Male osteoporosis: new insights in an understudied disease

Sex-Based Reporting of Common Musculoskeletal Conditions

Introduction: Sex- and gender-based differences affect all aspects of health and disease, including musculoskeletal conditions. However, it is unknown how often authors publish outcomes of common conditions based on sex. We reviewed the frequency with which articles in orthopedic journals published sex-specific outcomes with regard to a condition with known sex-based differences and one in which differences are less known. Materials and Methods: Articles that reported original clinical studies from four high-impact orthopedic journals were reviewed: Journal of Bone and Joint Surgery (JBJS), Clinical Orthopedics and Related Research (CORR), American Journal of Sports Medicine (AJSM), and Journal of Arthroplasty (JOA). JBJS and CORR were reviewed as journals intended for a general audience, while AJSM and JOA were included as subspecialty journals. Analysis of data based on sex beyond the statement of how many men and women were included was designated as successfully reporting sex-specific outcomes. The gender of authors was assessed for impact on reporting. Results: Sex-specific outcomes were reported in 24%-29% of articles regarding rotator cuff pathology and in 32%-40% of publications concerning knee osteoarthritis. There was a trend toward more publications with sex-specific outcomes in knee osteoarthritis (p = 0.0562). No significant changes in rates of reporting were noted over time. Articles listing a woman as the first or last author were significantly more likely to report results based on sex. Conclusions: While there was a trend for sex-specific outcomes to be reported more often in knee osteoarthritis, the level of reporting was still low. Reporting based on sex was higher if a woman was the first or last author. To improve care for all patients, sex-specific outcomes should be reported across all orthopedic conditions by all researchers.

Bone density loss on computed tomography at 3-year follow-up in current compared to former male smokers

OBJECTIVES

Cigarette smoking negatively affects bone quality and increases fracture risk. Little is known on the effect of smoking cessation and computed tomography (CT)-derived bone mineral density (BMD) decline in the spine. We evaluated the association of current and former smoking with BMD decline after 3-year follow-up.

METHODS

Male current and former smokers participating in a lung cancer screening trial who underwent baseline and 3-year follow-up CT were included. BMD was measured by manual placement of a region of interest in the first lumbar vertebra and expressed in Hounsfield Unit (HU). Multiple linear regression analysis was used to evaluate the association between pack years smoked and smoking status with BMD decline.

RESULTS

408 participants were included with median (25th-75th percentile) age of 59.4 (55.9-63.5) years. At the start of the study, 197 (48.3%) participants were current smokers and 211 (51.7%) were former smokers and had a similar amount of pack years. Current smokers had quit smoking for 6 (4-8) years prior to inclusion. There was no difference in BMD between current and former smokers at baseline (109±34 HU vs. 108±32 HU, p=0.96). At 3-year follow-up, current smokers had a mean BMD decline of -3±13 HU (p=0.001), while BMD in former smokers did not change as compared to baseline (1±13 HU, p=0.34). After adjustment for BMD at baseline and body mass index, current smoking was independently associated with BMD decline (-3.8 HU, p=0.003). Age, pack years, and the presence of a fracture at baseline did not associate with BMD decline.

CONCLUSIONS

Current smokers showed a more rapid BMD decline over a 3-year period compared to former smokers. This information might be important to identify subjects at risk for osteoporosis and emphasizes the importance of smoking cessation in light of BMD decline.

Osteoporosis Treatment Efficacy for Men: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the efficacy of treatment options to reduce osteoporotic fracture risk in men.

DESIGN

Systematic review and meta-analysis.

SETTING

Randomized clinical trials that evaluated the efficacy of a treatment for osteoporosis or low bone mineral density for adult men and reported fracture outcomes.

PARTICIPANTS

Men.

MEASUREMENTS

PubMed, Embase, and the Cochrane Library databases were searched for relevant studies. Information was extracted from included studies on participant sociodemographic characteristics, number of male participants, treatment evaluated, comparator for evaluated treatment, study duration, and fracture outcomes. Risk of bias of individual studies was assessed using measures recommended by the Cochrane Collaboration.

