NOEI Osteoporosis in Men, it is not just about the Women
PODCAST TRANSCRIPT: OSTEOPOROSIS IN MEN, IT IS NOT JUST ABOUT WOMENSuzanne Jan de Beur, MDIt is common misconception that osteoporosis is just a disease of women. There are also many men withosteoporosis, and in fact I think they are much more under-recognized than women. For example,women a lot of times will go to their OB/GYN and their OB/GYN will screen them for osteoporosis. Men -they either do not go to the doctor at all or when they go to the doctor they are being screened for thingslike cardiovascular risk. So, really men are very under-recognized when we think about having low bonemass and osteoporosis. As I said, in my practice, which is primarily osteoporosis, about a third of it aremen. So, osteoporosis - the definition is the same in both men and women. Men in fact before age 50are about three 3 more likely to have fractures. This is probably because of the activities they engage inearlier in life. However, among older institutionalized people, women fall more often than men, butwhen men fall they tend to fracture more, and men even though they have less hip fractures, actuallyhave a higher mortality or die of hip fractures more often than women.So, when you are looking at fractures and you are looking at hip fractures, you are looking at a 5-yearsurvival in men of about 72% and about 84% 5-year survival in women. Even those who do recover, menare much less likely to return to independent living after a fracture and are less able to mobilizeindependently about 3 months after the fracture, than women are. So, there are a lot of men out therewith osteoporosis. Men when they fracture tend to do less well than women with a higher mortality rateand more loss of independence.Now, men are little bit different than women with regard to their bone loss, in that about 50% of thetime you can identify an underlying condition that is contributing to the bone loss that may need to betreated in a different way other than just treating primary osteoporosis. In women, there is a suddendrop of estrogen around the time of menopause that can increase fracture risk, but in men over theirlifetime they have a drop in both estrogen and testosterone that can contribute to bone loss throughoutthe lifespan in men. Men have a few things that make them a little less prone to fracture, their bonegeometry and also their bone-remodeling pattern give them some mechanical advantages over women intheir bone structure. So, they may fracture less, but when they fracture they do less well.Say we have a man, many times they are going to present with fractures or they will present with adisorder where they are going to need treatment that is going to reduce bone density, such as androgendeprivation therapy for prostate cancer. They are going to be put on gonadal suppression therapy andphysician is going to recognize that they need to screen this person and treat them for low bone mass ifthey have it, or they may be put on chronic steroids for conditions and these are how men with low bonedensity come to medical light. But there are other disorders that can cause osteoporosis in men. Wetalked about gonadal suppression therapy but just hypogonadism itself is a risk factor for osteoporosis inmen. A lot of times lifestyle issues such as smoking and excessive alcohol intake, these account for alarge proportion of cases of osteoporosis in men. There are other disorders such as Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
hyperparathyroidism, hyperthyroidism that can cause osteoporosis in men and women. Vitamin Ddeficiency is a really strong and common cause of osteoporosis in men and women. In men in particular,there is a disorder called idiopathic hypercalcuria where there is excessive calcium loss through thekidney and the skeleton becomes compromised over time because the body uses the calcium in theskeleton to keep the blood calcium level in the normal range. This is relatively common in men and canbe a cause of lifelong bone loss and eventually osteoporosis.In men, there really needs to be a comprehensive secondary screen for osteoporosis, you really need tothink long and hard about what might be causing the low bone mass in this man and screen him forthings that can cause osteoporosis because many of them need different treatment than if you are justtreating idiopathic osteoporosis.How do we assess fracture risk in men? Well, we do it in a similar fashion to the way we assess fracturerisk in women. We use the FRAX tool. This is a web-based tool developed by the World HealthOrganization, where you put in characteristics of the patient and then they give you the 10-yearprobability of a major osteoporotic fracture and the 10-year probability of a hip fracture. Some of thethings you enter in are the age and the gender of the patient, the height and the weight of the patient,and then personal characteristics such as: are they a current smoker, do they drink more than 3 units ofalcohol a day, have they are taking glucocorticoid for 3 months straight in their lifetime, have they had afracture, have their parents had a hip fracture, do they have rheumatoid arthritis? Then you can put intheir femoral neck bone mineral density into the model and then it gives the output of the 10-yearprobability of an osteoporotic or a hip fracture. This really helps with discussion with the patientsbecause you are not talking about T-score, you are talking about a 10-year probability and people canreally get their hands around that understanding their risk.The lifetime risk of a fracture in a 50-year-old man is about 20%. This is compared to about 50% inwomen. So, the lifetime risk of a fracture is lower in men than women, but as I said before, a fracture inmen can be much more devastating than it can be in women. So, diagnostic considerations in men arefirst of all, people have to think about: they may have osteoporosis. If you have a man over 50 whopresents with a fracture that is not traumatic, that person needs to be screened for osteoporosis andmost likely treated. There are other barriers such as the scientific community has not developed aunifying clinical practice guideline for screening men with osteoporosis. Currently, the NationalOsteoporosis Foundation recommends screening men over 70, but this is not a universal guideline, andrisk factors for secondary osteoporosis in men are not as well studied as we would like.What we do once we find a man who has osteoporosis, what are the counseling issues with men versuswomen? I said most of the risk factors for men and women are the same, but most men do not havecomplete information about their bone health, either because they have not been screened becausetheir physician has not recognized it or they have not been screened because they have not asked to bescreened. I know there are a number of barriers for my patients who say, you know I go to get my bonedensity test and I have to go to a women’s breast center, or I have to wait in an OB/GYN office. Manytimes the places where there is screening equipment that can assess osteoporosis is sometimes not avery men-friendly environment, if you will. In addition to screening men, they need the same adviceabout dietary and supplemental nonpharmacologic treatment for osteoporosis. They need to keep on Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
