Osteoporosis in MenOsteoporosis in MenUpdate Ohio State: November 2011Update Ohio State: November 2011

Robert A. Adler, MDRobert A. Adler, MD

McGuire Veterans Affairs Med CtrMcGuire Veterans Affairs Med CtrVirginia Commonwealth UniversityVirginia Commonwealth University

Richmond, Virginia, USARichmond, Virginia, USA

DisclosuresDisclosures

Research SupportResearch Support NovartisNovartis GenentechGenentech Eli LillyEli Lilly AmgenAmgen MerckMerck

ObjectivesObjectives-- Participants should be able to:Participants should be able to:

Outline the etiology and risk factors Outline the etiology and risk factors Discuss use of fracture risk calculators Discuss use of fracture risk calculators

and other means to identify men at riskand other means to identify men at risk Describe current Rx and the challenges of Describe current Rx and the challenges of

using surrogates for patient outcomes in using surrogates for patient outcomes in chronic disease studieschronic disease studies

OP in Men EvaluationOP in Men Evaluation

Pathophysiology and ClassificationPathophysiology and Classification Primary osteoporosisPrimary osteoporosis Secondary osteoporosisSecondary osteoporosis

Choosing men for evaluationChoosing men for evaluation Laboratory EvaluationLaboratory Evaluation DXA DXA

Riggs and Melton NEJM Riggs and Melton NEJM 314:1676, 1986314:1676, 1986

Primary Osteoporosis: Type IPrimary Osteoporosis: Type I

Ages 51Ages 51--7575Women >> Men (6:1)Women >> Men (6:1) Trabecular bone lostTrabecular bone lost Vertebral and distal radius fracturesVertebral and distal radius fractures Associated with menopause in womenAssociated with menopause in women ?Cause in men?Cause in men

Type I OP in Men:Type I OP in Men:Potential CausesPotential Causes

Increased urinary calcium excretionIncreased urinary calcium excretion Long term negative calcium balanceLong term negative calcium balance Often have a history of kidney stonesOften have a history of kidney stones

Decreased IGFDecreased IGF--I with normal GHI with normal GH Low free estradiolLow free estradiol ?Low free 25 (OH) Vitamin D?Low free 25 (OH) Vitamin D Mastocytosis in marrow onlyMastocytosis in marrow only Cryptic secondary causesCryptic secondary causes

Riggs and Melton NEJM Riggs and Melton NEJM 314:1676, 1986314:1676, 1986

Primary Osteoporosis: Type II Primary Osteoporosis: Type II

Age > 70Age > 70Women > Men (2:1)Women > Men (2:1) Trabecular and Cortical BoneTrabecular and Cortical Bone Hip and vertebral fracturesHip and vertebral fractures AgeAge--related, other factorsrelated, other factors

I I I I I I

Radius Bone Mineral Content(g/cm)

>1.0 0.90–0.99 0.80–0.89 0.70–0.79 0.60–0.69 <0.60

8 10 13 17 20

5058

70

87

108

0

60

120Age 50-54 yearsAge 75-79 years

Fx Risk Increases With Fx Risk Increases With Advancing AgeAdvancing Age

Adapted from Hui SL et al. J Clin Invest. 1988;81:1804-1809.

Frac

ture

Ris

k/10

00 P

erso

n-Ye

ars

Fitzpatrick, Mayo Clin Proc Fitzpatrick, Mayo Clin Proc 77:453, 200277:453, 2002

Secondary OP: Short ListSecondary OP: Short List

GIOP (GlucocorticoidGIOP (Glucocorticoid--induced)induced) HyperthyroidismHyperthyroidismMalabsorptionMalabsorption Alcohol ExcessAlcohol Excess HypercalciuriaHypercalciuria HyperparathyroidismHyperparathyroidism HypogonadismHypogonadism

Causes of Secondary OPCauses of Secondary OP

HypogonadismHypogonadism Primary and secondary (organic)Primary and secondary (organic) Cancer chemotherapy (cyclophosphamide)Cancer chemotherapy (cyclophosphamide) Androgen withdrawal for prostate cancerAndrogen withdrawal for prostate cancer ?Testosterone decline with aging?Testosterone decline with aging

Chronic diseases, EtOHChronic diseases, EtOHMedications: examplesMedications: examples

AntiAnti--seizure meds seizure meds →→ OP &OP & osteomalaciaosteomalacia Neuroleptics (Neuroleptics ( Prolactin), PPIs, TZDs,Prolactin), PPIs, TZDs, AntiAnti--depressants?depressants?