RESULTS

Twenty-four articles reporting results for 22 studies (including 4,868 male participants) met strict inclusion criteria. Fixed-effects meta-analyses using the Mantel-Haenszel method demonstrated significantly lower risk of vertebral fractures with alendronate (relative risk (RR) = 0.328, 95% confidence interval (CI) = 0.155-0.692) and risedronate (RR = 0.428, 95% CI = 0.245-0.746) but not with calcitonin (RR = 0.272, 95% CI = 0.046-1.608) or denosumab (RR = 0.256, 95% CI = 0.029-2.238) than in controls. For bisphosphonates as a treatment category, meta-analyses demonstrated significantly lower risk of vertebral fractures (RR = 0.368, 95% CI = 0.252-0.537) and nonvertebral fractures (RR = 0.604, 95% CI = 0.404-0.904) than in controls. The meta-analysis finding that bisphosphonates significantly reduce nonvertebral fracture risk was not robust to sensitivity analysis.

CONCLUSION

Bisphosphonates reduce the risk of vertebral and possibly nonvertebral fractures for men with osteoporosis. Further studies are needed to evaluate the efficacy of bisphosphonates for reducing nonvertebral fracture risk and the efficacy of nonbisphosphonates for reducing vertebral and nonvertebral fracture risk in men with osteoporosis.

Development and Validation of Osteoporosis Risk-Assessment Model for Korean Men

PURPOSE

The aim of the present study was to develop an osteoporosis risk-assessment model to identify high-risk individuals among Korean men.

MATERIALS AND METHODS

The study used data from 1340 and 1110 men ≥50 years who participated in the 2009 and 2010 Korean National Health and Nutrition Examination Survey, respectively, for development and validation of an osteoporosis risk-assessment model. Osteoporosis was defined as T score ≤-2.5 at either the femoral neck or lumbar spine. Performance of the candidate models and the Osteoporosis Self-assessment Tool for Asian (OSTA) was compared with sensitivity, specificity, and area under the receiver operating characteristics curve (AUC). A net reclassification improvement was further calculated to compare the developed Korean Osteoporosis Risk-Assessment Model for Men (KORAM-M) with OSTA.

RESULTS

In the development dataset, the prevalence of osteoporosis was 8.1%. KORAM-M, consisting of age and body weight, had a sensitivity of 90.8%, a specificity of 42.4%, and an AUC of 0.666 with a cut-off score of -9. In the validation dataset, similar results were shown: sensitivity 87.9%, specificity 39.7%, and AUC 0.638. Additionally, risk categorization with KORAM-M showed improved reclassification over that of OSTA up to 22.8%.

CONCLUSION

KORAM-M can be simply used as a pre-screening tool to identify candidates for dual energy X-ray absorptiometry tests.

Musculoskeletal strength, balance performance, and self-efficacy in elderly ving tsun chinese martial art practitioners: implications for fall prevention

Objectives. To (1) compare the bone strength, lower limb muscular strength, functional balance performance, and balance self-efficacy between Ving Tsun (VT) martial art practitioners and nonpractitioners and (2) identify the associations between lower limb muscular strength, functional balance performance, and balance self-efficacy among the VT-trained participants. Methods. Thirty-five VT practitioners (mean age ± SD = 62.7 ± 13.3 years) and 49 nonpractitioners (mean age ± SD = 65.9 ± 10.5 years) participated in the study. The bone strength of the distal radius, lower limb muscular strength, functional balance performance, and balance self-efficacy were assessed using an ultrasound bone sonometer, the five times sit-to-stand test (FTSTS), the Berg balance scale (BBS), and the Chinese version of the activities-specific balance confidence scale, respectively. A multivariate analysis of covariance was performed to compare all the outcome variables between the two groups. Results. Elderly VT practitioners had higher radial bone strength on the dominant side (P < 0.05), greater lower limb muscular strength (P = 0.001), better functional balance performance (P = 0.003), and greater balance confidence (P < 0.001) than the nonpractitioners. Additionally, only the FTSTS time revealed a significant association with the BBS score (r = -0.575,  P = 0.013). Conclusions. VT may be a suitable health-maintenance exercise for the elderly. Our findings may inspire the development of VT fall-prevention exercises for the community-dwelling healthy elderly.

