ACP Guideline: Assess Osteoporosis Risk for Older Men, Get DXA for Those at Increased Risk

Osteoporosis is a serious health issue for men, as well as for women, yet it's "substantially underdiagnosed, undertreated and underreported" among male patients, according to a new clinical practice guideline (6-page PDF; About PDFs) from the American College of Physicians, or ACP. The guideline strongly recommends that physicians periodically evaluate their older male patients for osteoporosis risk factors and order dual-energy x-ray absorptiometry, or DXA, for men at increased risk who would be willing and able to take drugs to treat the condition.

The guideline is intended as a call to action for primary care physicians, says Amir Qaseem, M.D., Ph.D., M.H.A., senior medical associate in the ACP Clinical Programs and Quality of Care Department.

"ACP decided the guideline was needed because osteoporosis is a major public health issue for men, and it's becoming a bigger problem as the population ages," says Qaseem. "Studies show that osteoporotic fractures result in substantial disease, death and health costs in men. The one-year mortality rate in men after hip fracture is twice that in women."

The prevalence of osteoporosis is estimated to be 7 percent in white men, 5 percent in black men and 3 percent in Hispanic men, the ACP guideline says; data are not available for other ethnic groups.

The new guideline is based on a systematic review (18-page PDF; About PDFs) of 389 articles. Of those articles, 176 addressed risk factors for osteoporosis, and 27 addressed diagnostic tools for osteoporosis.

The meta-analysis showed that the most important risk factors for osteoporosis in men are:

Androgen deprivation therapy also is a strong predictor of both osteoporosis and fracture.

In addition, the researchers found some evidence that two risk factors -- cigarette smoking and low dietary intake of calcium -- cause low bone mass.

They found insufficient evidence regarding respiratory disease (independent of steroid use), type 2 diabetes, low dietary intake of vitamin D, thyroid disease and thyroid replacement therapy, gastrointestinal malabsorption, rheumatoid arthritis, and hyperparathyroidism to draw definitive conclusions about the contributions of these factors to osteoporosis in men. "All of these possible risk factors have plausible physiologic rationales, and some have data supporting an association with osteoporosis and fracture in women, but data in men are lacking," the guideline says.

"Most of the research and resulting evidence is about risk factors for osteoporosis in women," says Qaseem. "We need more research to understand whether the same risk factors apply in men."

The guideline also calls for more research, including research to evaluate osteoporosis screening tests in men. "DXA is the accepted reference standard for screening, but DXA isn't always readily available," says Qaseem. "We need more research to find alternative screening methods."

In 2002, the U.S. Preventive Services Task Force, or USPSTF, issued a practice guideline regarding osteoporosis screening and women, says Doug Campos-Outcalt, M.D., M.P.A., who serves as the AAFP staff liaison to the USPSTF. Furthermore, osteoporosis screening and prevention are on USPSTF's current list of topics in progress. But at this time, the task force is silent regarding osteoporosis and men, Campos-Outcalt says.

"The AAFP's Commission on Science will likely review ACP's new guideline and consider the possibility of supporting it," says Campos-Outcalt.