reaches a stable plateau, the interval between scans can be extended.
After starting antiresorptive therapy, the following should be measured after 3–6 months:
• Bone resorption markers:
o N-telopeptide of type I collagen (NTX) in serum or urine
• Bone formation marker:
o Serum procollagen type I N-terminal propeptide (PINP) (in case of monotherapy)
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