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Osteoporosis in men

Key sources
The following summarized guidelines for the evaluation and management of osteoporosis in men are prepared by our editorial team based on guidelines from the Osteoporosis Canada (OC 2023), the American College of Physicians (ACP 2023), the U.S. Preventive Services Task Force (USPSTF 2018), the European Academy of Andrology (EAA 2018), and the Endocrine Society (ES 2012).
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Guidelines

1.Diagnostic investigations

History and physical examination
As per OC 2023 guidelines:
Consider using the FRAX tool as the preferred method for fracture risk estimation.
C
Identify risk factors and assess for signs of undiagnosed vertebral fractures in patients with osteoporosis.
E
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  • Bone mineral density testing

  • Evaluation of secondary causes

  • Evaluation for fractures

2.Medical management

Indications for treatment: as per OC 2023 guidelines, initiate pharmacotherapy in ≥ 50 years old male patients with any of the following:
previous hip, vertebra, or ≥ 2 osteoporosis-related fractures
B
a 10-year major osteoporotic fracture risk of ≥ 20%
B
≥ 70 years with a T-score ≤ -2.5 of the femoral neck, total hip, or lumbar spine.
A
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  • Antiresorptive therapy (bisphosphonates)

  • Antiresorptive therapy (denosumab)

  • Anabolic therapy

3.Nonpharmacologic interventions

Lifestyle modifications
Advise smoking cessation in males at risk of osteoporosis.
B
Consider advising to reduce alcohol intake in males at risk of osteoporosis consuming ≥ 3 units of alcohol per day.
C

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  • Physical activity

  • Calcium and vitamin D supplementation

  • Other supplements

4.Specific circumstances

Patients with hypogonadism, clinical assessment: consider calculating the FRAX score in all patients with confirmed hypogonadism.
C

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  • Patients with hypogonadism (bone mineral density testing)

  • Patients with hypogonadism (laboratory testing)

  • Patients with hypogonadism (X-ray)

  • Patients with hypogonadism (lifestyle modifications)

  • Patients with hypogonadism (calcium and vitamin D supplementation)

  • Patients with hypogonadism (testosterone therapy)

  • Patients with hypogonadism (antiresorptive therapy)

  • Patients receiving androgen deprivation therapy

5.Preventative measures

Calcium and vitamin D supplementation: insufficient evidence to assess the balance of benefits and harms of vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in males.
I

6.Follow-up and surveillance

Indications for referral: consult with a healthcare professional with expertise in osteoporosis (such as a family physician, general internist, endocrinologist, rheumatologist, or geriatrician) when uncertainty exists about fracture risk or treatment, such as possible secondary causes of osteoporosis, comorbidities complicating management, and important adverse effects from pharmacotherapy.
E

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  • Assessment of treatment response

  • Follow-up