Men and Osteoporosis So you think that it cant happen to you - - PowerPoint PPT Presentation

Men and Osteoporosis

So you think that it can’t happen to you

Jonathan D. Adachi MD, FRCPC Alliance for Better Bone Health Chair in Rheumatology Professor, Department of Medicine Michael G. DeGroote School of Medicine

• St. Joseph’s Healthcare – McMaster University

Conflict of Interest

Jonathan D. Adachi

Consultant/Speaker

• Amgen
• Eli Lilly
• Merck
• Novartis
• Warner Chilcott

Clinical Trials

• Amgen
• Eli Lilly
• Merck
• Novartis

Stock

• None to declare

Male Osteoporosis

Do you suffer from osteoporosis?

How do you know?

Did you know that:

• Around 1 in 4 men have a fracture in the back
• That fractures in the back predict the risk of

further fractures

• That most men are unaware of these fractures
• That these fractures are not for the most part

related to trauma or injury

• That men are the weaker sex when it comes to
• steoporosis

Prevalence of vertebral fractures

10 20 30 40 50 60 50-54 55-59 60-64 65-69 70-74 75-79 80+ Fracture % Age - Years

Men Women

Jackson et al. Osteoporos Int 2000; 11(8):680-687.

Men Have Higher Bone Densities than Women, but…….

0.4 0.5 0.6 0.7 0.8 0.9 1 Peak Bone Mass 50-59 60-69 70-79 80+ Hip BMD Age

men women

10 20 30 40 50 60 50- 54 55- 59 60- 64 65- 69 70- 74 75- 79 80+ Fracture %

Age - Years

Men Women

0.4 0.5 0.6 0.7 0.8 0.9 1 Peak Bone Mass 50-59 60-69 70-79 80+ Hip BMD Age men women

Men are Fracturing at Higher Bone Densities than Women

Fractures as a Function of Age

4,000 3,000 2,000 1,000 35–39 > 85 > 85 Age Group, yr Incidence /1000,000 P-Yrs Men Women Hip Hip Vertebrae Vertebrae Colles’ Colles’ 65 65 35–39

Cooper et al. J Bone Miner Res 1992

Hip fracture incidence rates increase exponentially with age , 5 years later then rates seen in females

Consequences of Hip Fractures

• 27,000 Canadians suffered a hip

fractures in 20071

• 10% will refracture within a year2
• 50% of women will lose ability to live

independently

• 19% will require long-term nursing home

care

• 20% of women and 40 % of men will die

within first year

• 1. Papadimitropoulos et al. CMAJ 1997.
• 2. Canadian Consensus Conference on Osteoporosis. JOGC 2006

Consequences of Vertebral Fractures

 Vertebral fractures increase mortality risk (16% lower survival rate over 5 years) Cooper C et al. Am J Epidemiol 1993  Mortality rates increase as number of vertebral fractures increases Kado DM et al. Arch Intern Med 1999  Reduction of quality of life Adachi JD et al. BMC Musculoskeletal Dis 2002  Increases back pain and bed rest due to pain Nevitt et al Arch Intern Med 2000

Post Fracture Mortality

• Large Cohort study (Norway), 50 years +
• Risk of dying within 1-year for hip fracture

patients

Below 75 years: Women: 3.3 (95% CI: 2.1-5.2) Men: 4.2 (95% CI 2.8-6.4) Above 85 years : Women: 1.6 (95% CI 1.2-2.0) Men: 3.1 (95% CI 2.2-4.2)

Forsen et al. Osteoporos Int 1999; 10(1):73-78.

Institutionalization Post Hip Fracture

• Men 2X as likely as women

to move into a nursing home after a hip fracture¹

• After 2 years: More than

half the men had died or were institutionalized vs controls (12%)²

0% 10% 20% 30% 40% 50% 60%

Me Men Co Control Wome Women Co Control

¹Osnes et al. Osteoporos Int 2004; 15(7):567-574.

²Fransen et al. J Am Geriatr Soc. 2002;50(4):685-90.

Differences Between Men and Women Referred to Specialists:

CANDOO Study Results At the time of referral:

• Rates of prevalent vertebral fracture 2X as high in

men compared with women

• 3X higher for multiple vertebral fractures
• Mean baseline femoral neck and lumbar spine BMD

significantly higher in men than women

Sawka et al. J Rheumatol. 2004;31(10):1993-5.

Key Risk Factors for Fracture

AGE

• BMD at the hip declines with age (at least

2.5% per decade)

• BMD at the spine appears to increase with

age, however degenerative vertebral changes as one ages may falsely elevate BMD

• As a result lumbar spine BMD is seldom

helpful unless it is low

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Prior Fragility Fracture

What is a Fragility Fracture?

• A fracture that results from a force

equivalent to a fall from standing height

• r less.
• A fracture of the wrist, vertebra, hip,

pelvis or rib.

• A vertebral fracture which may occur

spontaneously.

• A strong predictor of future fracture as it

reflects decreased bone strength.