Hypogonadism & OPHypogonadism & OP

Organic hypogonadism causes OPOrganic hypogonadism causes OP Testosterone replacement increases bmdTestosterone replacement increases bmd No Fracture dataNo Fracture data Does the milder decline in testosterone Does the milder decline in testosterone

with aging lead to osteoporosis?with aging lead to osteoporosis?

Khosla JCEM 83:2266, 1998, Khosla JCEM 83:2266, 1998, LeBlanc JCEM 94:3337, 2009LeBlanc JCEM 94:3337, 2009

Declining Testosterone in AgingDeclining Testosterone in Aging

Common but mild decreaseCommon but mild decrease Total T not correlated with bone densityTotal T not correlated with bone density Better correlation of bioavail EBetter correlation of bioavail E22 & BMD& BMD Newer studies find some relation with T: Newer studies find some relation with T:

data from MrOS suggest men with lower data from MrOS suggest men with lower bioavail T may at higher risk for fracture bioavail T may at higher risk for fracture (but were also the men with lowest (but were also the men with lowest bioavail Ebioavail E22 and highest SHBG)and highest SHBG)

Secondary Factors in 1571 Secondary Factors in 1571 Older Men (MrOS)Older Men (MrOS)

HA Fink, ASBMR 2011HA Fink, ASBMR 2011

Comparative Effects: T & EComparative Effects: T & E

Healthy men ages 20Healthy men ages 20--5050 All received GnRH analogAll received GnRH analog→→ hypogonadismhypogonadism

Group A: Different doses of T gelGroup A: Different doses of T gel

Group B: T gel doses + anastrozoleGroup B: T gel doses + anastrozole

Serum CTX change determinedSerum CTX change determined

J Finkelstein et al, ASBMR 2011J Finkelstein et al, ASBMR 2011

Effect of T/E vs T onlyEffect of T/E vs T only

T/E (i.e. T gel) T/E (i.e. T gel) →→ ↓↓CTX with CTX with ↑↑ T gel doseT gel dose

T only (i.e. T gel + anastrozole) T only (i.e. T gel + anastrozole) →→ slight slight ↓↓ CTX CTX (but dose response present)(but dose response present)

Conclusions:Conclusions: T & E both affect bone turnover in menT & E both affect bone turnover in men

E more importantE more important

J Finkelstein et al, ASBMR 2011J Finkelstein et al, ASBMR 2011

EE22 may be important, butmay be important, but……

Assays for estradiol are problematic in the Assays for estradiol are problematic in the low male rangelow male range

What is the reference range?What is the reference range? Treat men with ETreat men with E22?? Treat men with SERMs?Treat men with SERMs? Testosterone Rx as a proTestosterone Rx as a pro--hormone and hormone and

hormone?hormone?

JK Amory et al. JCEM 89:503, JK Amory et al. JCEM 89:503, 20042004

T Rx in men w/ mildly T Rx in men w/ mildly [T][T]

75 men with mildly low T (ages 6475 men with mildly low T (ages 64--83)83) Received T or placebo for 3 yearsReceived T or placebo for 3 years One group received T + finasterideOne group received T + finasteride

