The treatment of osteoporosis in men consists of lifestyle measures and drug or hormonal therapy.
Non pharmacological therapy
1. Weight-bearing exercise.
2. Calcium and vitamin D supplementation:
1000 -1200 mg of calcium daily and 600-800 units of vitamin D
Secondary osteoporosis:
The cause of secondary osteoporosis should be identified and treated.
For example Testosterone therapy can be used to increase bone mineral density in young men with hypogonadism
Pharmacological therapy:
We start with fracture risk assessment using FRAX score calculator which estimates the 10-year probability of hip fracture or major osteoporotic fractures combined (hip, spine, shoulder, or wrist) for an untreated patient using femoral neck BMD and other risk factors for fractures:
http://www.shef.ac.uk/FRAX/tool.aspx?country=1
When to start pharmacotherapy?
1. Men ≥50 years with a history of hip or vertebral fracture or with osteoporosis (T-score ≤-2.5).
2. Men with osteopenia (T-score between -1.0 and -2.5) and with a10-year probability of hip fracture reaches 3 percent or the 10-year probability of osteoporotic fractures combined is ≥20 percent.
3. For those at moderate risk (10 to 20 percent), the decision to treat should be based upon the presence of additional risk factors.
Choice of therapy
Bisphosphonates are considered the treatment of choice.
Patients can start with weekly alendronate and risedronate, when oral bisphosphonate is intolerable patients can use IV zoledronic acid.
When zoledronic acid is intolerable or for patients with renal impairment (bisphosphonates are not recommended when GFR<30 ml/min), denosumab is the drug of choice.
Another option is Teriparatide, which can be used for men with severe osteoporosis (T score <-2.5) and at least one fragility fracture), or men who have failed previous therapy.
Denosumab prevents bone loss and reduces vertebral fracture risk in men with nonmetastatic prostate cancer receiving androgen deprivation therapy. Also, used in males with impaired renal function.
In case of treatment failure and no availability of another option, strontium ranlate can be used which acts by inhibiting bone resorption and may increases bone mineral density.
In males whit growth hormone deficiency, Growth hormone growth factor can be used
Monitoring:
1. Patient adherence to therapy
2. BMD measurements, obtain a follow-up DXA of hip and spine after two years, and if BMD is stable or improved, less frequent monitoring is needed.