Elder Chinese Martial Art Practitioners Have Higher Radial Bone Strength, Hand-Grip Strength, and Better Standing Balance Control

This study explored the feasibility of using Ving Tsun (VT) martial art as a fall-prevention exercise for male seniors. We compared the radial bone strength, hand-grip strength, and standing balance control of senior VT practitioners and nonpractitioners under various sensory environments. Sixteen male VT practitioners (mean age ± SD: years) and 17 sex- and age-matched control adults (mean age ± SD: years) participated in the study. The bone strength of the distal radius, hand-grip strength, and standing balance control were assessed using an ultrasound bone sonometer, a Jamar dynamometer, and sensory organization test (SOT) on the NeuroCom Balance Master, respectively. A multivariate analysis of variance (MANOVA) was used to compare the outcome variables between the two groups. Results revealed that VT practitioners had significantly higher radial bone strength (-score) on the dominant side (), hand-grip strength (dominant side, ; nondominant side, ), and standing balance control (SOT composite equilibrium score, ) than the control participants. Male elder VT practitioners had higher radial bone strength, hand-grip strength, and better standing balance control than nonpractitioners. Our findings shed light on the use of VT exercise to prevent falls and fall-related fractures of the distal radius in male elders.

Awareness of osteoporosis and its relationship with calcaneus quantitative ultrasound in a large Chinese community population

Background

The People’s Republic of China has the largest population affected by osteoporosis in the world. However, no population-based survey of osteoporosis awareness in People’s Republic of China has been reported. This study investigated the level of basic awareness of osteoporosis in a large community in People’s Republic of China. The relationship between level of awareness and quantitative ultrasound (US) measurements at the calcaneus was also assessed.

Methods

A questionnaire was completed by 9983 men and women aged 40 years or older in Nanjing, People’s Republic of China, between June and December 2011. During this time, the study participants underwent quantitative US measurement. Data from 9049 of the subjects were included in the final analysis.

Results

The proportion of subjects who were aware of osteoporosis was very low. Only 30.7% had heard of osteoporosis, and only 18.5% had heard of osteoporotic fracture. In total, 52.9% of the subjects drank milk, 16.0% took calcium, 7.1% took vitamin D, and 47.2% were performing regular physical activity. Logistic regression showed that more highly educated older women had significantly better awareness of osteoporosis (P < 0.05). Subjects with a history of a previous osteoporotic fracture also had better awareness (P < 0.05) than subjects without such a history, except for those who drank milk. Similar to previous reports, female sex, old age, a low education level, and a personal history of osteoporotic fracture were significantly associated with a low quantitative US measurement (P < 0.001). Further, drinking milk and having not heard of osteoporosis were significantly associated with a higher quantitative US measurement (P < 0.05), while other indicators of osteoporosis awareness were not associated with quantitative US values (P > 0.05).

Conclusion

Awareness of osteoporosis in People’s Republic of China is very low. National awareness strategies should be implemented, especially for poorly educated young men.

Pharmacogenetics of osteoporosis: towards novel theranostics for personalized medicine?

Osteoporosis is a complex multifactorial bone disorder with a strong genetic basis. It is the most common, severe, progressive skeletal illness that has been increasing, particularly in developed countries. Osteoporosis will no doubt constitute a serious clinical burden in healthcare management in the coming decades. The genetics of osteoporosis should be analyzed from both the disease susceptibility and the pharmacogenetic treatment perspectives. The former has been widely studied and discussed, while the latter still requires much more information and research. This article provides a synthesis of the literature on the genetics of osteoporosis and an update on progress made in pharmacogenetics of osteoporosis in recent years, specifically regarding the new molecular targets for antiresorptive drugs. In-depth translation of osteoporosis pharmacogenetics approaches to clinical practice demands a new vision grounded on the concept of "theranostics," that is, the integration of diagnostics for both disease susceptibility testing, as well as for prediction of health intervention outcomes. In essence, theranostics signals a broadening in the scope of inquiry in diagnostics medicine. The upcoming wave of theranostics medicine also suggests more distributed forms of science and knowledge production, both by experts and end-users of scientific products. Both the diagnosis and personalized treatment of osteoporosis could conceivably benefit from the emerging postgenomics field of theranostics.

