Male Osteoporosis: Deadly, but Ignored

Differences in the global exposure, mortality and disability of low bone mineral density between men and women: the underestimated burden in men

Talking about osteoporosis, we tend to focus on post-menopause women who are at increased risk due to estrogen depletion, while less attention has been paid to the disease in men. Currently, there is a lack of understanding about the difference of osteoporosis incidence and burden by sex. In this study, we used data from the Global Burden of Disease Study 2019 (GBD 2019) to compare the difference in the prevalence and burden of low bone mineral density (LBMD) between men and women, by location, year, age and socio-demographic index. We found the prevalence of LBMD was higher in women than in men. However, the age standardized mortality rate was greatly higher in men than in women. Using disability-adjusted life year (DALY) to measure the burden, we also observed higher age standardized DALY rate in men. Using sociodemographic index (SDI) as the measure of social development level, we found that higher mortality and DALY rates were mainly seen in middle and high SDI countries. Falls were the leading cause for of deaths and disabilities in both men and women with LBMD, followed by transport injuries. Fall-related mortality was higher in women, while transport injuries caused more deaths and disabilities in men. Conclusively, more attention should be paid to osteoporosis in men, and related policies, clinical practices, and guidelines are in need to reduce the burden of LBMD and osteoporosis in men.

Prospective risk of osteoporotic fractures in patients with advanced chronic obstructive pulmonary disease

Despite the high prevalence of osteoporosis in chronic obstructive pulmonary disease (COPD) patients, the fracture risk prediction tools are not routinely undertaken in the management of COPD. We quantified fracture risk using a validated risk prediction tool (Fracture Risk Assessment (FRAX®)) and determined potential bone-protection treatment needs in patients with advanced COPD. The 10-year probability of major osteoporotic or hip fracture was calculated using the FRAX tool in a cohort of patients attending a hospital complex COPD service. Patients were identified to be at low, intermediate and high risk based on their FRAX scores, in accordance with the National Osteoporosis Guideline Group recommendations, to assess the number of patients requiring bone mineral density (BMD) testing or bone protection therapy. Two hundred forty-seven patients [mean (standard deviation (SD)) age 66 (9.1) years, 26% current smokers, 40% women and median (interquartile range (IQR)) Medical Research Council (MRC) breathlessness scale 4 (0)] had a 10-year probability of 9.5% (6.1) and 3.8% (4.6) for major osteoporotic and hip fractures, respectively. Thirty-six percentage of patients were identified to be at intermediate risk of developing fragility fracture, requiring BMD assessment, while 9% were at high risk, requiring treatment. Thirty-two percentage of high-risk patients were on bisphosphonates. The FRAX score can be used to assess the fracture risk within the COPD cohort and assist with decision-making about BMD measurement and provision of bone protection therapy.

Cancer risk in patients with osteoporosis: a population-based cohort study

BACKGROUND

Osteoporosis has been associated with cancer development. We conducted a nationwide population-based cohort study in Taiwan to evaluate this possible association of osteoporosis with subsequent cancer development.

METHODS

A total of 35,979 patients diagnosed with osteoporosis between 2000 and 2010 identified from the National Health Insurance Research Database comprised the osteoporosis cohort, and each patient was randomly frequency matched with one individual from the general population (without osteoporosis) based on age, sex, and year of osteoporosis diagnosis to form the non-osteoporosis (control) cohort. Cox proportional hazard regression analysis was used to calculate adjusted hazard ratios and 95% confidence intervals and determine the effect of osteoporosis on cancer risk.

RESULTS

Patients with osteoporosis showed a significantly higher risk of developing liver and thyroid cancers and lower risk of colorectal cancer than did individuals without osteoporosis. Male patients with osteoporosis had a significantly increased risk for liver cancer, whereas female patients with osteoporosis had a significantly increased risk for thyroid cancer, but a significantly decreased risk for overall and colorectal cancers. In addition, more significant findings were observed when age ≤64 years or the follow-up duration was ≤5 years; however, a significantly lower risk for colorectal cancer was observed when follow-up duration was >5 years. Study limits including lack of data for some health-related behaviors, inclusion criteria of osteoporosis and potential selection bias have been discussed.

CONCLUSION

Patients with osteoporosis showed a higher risk for liver and thyroid cancers and a lower risk for colorectal cancer than did control individuals. Stratified analyses by sex, age, and follow-up duration showed various patterns in different cancers.