Amory et al JCEM 89:503, 2004Amory et al JCEM 89:503, 2004

BMD Response to TBMD Response to T

JK Amory et al, JCEM 89:503, JK Amory et al, JCEM 89:503, 20042004

TT--Rx: 3 Year StudyRx: 3 Year Study

Improvement in BMD, muscle massImprovement in BMD, muscle mass Decreased LDL cholesterolDecreased LDL cholesterol No change in HDL cholesterolNo change in HDL cholesterol No change in No change in PSA or prostate volumePSA or prostate volume

Effects of Testosterone and Effects of Testosterone and Metabolites in MenMetabolites in Men

Facial & Body HairAcne

Scalp Hair LossProstrate Growth

Dihydrotestosterone Muscle MassSkeletal Growth

SpermatogenesisSexual Function

Bone FormationBreast Tissue

Estradiol

Testosterone

OP in men: Etiology SummaryOP in men: Etiology Summary

Idiopathic OP in middle aged men: SpineIdiopathic OP in middle aged men: Spine AgingAging--associated OP: associated OP: ““old oldold old”” : Hip: Hip Secondary causes important in menSecondary causes important in men Testosterone for organic hypogonadismTestosterone for organic hypogonadism ?T for men with the mildly ?T for men with the mildly T of agingT of agingMost older men with osteoporosis have Most older men with osteoporosis have

normal testosterone level for age normal testosterone level for age –– Rx Rx other than T probably indicatedother than T probably indicated

Evaluation other than DXAEvaluation other than DXA

History and physical examHistory and physical examModest laboratory evaluationModest laboratory evaluation

Serum chemistriesSerum chemistries 2525--OH Vitamin DOH Vitamin D 24 hour urine calcium24 hour urine calcium CBC, occasional SPEP, UPEPCBC, occasional SPEP, UPEP Sometimes: TSH, PTH, Testosterone (Sometimes: TSH, PTH, Testosterone (++ LH, LH,

FSH, prolactin), celiac antibodiesFSH, prolactin), celiac antibodies

OP and Vitamin DOP and Vitamin D

C Ryan, Osteoporos Int 22:1845, C Ryan, Osteoporos Int 22:1845, 20112011

Men referred for OsteoporosisMen referred for Osteoporosis

About About ¾¾ had a secondary cause of had a secondary cause of osteoporosis osteoporosis

Many patients had multiple risk factors Many patients had multiple risk factors such as low Vitamin D, smoking, poor such as low Vitamin D, smoking, poor calcium intakecalcium intake

Even those with known secondary OP Even those with known secondary OP often had other diagnoses, risk factors often had other diagnoses, risk factors identifiedidentified

CS Ryan, Osteoporos Int 22:1845, CS Ryan, Osteoporos Int 22:1845, 20112011

Diagnosis SummaryDiagnosis Summary

Identify high risk menIdentify high risk men History & PE for secondary causesHistory & PE for secondary causes Limited lab testsLimited lab tests

CBC, Chemistries, ?PTH, ?TSHCBC, Chemistries, ?PTH, ?TSH 25 (OH) vitamin D levels25 (OH) vitamin D levels Urinary calcium excretionUrinary calcium excretion T/LH/FSHT/LH/FSH

Find underlying disorders requiring Find underlying disorders requiring specific treatmentspecific treatment

Osteoporosis in MenOsteoporosis in Men

Diagnosis before fracture!Diagnosis before fracture! Best test still DXA of spine, hip, and often Best test still DXA of spine, hip, and often

forearmforearm Spine DXA often not helpfulSpine DXA often not helpful Forearm BMD predicts fx well in menForearm BMD predicts fx well in men Who should get a DXA?Who should get a DXA?