top of their calcium intake, getting between a 1000 and 1200 mg of calcium between diet and food perday, as well as vitamin D supplementation to keep their bones strong and to reduce the risk of fracture.Then for men especially, tobacco and excess alcohol consumption are big factors and, though they aremodifiable risk factors, they need to be aggressively addressed. In addition to those, adequate weight-bearing exercise just as in women and fall prevention, always important; screening for eyesightdifficulties, screening for psychotropic medications that can cause poor awareness in falling, screeningthe home for throw rugs and other physical obstacles that may result in a fall and a fracture.What are the treatment options for men with osteoporosis? Most of the osteoporosis medications weredeveloped and the clinical trials were done in postmenopausal women and so a lot of managementdecisions are derived from extrapolatory data from the trials in women. But having said that, there havebeen trials showing the benefit of bisphosphonates in treatment of male osteoporosis, these includealendronate, risedronate, ibandronate and zoledronic acid. A trial of zoledronic acid in people with hipfractures to prevent secondary hip fractures (there were a cohort of men in that clinical trial) showedreduction in secondary hip fractures and also a reduction in mortality with treatment. There are othermedications such as an anabolic therapy or teriparatide, which actually works on the osteoblasts to buildbone that is approved for use in men. The selective estrogen receptor modulators are not approved orrecommended for use in men, nor is estrogen, as you can imagine, approved for use in men.Bisphosphonates are generally the first line of treatment in men. And then for men that either failtherapy with bisphosphonates or cannot tolerate bisphosphonates then teriparatide is considered inthose individuals. Hormone therapy with testosterone is warranted only for men with hypogonadism, sowe do not use testosterone as a therapy for osteoporosis in the absence of hypogonadism. Of coursecalcium, vitamin D, and lifestyle interventions are also important in treatment of osteoporosis in men.Adrienne Berarducci, PhD, ARNP, BC, CCDIn my particular practice, and again I cannot emphasize enough how important it is to measure patientsbecause all patients both men and women do not realize how much height they may have lost over theyears. So again I cannot stress enough how important that it is to measure patients and just open up thatdialogue when they know that they are not as tall as they thought they were. The other thing I noticedmore is especially in our older male patients over 70 years of age, there is significantly morehypogonadism than I would suspect, that I would have ever thought and that really needs to beevaluated for. We do not often look at some of the clinical signs such as fatigue in males and lack ofstamina. The ability to just be able to walk around as much as they used to, just screening to find outhow their activity levels have changed and how their energy levels have changed, often is enough tomake you think that “Hey, maybe I better look at this”. It is a very easily treatable disease. Depressionoften can be a sign of hypogonadism also in males that we tend to overlook.So, these are very important areas to screen for in both men and women, but we do primarily see it inmen or COPD patients who before we started using more of the inhaled steroids even though they alsoadd the risks of osteoporosis. Those that were treated in the past with long-term oral glucocorticoids.We often do not think about what men look like with osteoporosis. Often we say they look like BenFranklin; not all men with osteoporosis look hunched over like Ben Franklin, some just look like very frailelderly people and we need to look at those clinical signs to determine if the patient needs to bescreened to see if there is significant bone loss. They also need to be counseled in fracture prevention Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
and fall prevention and it is something we do not do often on men either. Also, assessing the type of footwear they are using.Anything that we can do to look to see what are the problems, where these things occur in male patients.Alcoholism is another big problem. Even in those patients who do not realize that they have an issuewith alcohol. Many of our elderly patients actually drink alcohol to medicate themselves. They use itbecause they are depressed and their depression gets worse when they drink more. We need to addressthese problems to resolve their nutritional issues related to alcohol consumption as it effects their abilityto absorb medications and nutrients, including calcium and vitamin D which puts them at further risk fordeveloping osteoporosis. We will need to carefully screen for the amount of alcohol patients are usingand not just ask them how many glasses, actually ask people ounces. It amazes me sometimes how muchalcohol patients really consume and I do in my own practice see this more in male patients, especiallythose who are living alone as they get older. And just generally not eating well. Many elderly patients arenot eating well because of economic issues, because of inability to get out, because of poor eyesight theycannot drive any more, access issues, but we see it even more profoundly in the male patients, especiallyelderly males who are alone, who are either widowed, have no significant others in the area, theirsiblings have all passed, their friends have passed. They do not eat well and they are depressed and theseare things that we do not look at often enough.Besides screening for these issues, we need to find out why they are depressed, how it is affecting theiractivity, how it is affecting their nutritional status, are they able to buy the type of foods they need andstart thinking about how it is affecting their bone health. We are finding, and in my own practice verysurprisingly, more and more of our patients, our elderly male patients are actually being diagnosed withosteopenia and osteoporosis. Much more than we saw 15 years ago. These are issues that we need toaddress more carefully. We still, even as healthcare providers, do focus our attention on osteoporosis inwomen and naturally because statistically we know more women have that disease. But there are anumber of different things that we really need to screen for, things like depression, finding out what typeof medications the patients took in the past to treat diseases, not just COPD, but even patients withrheumatoid arthritis and finding out if patients were treated in the past with glucocorticoids forosteoarthritis or severe back pain from disk injury. So, there are a number of different areas that weneed to look at to find out what has been going on with our patients in the past and how this has putthem at risk, in the person with the disease already or for future fracture risk. Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.