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  Osteoporosis
 
Author: Shehzad Basaria, MD Last modified: July 10, 2002
DIAGNOSTIC CRITERIA

  EPIDEMIOLOGY

  • Osteoporosis is one of the leading cause of morbidity, mortality and financial burden in both genders.
  • More than 1.5 million elderly men (>65 yrs)in the US have osteoporosis.
  • The prevalence of fractures in older men is 1/3 of women and the incidence of these fractures begins a decade later than women.
  • The incidence of hip fractures increases exponentially with aging. By the age of 90 years, there is a 25% chance of having an osteoporotic fracture.
  • Fracture related mortality is higher in men than women.

  RISK FACTORS

  • Endocrine: Hypogonadism,Cushing's syndrome,Hyperthyroidism,Hyperparathyroidism,Growth hormone deficiency,Vitamin D deficiency.
  • Drugs: Glucocorticoids,Dilantin,Synthroid overdose,Anticonvulsants,Alcohol,GnRH analogs,Heparin.
  • Genetic: Osteogenesis imperfecta,Ehler-Danlos syndrome,Marfan's syndrome.
  • Miscellaneous: Smoking,Idiopathic hypercalciuria,Immobilization.

  SIGNS AND SYMPTOMS

  • In many men the diagnosis is made while being evaluated for hypogonadism,chronic high dose glucocorticoid therapy,malabsorption syndromes,etc.
  • Minimal trauma fractures may be the initial presentation in some cases.
  • Sometimes osteopenia is detected in patients on spine films who present with backache and are found to have wedge compression spinal fractures.

  LABORATORY FINDINGS

  • DEXA scan or Quantitative CT are used for the diagnosis of osteoporosis. Degenerative joint disease in aging population may give artifactually normal bone density values on posterior views. Hence, lat
  • TSH,Calcium,Phosphate,Intact PTH,Testosterone,ALP,25OH Vitamin D,24-hr urine calcium,LFTs and renal function are standard tests to rule out secondary causes of osteoporosis.
  • Bone biopsy is needed in some men to diagnose osteomalacia.
 
TREATMENT
CALCIUM 1000 MG/DAY
  • Citracal is the best formulation since acidic milieu is not required for absorption (prevalence of achlorhydria increases with aging). Available in combination with Vitamin D.
VITAMIN D 800 IU/DAY
  • Two multivitamin tablets a day are sufficient.Is available in combination with Citracal as Citracal+D.
ANDROGEN THERAPY IN HYPOGONADAL MEN.
  • Transdermal therapy is more physiological.
  • Androgel 5gm/day is the starting dose.
  • Testoderm TTS 5mg/day patch also gives physiological levels and has minimal side effects amongst patches.
BISPHOSPHONATES.
  • Oral: Fosamax 10 mg/day or 70 mg/week are effective in improving bone density.
  • Intravenous: Pamidronate 30-60 mg over 2-4hrs every 3 months is an effective alternative.
GROWTH HORMONE THERAPY IN GROWTH HORMONE DEFICIENCY.
  • GH therapy should be continued for at least 18 months to show benefits.
 
 
REFERENCES
  1. Siddiqui NA, Shetty KR, Duthie EH Jr. ;  Osteoporosis in older men: discovering when and how to treat it. ;  Geriatrics. 1999 Sep;54(9):20-2, 27-8, 30.

  2. Farmer ME, White LR, Brody JA, Bailey KR. ;  Race and sex differences in hip fracture incidence. ;  Am J Public Health. 1984 Dec;74(12):1374-80.

  3. Zmuda JM, Cauley JA, Glynn NW, Finkelstein JS. ;  Posterior-anterior and lateral dual-energy x-ray absorptiometry for the assessment of vertebral osteoporosis and bone loss among older men. ;  J Bone Miner Res. 2000 Jul;15(7):1417-24.

  4. Center JR, Nguyen TV, Sambrook PN, Eisman JA. ;  Hormonal and biochemical parameters in the determination of osteoporosis in elderly men. ;  J Clin Endocrinol Metab. 1999 Oct;84(10):3626-35.

  5. Smith MR, McGovern FJ, Zietman AL, Fallon MA, Hayden DL, Schoenfeld DA, Kantoff PW, Finkelstein JS. ;  Pamidronate to prevent bone loss during androgen-deprivation therapy for prostate cancer. ;  N Engl J Med. 2001 Sep 27;345(13):948-55.

  6. Katznelson L, Finkelstein JS, Schoenfeld DA, Rosenthal DI, Anderson EJ, Klibanski A. ;  Increase in bone density and lean body mass during testosterone administration in men with acquired hypogonadism. ;  J Clin Endocrinol Metab. 1996 Dec;81(12):4358-65.

  7. Orwoll E, Ettinger M, Weiss S, Miller P, Kendler D, Graham J, Adami S, Weber K, Lorenc R, Pietschman ;  Alendronate for the treatment of osteoporosis in men. ;  N Engl J Med. 2000 Aug 31;343(9):604-10.

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