Health related quality of life in male patients with osteoporosis: results of a cross sectional study

INTRODUCTION

Osteoporosis is one of the most common diseases affecting elderly persons. Male patients with osteoporosis have rarely been the focus of earlier studies. This study explores health related quality of life (HRQoL) indicators in a sample of German male patients with osteoporosis to determine potential avenues for clinical practice changes.

METHODS

This cross-sectional study describes two HRQoL indicators (EQ5D and QUALEFFO-41) in a sample of male patients being treated for osteoporosis. Questionnaires were sent to all male patients being treated at the Dresden University Hospital outpatient endocrine clinic. Of the 344 patients invited to participate in the study 155 (57.2%) were included.

RESULTS

Overall HRQoL EQ-5D-scores for male patients with osteoporosis were greater than those of comparable groups of the German population. Patients with ≥2 fractures had the highest level of impairment in HRQoL. Of all the dimensions of EQ-5D-scores, pain/discomfort was the most affected. Better HRQoL (median values <10.0/QUALEFFO-41 scores) were detected in the whole sample for jobs around the house, activities of daily living and mobility compared to other dimensions. The highest levels of impairment were observed in the QUALEFFO-41 domains of general health perception, mental function and pain.

CONCLUSION

This analysis confirms the association between number of fractures and worse estimation of HRQoL in male patients. Because men are 3 times less likely to suffer from osteoporosis than women, the specific HRQoL characteristics of male patients with this disease can often be overlooked. Clinicians should consider mental health referral especially for osteoporotic male patients having experienced ≥2 fractures.

Clozapine protects bone mineral density in female patients with schizophrenia

Decreased bone mineral density (BMD) is common in patients with schizophrenia; however, the pathogenesis is unclear. Different classes of antipsychotic agents may affect BMD. This study systemically examined the effects of clozapine vs. other antipsychotics, and several hormonal and metabolic factors that may contribute to BMD in female patients with schizophrenia, who are more vulnerable than males. Forty-eight women with schizophrenia, treated with long-term antipsychotics of the prototype prolactin-sparing (PS) antipsychotic agent clozapine vs. prolactin-raising (PR) antipsychotics were enrolled. They were matched for demographic and clinical characteristics. Various factors, including blood levels of prolactin and sex hormones, psychopathological symptoms, global assessment of functioning, physical activity, and menopausal status, were determined to explore their contribution to low BMD (LBMD), defined as a dual-energy X-ray absorptiometer (DEXA) T score <-1. Overall, women receiving clozapine have better bone density than women receiving PR antipsychotics. Compared to PR antipsychotics, PS clozapine therapy is a protective factor (odds ratio 28.2, 95% confidence interval 2.37-336.10, p=0.008) for LBMD. Predictors for higher bone density in the clozapine group included higher clozapine dose (p<0.001), younger age (p<0.001), and higher thyroid-stimulating hormone level (p<0.001); in the PR group, higher body mass index (p=0.003) and lower alkaline phosphatase level (p=0.007) were associated with LBMD. This study suggests that clozapine treatment is beneficial for BMD compared to PR antipsychotic treatment in women with chronic schizophrenia, and clozapine's bone-density protecting effect is dose-related.

The role of distal third radius dual energy X-ray absorptiometry (DXA) and central DXA in evaluating for osteopenia and osteoporosis in men receiving androgen deprivation therapy for prostate cancer

The authors assessed the use of distal third radius dual energy X-ray absorptiometry (DXA) concomitantly with central (hip and lumbar spine) DXA to identify men with osteopenia or osteoporosis receiving androgen deprivation therapy (ADT) for prostate cancer. Initial classification with central DXA demonstrated 60 (17%) normal, 187 (55%) osteopenic, and 96 (28%) osteoporotic patients. Sixteen of 60 (27%) normal patients were reclassified as osteopenic (14) or osteoporotic (2), and 20 of 187 (11%) osteopenic patients were reclassified as osteoporotic with the combination of central DXA plus distal third radius DXA. The difference in reclassification was statistically significant. The addition of distal third radius to central DXA scanning in men with bone loss associated with ADT identifies a statistically significant number of men being reclassified as having osteopenia or osteoporosis. Combined central and distal third radius DXA scanning should be considered routine in the evaluation of all men suspected of bone loss associated with ADT. This has specific significant clinical relevance because of the large number of men with nonevaluable central DXA studies. Fracture risk prediction and treatment recommendations based on this reclassification will need to be determined by follow-up studies.