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Height Loss

• Prospective Height

loss >2 cm

• Historical Height

Loss > 6 cm

• Wall to occiput >6

cm

• Rib Pelvis distance

< 2 finger-breadths (FBs)

2 FBs 3 FBs

8 cm 12 cm HL = 3 cm HL = 8 cm

Other Factors

Low Weight/BMI

• BMD is 4-7% lower for every 10 kg decrease in

weight

• Low baseline weight/BMI is a strong predictor
• f subsequent bone loss at the hip
• Weight/BMI loss is predictive of subsequent of

bone loss at lumbar spine and hip

Smoking

• Smoking (current and former)

associated with low BMD

• A dose response relationship

exists between pack-years of smoking and low BMD

• Current smoking (versus never or

former) is predictive of subsequent bone loss at the hip

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Strength

• Muscle strength

associated with greater BMD at lumbar spine and hip

• Immobility, functional

limitation, & lower limb disability lead to greater bone loss

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Family History

• Maternal history of osteoporosis or fracture

associated with low BMD at lumbar spine and hip

• Paternal history of fracture associated with

low BMD at lumbar spine and hip

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Androgen Deprivation Therapy

• Prostate cancer patients showed a significant

decrease in BMD at the lumbar spine and hip at 6- and 12-months

• Rate of bone loss approx. 2-6.5% at the hip

and 2-8% at the lumbar spine during 12- months

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Calcium

• Calcium intake (dietary or supplements) is

associated with greater BMD at lumbar spine and hip

• Calcium intake (dietary or supplements) is NOT

predictive of the rate of bone loss

• Too much supplemental calcium may be

associated with side effects:

– Stomach problems – Kidney stone – Cardiovascular disease

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Physical Activity

• Being physically active

was associated with greater BMD at lumbar spine and hip

• Physical activity was

NOT predictive of the rate of subsequent bone gain

Systematic Review -Osteoporosis Canada & Ontario Ministry of Health (Papaioannou et al, 2006)

Alcohol

• Moderate alcohol intake was NOT associated

with BMD at lumbar spine and hip

• Moderate alcohol intake was NOT predictive
• f the rate of bone loss

What about BMD testing in men?

BMD in Men

• BMD testing for all men over age 65 advised
• BMD testing advised for younger men in the

presence of secondary causes of osteoporosis and other risk factors for fracture

BMD and Fractures in Men

• Increasing evidence to support that BMD

alone does not tell the whole story

• BMD remains the most readily quantifiable

predictor of fracture risk for untreated individuals who have not yet suffered a fragility fracture

• However, many factors other than low bone

mass predict the risk for future fracture

Osteoporosis Investigation :

Laboratory Tests

• Complete blood count
• Serum calcium
• Albumin
• Liver transaminases
• Serum creatinine
• Alkaline phosphatase
• Thyroid stimulating hormone (TSH)
• Testosterone – Total; Free or bioavailable

Khan A et al, Management of osteoporosis in men: an update and case example; Can. Med. Assoc. J., Jan 2007; 176: 345 - 348

Osteoporosis Investigation :

Laboratory Tests Suggested by Clinical Evaluation

• Parathyroid Hormone (PTH)
• Serum 25-hydroxy Vitamin D (25-OHD)
• Serum immunoelectrophoresis
• Celiac antibody testing
• 24-hour urine: calcium
• 24-hour urine: free cortisol

Khan A et al, Management of osteoporosis in men: an update and case example; Can. Med. Assoc. J., Jan 2007; 176: 345 - 348

Who Should be Treated?

• Men aged 65+ with T-score <-2.5 (any site)
• Men aged 50+ with fragility or vertebral

compression fracture, with T-score <-1.5

• Men of any age receiving glucocorticoid

therapy for >3 months, and T-score <-1.5

• Men of any age with hypogonadism (any

cause) and T-score <-1.5

What are the Treatment’s Available?

Non-Pharmacological Treatment

• Dietary calcium and

Vitamin D should be the first things on your prescription sheet

• Weight bearing exercises

at all ages can make a difference and reduce the risk of fractures

Vitamin D

• Vitamin D3 increases Calcium absorption by

30 – 80%

• Reduces risk of falls among ambulatory or

institutionalized elderly by more than 20%1

• Milk fortified with D3 contains 100 IU per 250

mL glass

• Food such as margarine, eggs, salmon and fish
• ils contain small amounts of D3

Pharmacological Therapies

• Alendronate (Fosamax, Fosavance)
• Risedronate (Actonel, Actonel DR)
• Denosumab (Prolia)
• Teriparatide (Forteo)

Summary

• Osteoporosis and fractures are common in

men

• Most men are not aware that they have
• steoporosis
• Most men are not treated for osteoporosis
• Institutionalization for fractures is more

common in men

• Men have a greater risk of dying from their

fractures than do women

Conclusion

• Men need to be aware of osteoporosis
• Men at high risk for fractures need to be

treated