Hochberg & Adler, Nature Clin Hochberg & Adler, Nature Clin Prac Rheum 4:626, 2008Prac Rheum 4:626, 2008

DXA Testing in MenDXA Testing in Men

What age?What age? ACP Guidelines: Men > 70 years old, ACP Guidelines: Men > 70 years old,

younger if risk factors presentyounger if risk factors present NOF: DXA at 70, earlier with risk factorsNOF: DXA at 70, earlier with risk factors USPSTF: Not enough evidence to screen USPSTF: Not enough evidence to screen

men at age 70men at age 70 Case finding: Age an important risk factorCase finding: Age an important risk factor

WHO: Validated Risk FactorsWHO: Validated Risk Factors BMD of femoral neckBMD of femoral neck BMI (can substitute for BMD??)BMI (can substitute for BMD??) AgeAge Prior Fragility FracturePrior Fragility Fracture Glucocorticoid ExposureGlucocorticoid Exposure Parental history of Hip FractureParental history of Hip Fracture Current SmokingCurrent Smoking Excess Alcohol IntakeExcess Alcohol Intake Secondary Causes (e.g. Rheumatoid Arthritis)Secondary Causes (e.g. Rheumatoid Arthritis) www.shef.ac.uk/FRAX/www.shef.ac.uk/FRAX/ www.fractureriskcalculator.comwww.fractureriskcalculator.com

FRAX Calculation ToolFRAX Calculation Tool

FRAXFRAX®® vs. Garvan Calculatorvs. Garvan Calculator

81 yo man, 66.2Kg, 81 yo man, 66.2Kg, 168.3cm tall, no other 168.3cm tall, no other risk factorsrisk factors

BMD 0.736 g/cmBMD 0.736 g/cm22

10 yr hip fx risk: 2.4%10 yr hip fx risk: 2.4% 10 yr OP fx risk: 6.8%10 yr OP fx risk: 6.8% Generally would not Generally would not

treat (U.S.)treat (U.S.)

81 yo man, no falls or 81 yo man, no falls or fracturesfractures

BMD 0.736 g/cmBMD 0.736 g/cm22

10 yr hip fx risk: 5.1%10 yr hip fx risk: 5.1% 10 yr OP fx risk: 10 yr OP fx risk:

25.3%25.3% Treat!Treat! Based on Australian Based on Australian

populationpopulationSK Sandhu, Osteoporos Int SK Sandhu, Osteoporos Int

21:863, 201021:863, 2010

Garvan vs FRAX in WomenGarvan vs FRAX in Women% Probability of Fx% Probability of Fx

SK Sandhu OI 21:863, 2010SK Sandhu OI 21:863, 2010

Garvan vs. FRAX in MenGarvan vs. FRAX in Men% Probability of Fx% Probability of Fx

SK Sandhu, OI 21:863, 2010SK Sandhu, OI 21:863, 2010

FRAX vs. GarvanFRAX vs. Garvan

Why are there such differences?Why are there such differences?Why does Garvan identify more men?Why does Garvan identify more men?

Garvan includes falls Garvan includes falls FRAX includes glucocorticoid useFRAX includes glucocorticoid use Both rely on femoral neck BMDBoth rely on femoral neck BMD

Femoral Neck BMD Femoral Neck BMD ++ OAOA

RK Chaganti OI 21:1307, 2010RK Chaganti OI 21:1307, 2010

DXA in Older MenDXA in Older Men

Spine BMD often spuriously highSpine BMD often spuriously high Hip BMD also affected by arthritisHip BMD also affected by arthritis Forearm BMD identifies osteoporosisForearm BMD identifies osteoporosis

HyperparathyroidismHyperparathyroidism Androgen deprivation therapyAndrogen deprivation therapy ?Decrease of T/E?Decrease of T/E22 with aging?with aging?

JM Bruder, Urology 67:152, 2006JM Bruder, Urology 67:152, 2006

Men on ADT: DXA vs FRAXMen on ADT: DXA vs FRAX®®

115 Men sent from GU clinic115 Men sent from GU clinic 58% African58% African--AmericanAmerican Age 77 Age 77 ++ 8 (518 (51--91)91) BMI 28.8 BMI 28.8 ++ 4.9 (17.64.9 (17.6--42.4)42.4) Duration of ADT 3.6 Duration of ADT 3.6 ++ 3.3 (0.13.3 (0.1--11)11) DXA of spine, hip, forearmDXA of spine, hip, forearm