Screening for Male Osteoporosis at an Academic Medical Center

Recent findings suggest that men have higher mortality rates than women after a hip fracture. Although the risk of osteoporotic fractures in men is increasing, male osteoporosis still remains underdiagnosed and undertreated. In general, male osteoporosis is given low priority by policy makers in public health initiatives. The purpose of this study is to examine the patterns of use and gender distribution of DXA (dual-energy X-ray absorptiometry) scan usage at a university medical center in the United States. The total number of DXA scans increased during the study period while the percentage of men studied actually declined. The results of this study may lead to heightened awareness among providers who are caring for male patients at risk for osteoporosis.

Knowledge of osteoporosis among men in the primary care setting

OBJECTIVES

Osteoporosis has been often viewed as a disease affecting women; however, men are at risk for osteoporosis, and the mortality after hip fracture in men older than 75 years of age is significantly higher than in women. We aimed to assess knowledge of osteoporosis and its risk factors in men.

METHODS

A questionnaire assessing knowledge of osteoporosis was presented to 136 male patients randomly in Internal Medicine and Family Practice clinics at Saint Joseph Hospital.

RESULTS

A total of 136 men agreed to fill in the questionnaire. Only 130 patients who completed the entire questionnaire were included in the data analysis. Twenty-three percent of men surveyed had never heard about osteoporosis. Thirty-nine percent were unaware that osteoporosis is directly responsible for disabling hip fractures. Sixty-seven percent did not know that a potential outcome of hip fracture is death. Only 38% recognized that smoking is a risk factor, 20% knew that excessive caffeine intake can put them at risk, and 35% realized that excessive alcohol intake is a risk factor. Only 21% could correctly identify the calcium-rich foods among the choices. There was a positive relationship (P < 0.05) between receiving an official discussion with a physician regarding osteoporosis and the actual score on the "knowledge of osteoporosis" questionnaire.

CONCLUSION

A significant percentage of men are unaware of the complications and risk factors for osteoporosis. Receiving educational information about osteoporosis from a physician should be considered at an early stage, especially for those patients with modifiable risk factors.

Heterogeneity of biological bone markers in idiopathic male osteoporosis

In men with idiopathic osteoporosis, histomorphometric studies reported both increased resorption and decreased remodeling. We aimed at examine bone remodeling in these patients by biological marker measurement. We compared pre-treatment carboxy-terminal cross-linking telopeptide of type I collagen (CTX) and bone alkaline phosphatase (bALP) levels in 49 men, mean age 59 ± 14 year, with idiopathic osteoporosis with fractures (40 patients) or osteoporosis diagnosed by densitometry (9 patients) with 50 age-matched controls. The influence of baseline remodeling level on alendronate efficacy was studied. Bone remodeling markers (CTX and bALP) did not significantly differ between patients and controls and were correlated in both groups. There was no correlation between these markers, vitamin D and PTH levels. Twenty-one patients underwent repeat densitometry after 1 year of alendronate (70 mg/week). Mean annual BMD increase, spine +4.1 ± 3.9%, and hip +1.5 ± 1.2% showed no correlation with baseline CTX. Bone remodeling is very heterogeneous and formation and resorption remain biologically coupled in both idiopathic male osteoporosis and controls. Baseline remodeling level does not affect the action of alendronate on BMD.

Male osteoporosis

Osteoporosis develops in males approximately 10 years later than in females. Low vitamin D is a common problem. Decline in testosterone represents a major cause for osteoporosis in men. Bisphosphonates are the treatment of choice for osteoporosis in older males.

