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 Clinical Trials Consultant/Speaker • • Amgen Amgen • • Eli Lilly Eli Lilly • • Merck Merck • • Novartis Novartis • Warner Chilcott 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 60 Men Women Fracture 50 % 40 30 20 10 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 ……. 1 Hip BMD 0.9 0.8 men 0.7 women 0.6 0.5 0.4 Peak 50-59 60-69 70-79 80+ Bone Mass Age

Men are Fracturing at Higher Bone Densities than Women Hip 60 Men Women BMD 1 50 Fracture men 0.9 % 40 women 0.8 30 0.7 0.6 20 0.5 10 0.4 Peak 50-59 60-69 70-79 80+ 0 Bone 50- 55- 60- 65- 70- 75- 80+ Mass 54 59 64 69 74 79 Age Age - Years

Fractures as a Function of Age Incidence /1000,000 P-Yrs Men Women 4,000 3,000 Hip Hip 2,000 Vertebrae Vertebrae 1,000 Colles’ Colles’ 35 – 39 > 85 > 85 65 35 – 39 65 Age Group, yr Hip fracture incidence rates increase exponentially with age , 5 Cooper et al. J Bone Miner Res 1992 years later then rates seen in females

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 60% to move into a nursing home after a hip fracture¹ 50% 40% • After 2 years: More than 30% half the men had died or 20% were institutionalized vs 10% controls (12%)² 0% Men Me Co Control Wome Women Co Control ¹ Osnes 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 HL = 3 cm HL = 8 cm • Prospective Height 8 cm loss >2 cm 12 cm • Historical Height Loss > 6 cm 3 FBs 2 FBs • 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