RA Adler, Osteoporos Int 21:647, RA Adler, Osteoporos Int 21:647, 20102010

Men on ADT: DXA vs FRAXMen on ADT: DXA vs FRAX®®

Current Smoking 14.8%Current Smoking 14.8% History of adult fracture 8.7%History of adult fracture 8.7% Parental hip fracture 0.9%Parental hip fracture 0.9% Rheumatoid Arthritis 0%Rheumatoid Arthritis 0% Prednisone use 2.6%Prednisone use 2.6%

FRAXFRAX®® vs. Tvs. T--scorescore

0 10 20 30 40 50 60 70 80

Rx by T-score < -1.5

Rx by T-score < -2.0

Rx by T-score < -2.5

Rx by FRAX w/ BMD

Rx by FRAX w/o BMD

Percent

BMD vs FRAX ScoreBMD vs FRAX Score

Adler RA, Osteoporos Int 21:647, Adler RA, Osteoporos Int 21:647, 20102010

Screening, diagnosis, evaluation, and treatment of male osteoporScreening, diagnosis, evaluation, and treatment of male osteoporosisosis

Indications present ?

yes Re-assess in 2 years*

no

Central DXA(spine & hip♦)

T-score≤-2.5 in spine or hip+

T-score>-2.5 but <-1

T-score≥-1 in spine or hip

GC/ADT/Other 2˚ causesConsider evaluation and Rx

Repeat BMD 12 months

Low trauma FxEvaluate & consider

treatment

No 2˚ Causes or FxRe-evaluate in 2 yearsLifestyle Counseling

Ensure adequate Ca/D

No OsteoporosisLifestyle Counseling

Ensure adequate Ca/ D

Hx, PE &Basic Labs

(25OHD, 24 hr U Ca/Cr,SCa/albumin/Cr)

Consider PTH, PO4, TSH, Testosterone, CBC, ESR, AP

Rx Abnormalities** and/or refer pt

1. Ensure adequate Ca: 1200 mg/d2. Ensure adequate Vit D: 800+ IU/d3. non-pharmacologic interventions to

reduce fracture risk4. Oral bisphosphonates

AbnormalNormal

Re-evaluate forRx of Osteoporosis

Glucocorticoid therapy (5 mg/d x > 3 mos)Low trauma fx after age 45 yrsRadiographic evidence of vertebral osteopenia or FxAndrogen deprivation therapy (ADT)/ hypogonadismAnticonvulsant therapy (>2 yrs)Gastrectomy/ malabsorption/celiac/bariatric surgeryExcess alcohol consumptionOther conditions/ medications*

* See FAQs for explanation** see FAQs for Rx of low vitamin D+ for T-score ≤ -2.5 & multiple Fx or T-score ≤ -3.5,consider referral to a metabolic bone specialist♦ Do a forearm BMD if spine can not be interpreted

Refer to metabolic bone specialistif Bisphosphonates are contraindicated ,or pt intolerant or not responsive

Treatment

VA AlgorithmVA Algorithm

DXA in men with following risk factors:DXA in men with following risk factors: Oral glucocorticoid Rx (Oral glucocorticoid Rx (>> 5 mg pred X 3 mos)5 mg pred X 3 mos) Low trauma fx or fx on spine xLow trauma fx or fx on spine x--rayray ADT/hypogonadismADT/hypogonadism AntiAnti--convulsant Rxconvulsant Rx Gastrx, malabsorption, bariatric surgeryGastrx, malabsorption, bariatric surgery Current smoking, excess EtOHCurrent smoking, excess EtOH

VA prefers case finding but age is not VA prefers case finding but age is not considered an indication (yet)considered an indication (yet)