Development of clinical utility of zoledronic acid and patient considerations in the treatment of osteoporosis

Osteoporosis is a major health concern, which results in the increased risk of fractures. There is a high risk for the first or consecutive fractures leading to considerable morbidity and debilitating consequences if osteoporosis is untreated. Currently, bisphosphonates are the mainstay of treatment for osteoporosis though long-term persistence and adherence to bisphosphonates, especially those taken orally, remain low. This medication noncompliance has serious consequences on osteoporotic patients as it is associated with a significantly higher fracture risk. Intravenous (IV) zoledronic acid (ZOL), developed to increase compliance by overcoming the frequent and burdensome dosing requirements of oral bisphosphonates, is the first and the only once-yearly bisphosphonate globally approved for use in the treatment of up to 6 indications of osteoporosis. Several clinical studies have documented that a single infusion of IV ZOL resulted in decreased bone turnover and improved bone density for at least 12 months post infusion. This article traces the development of ZOL's clinical utility and evaluates its patient preference by collating data from all major clinical trials, studying the efficacy and safety of ZOL in the treatment of osteoporosis and other benign bone disorders.

Bone mineral density results influencing health-related behaviors in male athletes at risk for osteoporosis

The purposes of this study were to determine the role of bone mineral density (BMD) and mood in influencing health-related behaviors of serious leisure male athletes (cyclists and triathletes) at risk for osteoporosis. A cross-sectional design evaluated BMD in 18-60-yr-old serious leisure male cyclists by dual-energy X-ray adsorptiometry (DXA). Activity was measured using the International Physical Activity Questionnaire; personality was assessed using the NEO-60; and quality of life using Short-Form Health 12 (SF-12). Participants completed an online survey questionnaire after completing their DXA testing a minimum of 3 mo before assessing health-related behaviors and general attitudes toward general health and well-being. Forty-two (61.9%) participants responded to the follow-up questionnaire. Serious leisure male athletes are more likely to initiate significant health-related behavioral changes after learning of their bone density results including calcium supplementation and weight-bearing exercise. Men with low BMD (LBMD) had higher openness subscales on NEO-60 compared with men with normal BMD. SF-12 mental and physical health scores were significantly lower in men with LBMD. Perhaps, the interaction and interplay of genetics, activity and behaviors, and aspects of mental and psychological functions contribute to their reduction in BMD and heightened risk for fracture. Findings from this study suggest that early BMD testing in "serious athletes" has important clinical relevance for their potential risk for osteoporosis in the future.

Effects of low, moderate and relatively high chronic exposure to cadmium on long bones susceptibility to fractures in male rats

The study investigated the risk of the femur and tibia fractures on a male rat model of low, moderate and relatively high human exposure to cadmium (1, 5 and 50mg Cd/l in drinking water for 12 months). Bone mineral density (BMD) and biomechanical properties at the proximal and distal femur, and femoral and tibial diaphysis as well as the bone content of mineral and organic components, were evaluated. The exposure to 1mg Cd/l caused only very subtle changes in biomechanical properties at the femoral neck and distal femur. In the rats treated with 5mg Cd/l, a decrease in the distal femur BMD (by 5.5%) and enhanced vulnerability to fracture at the femoral neck, distal femur, and tibia diaphysis were observed. At the highest Cd treatment, the BMD decreased (by 6.5-11%) and the biomechanical properties weakened at all regions of the femur and tibia. Moreover, a decrease in the femur and tibia content of mineral components (by 11.5% and 10%, respectively) and the tibia content of organic components (by 7%) was noted. The results seem to indicate that low chronic exposure to Cd can have no influence on the bone resistance to fracture, whereas moderate (and particularly relatively high) exposure seriously increases the risk of fracture of long bones in males. The observations, together with our findings on an analogous female rat model, provide evidence that males are less vulnerable to Cd-induced demineralization and weakening of biomechanical properties of the femur and tibia than females.

Depression as a risk factor for osteoporosis

Osteoporosis is a major public health threat. Multiple studies have reported an association between depression and low bone mineral density, but a causal link between these two conditions is disputed. Here we review the endocrine and immune alterations secondary to depression that might affect bone mass. We also discuss the possible role of poor lifestyle in the etiology of osteoporosis in subjects with depression and the potential effect of antidepressants on bone loss. We propose that depression induces bone loss and osteoporotic fractures, primarily via specific immune and endocrine mechanisms, while poor lifestyle habits and use of specific antidepressants are potential contributory factors.