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Osteoporosis
Osteoporosis and Men
Osteoporosis and Men
by Carol Lewis
FDA
More than 10 million Americans have
osteoporosis, according to the National Institute on Aging. Eighteen
million more have lost enough bone to make them more likely to develop
the disease. The majority of these 28 million are women. But men are at
risk for the bone-thinning disease, too.
Osteoporosis gradually weakens bones
and can lead to painful and debilitating fractures. It is characterized
by low bone density (how solid bones are) and structural deterioration
of bone tissue.
Often called the "silent
disease," osteoporosis usually progresses without symptoms until it
is diagnosed following a fracture.
Osteoporosis is seen less often in men
than in women because men generally have larger, stronger bones, and
because men don't usually experience the abrupt and substantial hormonal
changes that women do following menopause. Also, bone loss begins later
and advances more slowly in men than in women. However, the National
Institutes of Health says that the problem of osteoporosis in men
recently has been recognized as an important public health issue,
especially in light of estimates that the number of men above age 70
will double between 1993 and 2050.
Today, more than 2 million American men
have osteoporosis, and another 3 million are at risk for the disease,
according to the National Osteoporosis Foundation (NOF). Each year, men
suffer one-third of all hip fractures, and one-third of these men will
not survive more than one year. In addition to hip fractures, men most
often experience fractures of the spine and wrist due to osteoporosis.
But changing attitudes and improved
technology are brightening the outlook for men with osteoporosis.
Although some bone loss is expected as men age, osteoporosis is no
longer viewed as an inevitable consequence of aging. Diagnosis and
treatment need no longer wait until bones break. New products are
becoming available specifically to treat men with osteoporosis.
Bone Life
Bones grow in length and density during
a person's younger years. Bone density relates to the mineral content of
the tissue. People reach their maximum height during their teens, but
bone density continues to increase until about age 30. After that point,
bones slowly start to lose density and strength. Throughout life, bone
density is affected by heredity, sex hormones, physical activity, diet,
lifestyle choices, and the use of certain medications.
In their 50s, men do not experience the
rapid loss of bone mass that women have in the years following
menopause. "But some men do have a hormonal drop-off in
testosterone, with skeletal consequences that are similar to those seen
in women following reduction of estrogen," explains Bruce
Schneider, a medical officer in the FDA's Division of Metabolic and
Endocrine Drug Products. Testosterone may diminish as a result of
hypogonadism, a condition marked by decreased function of the testicles.
Testosterone levels also may decrease naturally as a man ages. This loss
of sex hormone eventually can result in accelerated bone loss. Whether
bone loss at this point translates into osteoporosis, however, depends
on how much bone a man has when the loss begins, and how quickly he
loses it.
By age 65 or 70, men and women lose
bone mass at similar rates, and the absorption of calcium, an essential
nutrient for bone health throughout life, decreases in both sexes.
Prevention, Diagnosis and Treatment
In men, there are two main types of
osteoporosis: primary and secondary. In primary osteoporosis, there may
be no identifiable cause (idiopathic) or it may be the result of
age-related bone loss. Often, these two conditions overlap, and
distinguishing between them is arbitrary. Secondary osteoporosis in men
can be due to a variety of causes. Low testosterone (hypogonadism),
medications such as prednisone that can lead to steroid excess, and
alcoholism are among the important causes of secondary osteoporosis in
men.
Once bone is lost, it cannot be
completely replaced using currently available therapies. Therefore, it
is essential that men be evaluated and treated before significant bone
loss has occurred. Building strong bones during childhood and
adolescence can be the best defense against developing osteoporosis
later.
Although it cannot be cured,
osteoporosis can be slowed down, and steps can be taken to help prevent
the disease. A special kind of X-ray, the bone mineral density (BMD)
test, is a safe, accurate, quick, painless, and noninvasive way to
diagnose osteoporosis, detect low bone density, monitor the
effectiveness of treatments, and predict the risk for future fractures.
Mone Zaidi, M.D., Ph.D., director of
the bone program at the Mount Sinai School of Medicine in New York, says
that men should get a BMD test if they have a bone fracture, experience
lower back pain, or notice height loss.
"If one falls on an outstretched
hand, that shouldn't break the wrist," says Zaidi. "If it
does, there's a problem."
In 2001, the FDA approved Fosamax (alendronate)
to increase bone mass in men with osteoporosis. Fosamax works by
reducing the activity of the cells that cause bone loss. The drug was
already approved to prevent and treat postmenopausal osteoporosis in
women based on studies that indicated it not only increased BMD, but
also reduced fractures related to a loss of bone mass. The study in men
was designed only to examine the effect on BMD, not on fracture risk.
However, it is believed that ultimate fracture benefits are likely to
occur in men who experience increases in BMD with treatment, although
the relationship between BMD increases and fracture benefits may differ
between the genders.
More recently, a novel approach to
treating osteoporosis in postmenopausal women and in men with primary or
hypogonadal osteoporosis is being investigated. The active portion of
human parathyroid hormone (PTH), which regulates normal calcium and
phosphate metabolism in bones, has been administered by daily injections
and shown to stimulate new bone formation, leading to increased bone
mineral density. Post-menopausal women treated with this agent showed a
reduction in the incidence of osteoporotic fractures relative to those
treated with calcium and vitamin D alone. Like Fosamax, the trial of
parathyroid hormone in men was not designed to test the effect of
treatment on the risk of fractures. However, based on the study in
women, some beneficial effect on fracture risk reduction is likely.
Until Fosamax was approved for men with
osteoporosis, the FDA had approved medications only for the prevention
and treatment of osteoporosis in postmenopausal women and
steroid-induced osteoporosis in both men and women. Steroids, a class of
compounds that includes prednisone and cortisone, are powerful
anti-inflammatory substances that are used to treat many diseases,
including rheumatoid arthritis and asthma. Steroids can cause bone to be
removed faster than it is formed, and loss of bone density can occur,
increasing the risk for osteoporosis and related fractures. Fosamax and
Actonel (risedronate) are approved for use by men and women with
steroid-induced osteoporosis.
Tailored to the particular reason for
bone loss, the treatment plan for men with osteoporosis will include
proper nutrition, exercise, and lifestyle modifications for preventing
bone loss and, if needed, one of the FDA-approved osteoporosis
medications. Doctors may want to monitor bone density and testosterone
levels, recommending testosterone replacement as necessary, and may
suggest changes to the current steroid dosage if they feel bone loss is
due to steroid use. Finally, maintenance of adequate calcium and vitamin
D intake is very important in the treatment and prevention of
osteoporosis.
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