Recommendations for menRecommendations for men

Use FRAXUse FRAX®® with cautionwith caution Consider Garvan nomogram for menConsider Garvan nomogram for men Evaluate high risk men for osteoporosisEvaluate high risk men for osteoporosis Treat those with osteoporosis based on Treat those with osteoporosis based on

male databasemale database Consider treatment in men with Consider treatment in men with

osteopenia and other risk factors osteopenia and other risk factors –– clinical clinical judgment still importantjudgment still important

www.fractureriskcalculator.comwww.fractureriskcalculator.com

FDA Approved Rx for MenFDA Approved Rx for Men

AlendronateAlendronate RisedronateRisedronate Zoledronic AcidZoledronic Acid Denosumab (Men on ADT)Denosumab (Men on ADT) TeriparatideTeriparatide Rx studies: T < Rx studies: T < --2.5 by the male database 2.5 by the male database

or T or T << --2 plus a fragility fracture2 plus a fragility fracture

Orwoll NEJM 343:604, 2000Orwoll NEJM 343:604, 2000

ALN increases BMD in MenALN increases BMD in Men

0

1

2

3

4

5

6

7

8

0 6 12 18 24

PlaceboALN

Orwoll NEJM 343:604, 2000Orwoll NEJM 343:604, 2000

ALN Decreases Vert Fx (XALN Decreases Vert Fx (X--ray)ray)

01

23

45

6

78

Fx Incidence

PlaceboALN

JD Ringe Rheumatol Int JD Ringe Rheumatol Int 26:427,200626:427,2006

Risedronate Risedronate BMD in MenBMD in Men

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

1 Year % Change in Spine BMD

Placebo

Risedronate

Risedronate Risedronate Hip Fx after CVAHip Fx after CVA

Metacarpal BMD increased more in Metacarpal BMD increased more in risedronate men, on both normal and risedronate men, on both normal and hemiplegic sideshemiplegic sides

10 hip fractures in placebo group, 2 in 10 hip fractures in placebo group, 2 in risedronate grouprisedronate group

RR 0.19 [0.04RR 0.19 [0.04--0.89]0.89] NNT 16 [9NNT 16 [9--32]32]

Y Sato, Arch Intern Med Y Sato, Arch Intern Med 165:1743, 2005165:1743, 2005

IV Zoledronic AcidIV Zoledronic Acid

FDAFDA--approved to increase BMD in men approved to increase BMD in men and after hip fractureand after hip fracture

Once yearly intravenous infusionOnce yearly intravenous infusion Good choice for patients with esophageal Good choice for patients with esophageal

motility disorders, Barrettmotility disorders, Barrett’’s, GERD not s, GERD not under controlunder control

Potential improvement in adherence to RxPotential improvement in adherence to Rx

E Orwoll, J Bone Miner Res E Orwoll, J Bone Miner Res 25:2239, 201025:2239, 2010

Response to ZA in menResponse to ZA in men

-1%

0%

1%

2%

3%

4%

5%

Spine Total Hip Total Forearm

1/3 Distal Radius

Overall

Per Year

DA Johnson, Endocr Pract DA Johnson, Endocr Pract 16:960, 201016:960, 2010

Orwoll JBMR 18:9, 2003Orwoll JBMR 18:9, 2003

Effect of PTH 1Effect of PTH 1--34 in Men34 in Men

Denosumab in Men on ADTDenosumab in Men on ADT

3 year study of 734 men on Denosumab 3 year study of 734 men on Denosumab vs. 734 men on placebo (All: Cal/D)vs. 734 men on placebo (All: Cal/D)

Denosumab increased BMD at:Denosumab increased BMD at: SpineSpine HipHip Distal 1/3 radiusDistal 1/3 radius

Denosumab decreased vertebral fx (xDenosumab decreased vertebral fx (x--ray)ray) Denosumab FDADenosumab FDA--approved: men on ADTapproved: men on ADT

MR Smith, NEJM 361:745, 2009MR Smith, NEJM 361:745, 2009

OP Rx in MenOP Rx in Men

Most p.o. bisphosphonate studies used Most p.o. bisphosphonate studies used daily dosingdaily dosing

Some studies: Some studies: ↓↓vertebral fx on xvertebral fx on x--rayray Same Same ∆∆ bone markers as in womenbone markers as in women No studies show No studies show ↓↓clinical fracturesclinical fractures Thus, all Rx based on Thus, all Rx based on ““bridgingbridging”” studies studies

and surrogates for fracture!and surrogates for fracture!

