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 osteoporosis
Prevalence of vertebral fractures Fracture % 60 50 40 30 20 10 Men Women 0 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age - Years Jackson et al. Osteoporos Int 2000; 11(8):680-687.
Men Have Higher Bone Densities than Women, but. Hip BMD 1 0.9 0.8 0.7 0.6 0.5 0.4 Peak Bone Mass 50-59 60-69 70-79 80+ Age men women
Men are Fracturing at Higher Bone Densities than Women 60 50 Fracture % 40 Men Women Hip BMD 1 0.9 0.8 men women 30 0.7 20 0.6 10 0 50-54 55-59 60-64 65-69 70-74 Age - Years 75-79 80+ 0.5 0.4 Peak Bone Mass 50-59 60-69 70-79 80+ Age
Fractures as a Function of Age Incidence /1000,000 P-Yrs Men Women 4,000 3,000 Hip 2,000 1,000 Hip Vertebrae Colles Colles Vertebrae 35 39 65 > 85 35 39 65 > 85 Age Group, yr Hip fracture incidence rates increase exponentially with age, 5 years later then rates seen in females Cooper et al. J Bone Miner Res 1992
Consequences of Hip Fractures 27,000 Canadians suffered a hip fractures in 2007 1 10% will refracture within a year 2 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 60% 50% 40% 30% 20% 10% 0% Men Control Women Control ¹Osnes et al. Osteoporos Int 2004; 15(7):567-574. ² Fransen 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 or 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 3 FBs HL = 3 cm 8 cm 2 FBs HL = 8 cm 12 cm Prospective Height loss >2 cm Historical Height Loss > 6 cm Wall to occiput >6 cm Rib Pelvis distance < 2 finger-breadths (FBs)
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 of 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 of 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 oils 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 osteoporosis 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