Evaluation and treatment rates in men at risk for osteoporosis are strikingly low, according to study results published in the Journal of Investigative Medicine. Approximately half of men age ≥75 years with age alone as a risk factor for fractures, and the majority of men age ≥70 years with additional high-risk factors for fractures — including previous fracture, chronic oral glucocorticoid use, and androgen deprivation therapy — meet the threshold criteria for treatment.
Older studies have reported low rates of appropriate osteoporosis management in elderly men. However, as various clinical guidelines for osteoporosis in women and men have been published in the last decade, the goal of this study was to investigate the prevalence of evaluation and treatment of osteoporosis in older patients.
Data from the Veterans Integrated Service Network was used to identify individuals with age alone (≥70 years) as a significant risk factor for fracture and older men at very high risk for fracture, including 3 groups of men age ≥70 years with an additional risk factor for fracture: previous hip fracture, chronic glucocorticoid therapy, or androgen deprivation therapy for prostate cancer.
The researchers quantified the number of participants who underwent screening for osteoporosis by measuring the percentage of patients who had bone mineral density measured by dual-energy X-ray absorptiometry (DXA) and serum 25-hydroxyvitamin D. Assessment of treatment for osteoporosis was based on prescription for calcium and vitamin D and bisphosphanates. Denosumab and teriparatide were rarely used during the study period.
The cohort included 13,704 older men and women treated at a Veterans Affairs medical center from January 2000 to August 2010 who had complete data, allowing calculation of a modified Fracture Risk Assessment Tool (FRAX) score.
Unsurprisingly, the 10-year risk for hip fracture, as assessed by limited FRAX score, increased with age in men and women who had age alone as a significant risk factor for fracture. The results indicated that approximately half (48%) of men age ≥75 years and nearly 90% of men age ≥80 years with age alone as a risk factor had a calculated 10-year hip fracture risk ≥3%. However, despite this risk being sufficient to warrant treatment for osteoporosis, only a minor fraction (10% to 13%) of patients had undergone bone densitometry and ≤7% received bisphosphonate therapy for osteoporosis.
A majority of men age ≥70 years with 1 of the 3 risk factors for fractures had a calculated 10-year hip fracture risk ≥3%. The percentage of men with a 10-year risk for hip fracture exceeding this threshold was 95% in men with previous hip fracture, 69% in men reporting chronic glucocorticoid use, and 74% in men receiving androgen deprivation therapy. However, <40% of men in each subgroup had undergone bone densitometry and <25% in each subgroup had received bisphosphonate treatment for osteoporosis.
The study had several limitations, including its retrospective design, differences in follow-up times, incomplete data as treatment and evaluation provided outside of the Veterans Affairs system are not always recorded, and lack of information regarding other risk factors for fractures or secondary causes of osteoporosis. The main limitation of this study was related to the unavailable DXA scan results. Because the researchers did not have access to this information, the limited FRAX score considered only ethnicity, age, weight and height, and the 3 aforementioned risk factors.
“[W]e believe that there is a need for developing strategies to improve the evaluation and management of osteoporosis in all older men, particularly among elderly men with a very high risk [for] fracture,” concluded the investigators.
Narla RR, Hirano LA, Lo SHY, Anawalt BD, Phelan EA, Matsumoto AM. Suboptimal osteoporosis evaluation and treatment in older men with and without additional high-risk factors for fractures [published online February 14, 2019]. J Investig Med. doi:10.1136/jim-2018-000907