The Relationship Between Cardiorespiratory Fitness and Bone Mineral Density in Men: A Cross-sectional Study

OBJECTIVE

To determine the relationship between estimated cardiorespiratory fitness (CRF) and femoral neck (FN) bone mineral density (BMD) in men.

PATIENTS AND METHODS

This cross-sectional study included 2569 men aged 50 to 90 years (mean, 63.5 years) who had at least 1 health examination at a preventive medicine clinic between January 27, 1998, and February 24, 2015. Maximal treadmill tests were conducted using the Balke protocol and were used to estimate CRF. We stratified patients into low, moderate, and high CRF categories. The FN BMD was measured by dual-energy x-ray absorptiometry. Odds ratios (ORs) for T-scores of -2.5 or less (osteoporosis) and -1.0 or less (low BMD) were calculated for categorical CRF and were adjusted for weight, age, and days per week of resistance activity.

RESULTS

The sample prevalence of osteoporosis in the FN was 4.1% and of low BMD was 49.4%. There was a significant inverse association between higher CRF category and osteoporosis measured at the FN (moderate vs low: OR=0.34; 95% CI, 0.16-0.74; high vs low: OR=0.19; 95% CI, 0.09-0.42) and low BMD (moderate vs low: OR=0.64; 95% CI, 0.43-0.96; high vs low: OR=0.43; 95% CI, 0.29-0.65).

CONCLUSION

In men, CRF is directly associated with BMD. These results suggest that moderate-to-high CRF levels attained through regular physical activity may attenuate age-related decline in BMD. Further studies are needed to determine whether this translates to a lower risk of osteoporotic fracture in more fit men.

Osteoarticular diseases and physical performance of Brazilians over 80 years old

Abstract Objective To investigate the physical performance of Brazilian individuals older than 80 years with and without OD. Methods The sample consisted of 135 individuals (aged > 80 years) of both gender. Identification of osteopenia/osteoporosis was verified by Dual Energy X-ray Absorptiometry, and the presence of others osteoarticular diseases (OD) was obtained using a questionnaire of morbidities. Physical performance was analyzed by motor tests. Results Men presented higher proportion of osteopenia/osteoporosis compared to women (p = 0.013). The proportion of older people with arthritis/osteoarthritis for women and men was 33% and 26%, respectively, and with OD in the spine was 19% and 12%, respectively. No significant difference for physical performance, measured by each test and overall score, was observed between groups of OD. According to gender, male with OD presented lower performance in gait speed, balance and overall score (p < 0.05), while older people with osteopenia/osteoporosis are at higher risk for low physical performance (OR 2.73; CI 95% 1.31-5.66). Conclusion In conclusion it was verified in older people with age of 80 years or more, a high prevalence of OD, especially in men, and the presence of these diseases interfered negatively their physical performance.

Study of Adverse Effect Profile of Parenteral Zoledronic Acid in Female Patients with Osteoporosis

INTRODUCTION

Osteoporosis is still a under recognized entity in the population. Osteoporosis-related fractures can be prevented if people at risk can be screened, diagnosed and treated early. Bisphosphonates remain the mainstay of osteoporosis treatment as they have multimodal action. Oral bisphosphonate therapy has, significant gastrointestinal side effects leading to noncompliance. Of late parenteral Zoledronic Acid is being used as once or twice yearly infusion for the treatment of osteoporosis.

AIM

Our article studies the side effect profile and tolerability of parenteral Zoledronic Acid, one of the most potent bisphosphonate used in clinical practice in patients with osteoporosis.

MATERIALS AND METHODS

This study was done in KMC hospitals where 49 patients diagnosed with osteoporosis were included for the study. After obtaining a written informed consent each patient received one infusion of 5 mg Zoledronic Acid as per standard treatment protocol. Patient was monitored for clinical improvement and development of any adverse effects.

CONCLUSION

In our study all subjects reported significant pain relief after infusion of Zoledronic Acid. Zoledronic Acid had very few serious adverse effects that can be prevented through pre-infusion screening, maintaining good hydration and careful patient monitoring. In our population the patients only experienced mild symptoms of pyrexia, arthralgia myalgia and influenza like symptoms which resolved with symptomatic treatment.

Fracture incidence in a large cohort of men age 30 years and older with osteoporosis

In this large retrospective study of men with presumed osteoporosis, we estimate the rate of osteoporosis-related fractures in men age ≥30 years. Our results suggest that spine and hip fractures continue to be a considerable disease burden for osteoporotic men of all ages.

INTRODUCTION

The purposes of this study were to describe a cohort of men with presumed osteoporosis and estimate the incidence rates of fractures by age.