Choosing Rx in MenChoosing Rx in Men--11

Problems with calcium & vitamin DProblems with calcium & vitamin D Calcium Calcium ConstipationConstipation Getting enough Vitamin DGetting enough Vitamin D

Problems with bisphosphonate adherenceProblems with bisphosphonate adherence No difference in how patient feelsNo difference in how patient feels Special method of oral RxSpecial method of oral Rx

Rx based on surrogates for fractureRx based on surrogates for fracture How to choose a bisphosphonate?How to choose a bisphosphonate?

JS Finkelstein et al, NEJM JS Finkelstein et al, NEJM 349:1216, 2003349:1216, 2003

Choosing Rx in Men Choosing Rx in Men -- 22

Teriparatide ContraindicationsTeriparatide Contraindications H/o radiation to boneH/o radiation to bone Potential for osteoblastic metastases Potential for osteoblastic metastases –– thus thus

not for patients with prostate cancernot for patients with prostate cancer Previous/concurrent bisphosphonate Rx may Previous/concurrent bisphosphonate Rx may

blunt or delay response to PTHblunt or delay response to PTH Use PTH in drugUse PTH in drug--nanaïïve patients with ve patients with

severely low bone mass/high fracture risk severely low bone mass/high fracture risk

Jones G, Osteo Int 4:277, 1994Jones G, Osteo Int 4:277, 1994

Risk of Fracture in Older MenRisk of Fracture in Older Men

Age 50: Lifetime risk about 13%Age 50: Lifetime risk about 13% Lifetime atraumatic fracture risk (Dubbo)Lifetime atraumatic fracture risk (Dubbo)

Age 60Age 60 25.6%25.6%

Schuit et al Bone 34:195, 2004Schuit et al Bone 34:195, 2004

Age & Hip Fx: RotterdamAge & Hip Fx: Rotterdam

0

5

10

15

20

25

30

60-64 65-69 70-74 75-79 80-84 85+

MenWomen

Fx/100person-yr

% Patients Who Died at 1 yr % Patients Who Died at 1 yr (Age 75(Age 75--84) 84)

Block, Calcif Tissue Int 61:84, Block, Calcif Tissue Int 61:84, 19971997

Hip Fracture & MortalityHip Fracture & Mortality

Women have twice the risk of hip fractureWomen have twice the risk of hip fractureMen with hip fracture have twice the risk of Men with hip fracture have twice the risk of

dying from a hip fracturedying from a hip fracture Thus, the overall mortality rate from hip Thus, the overall mortality rate from hip

fracture is about the same in men and fracture is about the same in men and women!women!

Osteoporosis in Men Osteoporosis in Men -- SummarySummary

Secondary OP important in menSecondary OP important in menModest evaluation Modest evaluation →→ Dx, risk factorsDx, risk factors Large holes in knowledge baseLarge holes in knowledge base Role of testosterone still unclearRole of testosterone still unclear FRAXFRAX®®/Garvan nomogram may help/Garvan nomogram may help Treatment options increasingTreatment options increasing Need to find those men at highest riskNeed to find those men at highest risk

F. Borgstrom et al, Bone 34:1064, F. Borgstrom et al, Bone 34:1064, 20042004

Men Fracture Too!Men Fracture Too!ConclusionConclusion

Osteoporosis is not just a disorder of Osteoporosis is not just a disorder of postmenopausal womenpostmenopausal women

Men with osteoporosis need to be Men with osteoporosis need to be identifiedidentified This is a silent disorder with fatal This is a silent disorder with fatal

consequencesconsequences Finding cases, diagnosing and treating OP Finding cases, diagnosing and treating OP

in men will save lives and moneyin men will save lives and money