International Working Group Releases First Guideline for Osteoporosis in Men

Jean-Yves Reginster, MD, PhD

Credit: International Osteoporosis Foundation

The International Osteoporosis Foundation published the first evidence-based guideline for the management of osteoporosis in men.¹ The international multidisciplinary working group, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), crafted the new guidelines.

Osteoporosis is often considered a “women’s disease,” despite many men having the bone disease. It is estimated 1 in 5 men over ≥ 50 years old will experience an osteoporosis fracture at some point in their lifetime, with the number of hip fractures in men predicted to rise by approximately 310% between 1990 and 2050. However, since osteoporosis is viewed as a women’s disease, the condition is often under-diagnosed and under-treated in men.

“It's important to recognize that osteoporosis in men carries substantial morbidity and mortality, with rates comparable to or even exceeding those in women with the condition,” stated Jean-Yves Reginster, MD, PhD, senior author and president of ESCEO, in a press release.

This new guideline provides GRADE-assessed recommendations for the diagnosis, monitoring, and treatment of osteoporosis in men. The guidelines also cover disease burden; how to assess fracture risk in men with an appropriate interpretation of bone densitometry and absolute fracture risk; and thresholds for treatment. The working group also notes areas in need of further research, particularly evaluating the efficacy of anti-osteoporosis medications, such as denosumab and bone-forming therapies.

“The ESCEO international working group was convened to provide new management recommendations that are informed by the latest developments in research and up-to-date expert opinion related to diagnostic and screening approaches for osteoporosis and its associated high fracture risk in men,” Reginster said.

Assessment Recommendations

The guideline includes many recommendations for managing osteoporosis in men.² According to the guideline, clinicians are advised to:

• Use a female reference database for densitometric diagnosis of osteoporosis in men. *
• Use the tool FRAX to assess the fracture risk and to set intervention thresholds that should be age-dependent.
• Use BMD and FRAX probability to get the trabecular bone score as it provides important information for the fracture risk assessment.
• Use Biochemical markers of bone turnover to assess adherence to anti-resorptive therapy.
• Assess serum total testosterone as a part of a pre-treatment assessment.

General Treatment Recommendations

• Men with a prior fragility fracture are recommended to be treated with anti-osteoporosis medications.
• The anti-osteoporosis treatment regimen should be tailored to an individual’s baseline fracture risk.
• Consider appropriate hormone replacement therapy for men with low levels of total or free serum testosterone.

High Fracture Risk Treatment Recommendations

• Denosumab or zoledronate are second-line treatments for men with a high fracture risk.

Very High Fracture Risk Treatment Recommendations

• Oral bisphosphonates (alendronate or risedronate) are considered first-line treatments for men with osteoporosis at a very high risk of osteoporotic fracture.
• Men at very high fracture risk should start sequential therapy with a bone-forming agent and end with an anti-resorptive agent.
• Bone-forming agents during a first-line treatment in men with a very high fracture risk should be used per the recommendations of the regulatory authorities.

Patient-Specific Recommendations

• Ensure vitamin D and calcium repletion for men ≥ 65 years.
• Recommend physical exercise and a balanced diet.

“We hope that these guidelines will assist clinicians in their clinical practice and encourage them to be proactive in managing osteoporosis in their male patients,” said Nicholas Harvey, PhD, senior author and chairman of the International Osteoporosis Foundation (IOF) Committee of Scientific Advisors, in a press release. “Following an approach similar to that advocated for women with osteoporosis, we recommend the use of oral anti-resorptive agents as first-line agents in men at a high risk of fracture and the use of bone-forming agents followed sequentially by anti-resorptive agents in men at a very high risk of fracture.”

* The recommendations were graded as “weak recommendations” if 75% of voters selected “strong do” or “weak do” and were graded as “strong recommendations if “75% of voters selected ‘strong do.’ Strong recommendations are in bold.

References

1. New Evidence-Based Guideline for The Management of Osteoporosis In Men. International Osteoporosis Foundation. March 25, 2024. https://www.osteoporosis.foundation/news/new-evidence-based-guideline-management-osteoporosis-men-20240325-1145. Accessed April 3, 2024.
2. Fuggle NR, Beaudart C, Bruyère O, et al. Evidence-Based Guideline for the management of osteoporosis in men. Nat Rev Rheumatol. 2024;20(4):241-251. doi:10.1038/s41584-024-01094-9