METHODS

Using US administrative claims data, we identified 43,813 men ≥30 years old with an osteoporosis diagnosis or use of an osteoporosis medication. Men were followed for a minimum of 12 months after diagnosis or treatment of osteoporosis (index date), until the earliest of fracture (hip, spine, pelvis, distal femur, humerus, wrist, forearm), disenrollment, or study end date.

RESULTS

During the study period, there were 3834 first fractures following the index date and 3303 fractures in the 6-month period prior to the diagnosis/treatment of osteoporosis. Incidence rates of osteoporosis-related fracture, estimated from the index date onward, increased with age, although did not significantly differ from one another in younger age groups (30-49 and 50-64 years). Spine fractures had the highest incidence rate in men across all age groups, increasing from 10.8 per 100,000 person-years (p-yrs) (95% confidence interval (CI) 9.1, 12.7), 12.2 per 100,000 p-yrs (95% CI 11.2, 13.3), and 15.3 per 100,000 p-yrs (95% CI 13.8, 16.9) in men 30-49, 50-64, and 65-74 years to 33.4 per 100,000 p-yrs (95% CI 31.5, 35.4) in men ≥75 years. Hip fractures were the second most common, with the incidence rate reaching 16.2 per 100,000 (95% CI 14.9, 17.6) in the ≥75-year group.

CONCLUSION

These incidence rates suggest that spine and hip fractures are a considerable disease burden for men of all ages diagnosed and/or treated for osteoporosis.

Clinical experience with intravenous zoledronic acid in the treatment of male osteoporosis: evidence and opinions

Osteoporosis frequently remains underrecognized and undertreated in men. Most osteoporosis-related fractures could be prevented if men at risk would be diagnosed, treated, and remained compliant with therapy. Bisphosphonates, the mainstay of osteoporosis treatment, are potent antiresorptive agents that inhibit osteoclast activity, suppress in vivo markers of bone turnover, increase bone mineral density, decrease fractures, and likely improve survival in men with osteoporosis. The focus of the article is on intravenous zoledronic acid, which may be a preferable alternative to oral bisphosphonate therapy in patients with cognitive dysfunction, the inability to sit upright, polypharmacy, significant gastrointestinal pathology or suspected medication noncompliance. Zoledronic acid is approved in the United States (US) and European Union (EU) as an annual 5 mg intravenous infusion to treat osteoporosis in men. The zoledronic acid 4 mg intravenous dose has been studied in the prevention of bone loss associated with androgen deprivation therapy. This article reviews the evidence for zoledronic acid, currently the most potent bisphosphonate available for clinical use, and its therapeutic effects in the treatment of men with osteoporosis.

Risk factors for diminished bone mineral density among male hemodialysis patients--a cross-sectional study

This cross-sectional study was performed to characterize the factors affecting bone mass in male hemodialysis subjects. We found that of all the factors analyzed, the strongest correlation was with body mass index. In fact, after adjusting for body weight, the correlations with bone turnover markers and sex hormones were no longer significant.

PURPOSE

Abnormalities in bone and mineral metabolism are commonly seen in patients with end-stage renal disease, reducing bone quality and raising the risk of fracture. This cross-sectional study was performed to characterize risk factors affecting bone mass among male hemodialysis subjects.

METHODS

For this cross-sectional study, we recruited 66 men from three local hemodialysis units. Subjects received dual emission X-ray absorptiometry assessment of three sites (lumbar spine, hip, and distal radius) and the values were correlated with the levels of sex hormones, non-renally excreted bone turnover markers, and mineral metabolism markers.

RESULTS

Subjects were found to have bone mineral density (BMD) reduced predominantly at the distal radius, with Z score < −2 seen in 15.4 % and T score < −2.5 in 21 % of men. Independent predictors of bone density included levels of bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase 5b, which were inversely correlated with the femoral neck Z score. Factors positively associated with an increased Z score included body mass index at all sites and free estradiol levels at the hip and distal radius. Markers of mineral metabolism (e.g., calcium, phosphate, and 25-hydroxyvitamin D) were not correlated with Z scores of any site or with bone turnover markers. After adjusting for body weight, the associations between BMD, sex hormones, and bone turnover markers were no longer significant.

CONCLUSION

We recommend that future studies seeking to assess the factors affecting bone strength among male hemodialysis subjects incorporate a weight-adjusted analysis. Additionally, dialysis-dependent men receiving dual emission X-ray absorptiometry should have the distal radius site added to the standard assessment.

Eldecalcitol: a review of its use in the treatment of osteoporosis

Eldecalcitol (1α,25[OH](2)-2β-(3-hydroxypropyloxy)vitamin D(3); ED-71; Edirol®) is an orally administered analogue of active vitamin D (calcitriol) that is available in Japan for the treatment of osteoporosis. Two randomized, double-blind, multicentre trials were conducted in patients with osteoporosis. In a placebo-controlled, dose-ranging trial, eldecalcitol significantly reduced serum bone-specific alkaline phosphatase (BALP) and serum osteocalcin, markers of bone formation, more than placebo. Eldecalcitol at a 1.0 μg/day dosage, but not at lower dosages, also significantly reduced urinary type I collagen N-telopeptide (NTX), a marker of bone resorption, more than placebo. In a comparison with alfacalcidol (a prodrug of calcitriol), eldecalcitol produced significantly greater reductions in serum BALP and urinary NTX, and had a positive effect on CT markers of femoral biomechanical properties. In the comparison with alfacalcidol, eldecalcitol 0.75 μg/day significantly reduced the 3-year incidence of vertebral fractures, with an absolute risk reduction of 4.1% over this period, representing a relative risk reduction of 26%. There was no significant difference in the rate of non-vertebral fractures. In both trials, eldecalcitol treatment was also associated with an increase in bone mineral density, whereas patients who received the comparators generally had a reduction in bone mineral density. Increases in blood calcium (to >2.6 mmol/L) and urinary calcium (to >0.1 mmol/L glomerular filtrate) were the most clinically important treatment-emergent adverse events. In the placebo-controlled, dose-ranging trial, 23% and 25% of patients in the eldecalcitol 1 μg/day group had increased blood and urinary calcium compared with 7% and 7%, 6% [corrected] and 9%, and 0% and 1.9% in the eldecalcitol 0.5 and 0.75 μg/day, and placebo groups, respectively. In the comparison with alfacalcidol, 21.0% and 13.5% of eldecalcitol 0.75 μg/day and alfacalcidol 1.0 μg/day recipients had increased blood calcium, whereas hypercalcaemia (defined as a serum calcium >2.9 mmol/L) occurred in 0.4% and urolithiasis in 1.3% of eldecalcitol recipients over 36 months of treatment. Eldecalcitol is an efficacious treatment for patients with osteoporosis that should be further investigated in head-to-head trials with other recommended first-line pharmacological treatments.

Are we missing osteoporosis-related vertebral fractures in men?

STUDY DESIGN

Retrospective study.

PURPOSE

To assess the prevalence of osteoporosis related spinal fractures among Saudi Arabian males.

OVERVIEW OF LITERATURE

Vertebral fractures are the most common complication of osteoporosis and is the first sign in both sexes and only 25 to 30% of radiographically observed vertebral deformities are recognized.

METHODS

We analyzed the chest radiographs of consecutive Saudi Arabian men ≥ 50 years and who visited the emergency room of King Fahd University Hospital, Al Khobar, Saudi Arabia for a period of 12 months between November 1, 2007 and October 31, 2008. The site and type of fractures were classified as per the semi-quantitative technique. The other data retrieved from the medical records of patients included medications and clinical investigations for osteoporosis.

RESULTS

Nine hundred seventy chest radiographs were performed during the study period and 876 radiographs could be analyzed. One hundred fifteen patients (13.1%) had 157 fractures. The mean age was 67.85 ± 10.1 years. There was more than one fracture in 21 patients (18.2%). The majority of fractures (n = 102, 64.9%) were observed in thoracic spine. Seventy-one (45.2%) fractures were classified as mild, 54 (34.4%) were moderate and 32 (20.4%) were severe. For 26 (22.6%) patients, the report of the radiologist highlighted the fracture.

CONCLUSIONS

Saudi Arabian males with osteoporosis continue to be missed despite the high prevalence osteoporosis leading to vertebral fractures. We believe it is important for physicians to identify vertebral fractures early and treat then appropriately before an extremity fracture occurs with high mortality.

Vitamin D Status and Response to Daily 400 IU Vitamin D3 and Weekly Alendronate 70 mg in Men and Women with Osteoporosis

Background

Suboptimal vitamin D status is common in elderly individuals. However, the extent of vitamin D inadequacy in men and women being treated for osteoporosis in a family practice setting has not been well characterized.

Objective:

To describe the distribution of serum 25-hydroxyvitamin D (25-[OH] D) in Canadian men and postmenopausal women with osteoporosis taking 400 IU or less of vitamin D daily and to evaluate the safety, tolerability, and impact of vitamin D3 supplementation 400 IU daily taken concurrently with alendronate sodium 70 mg weekly.

Methods:

This was a prospective, single-cohort, open-label, multicenter study. Community-dwelling men and postmenopausal women with osteoporosis were recruited at 197 sites across Canada. Patients received vitamin D3 400 IU/day supplementation coadministered with alendronate 70 mg/wk for 16 weeks. The primary outcome was the distribution of serum 25-(OH) D at baseline. Secondary outcome measures included changes from baseline in serum 25-(OH) D levels, adherence to study treatments, and incidence of treatment-related adverse events (AEs).

Results:

Of the 681 patients included in the analysis, 485 (71.2%) completed the study. Patients were predominantly female (83.1%) with a mean (SD) age of 67.6 (10.7) years. At baseline, mean (SD) serum 25-(OH) D concentration was 25.4 (9.9) ng/mL and 68.0% of the patients had inadequate (less than 30 ng/mL) vitamin D status. At week 16, concentrations increased by 35.1% to 31.2 (9.2) ng/mL (p < 0.001) and the proportion of patients with inadequate 25-(OH) D levels was reduced to 47.0%. Adherence to the treatment regimen was high (greater than 95%). Gastrointestinal disorders were the most frequently reported (6.9%) treatment-related AEs.

Conclusions:

About two thirds of patients previously diagnosed with osteoporosis have inadequate vitamin D status. A treatment regimen consisting of alendronate 70 mg/wk administered with daily vitamin D3 400 IU supplementation significantly increased patients' serum 25-(OH) D levels, but 47% did not achieve optimal levels. These results support both the National Osteoporosis Foundation and Osteoporosis Canada recommendations for higher vitamin D supplement doses (at least 800 IU daily) in osteoporotic patients receiving pharmacologic therapy for osteoporosis and for monitoring their serum 25-(OH) D response.

Inhibition of sclerostin by monoclonal antibody increases bone formation, bone mass, and bone strength in aged male rats

The purpose of this study was to evaluate the effects of sclerostin inhibition by treatment with a sclerostin antibody (Scl-AbII) on bone formation, bone mass, and bone strength in an aged, gonad-intact male rat model. Sixteen-month-old male Sprague-Dawley rats were injected subcutaneously with vehicle or Scl-AbII at 5 or 25 mg/kg twice per week for 5 weeks (9-10/group). In vivo dual-energy X-ray absorptiometry (DXA) analysis showed that there was a marked increase in areal bone mineral density of the lumbar vertebrae (L(1) to L(5) ) and long bones (femur and tibia) in both the 5 and 25 mg/kg Scl-AbII-treated groups compared with baseline or vehicle controls at 3 and 5 weeks after treatment. Ex vivo micro-computed tomographic (µCT) analysis demonstrated improved trabecular and cortical architecture at the fifth lumbar vertebral body (L(5) ), femoral diaphysis (FD), and femoral neck (FN) in both Scl-AbII dose groups compared with vehicle controls. The increased cortical and trabecular bone mass was associated with a significantly higher maximal load of L(5) , FD, and FN in the high-dose group. Bone-formation parameters (ie, mineralizing surface, mineral apposition rate, and bone-formation rate) at the proximal tibial metaphysis and tibial shaft were markedly greater on trabecular, periosteal, and endocortical surfaces in both Scl-AbII dose groups compared with controls. These results indicate that sclerostin inhibition by treatment with a sclerostin antibody increased bone formation, bone mass, and bone strength in aged male rats and, furthermore, suggest that pharmacologic inhibition of sclerostin may represent a promising anabolic therapy for low bone mass in aged men.

Risk factors for osteoporosis in healthy males

We investigated the correlation of bone mineral density (BMD) with risk factors and laboratory parameters (e.g., markers of bone turnover, biochemical indicators, and hormonal factors) in males without secondary osteoporosis. A total of 105 males were divided into two groups: Group 1 (n: 52) <60 years, and Group 2 (n:53) ≥ 60 years. The subjects were evaluated for risk factors (European Vertebral Osteoporosis Study (EVOS) and BMD) and for biochemical (i.e., blood calcium, blood phosphorus, urinary calcium/phosphorus, creatinine clearance, osteocalcin, and deoxypyridinoline) and hormonal markers (follicle-stimulating hormone [FSH], luteinizing hormone [LH], free testosterone [fT], and parathyroid [PTH]) of bone mineral metabolism. In Group 1, no significant relationship was observed between risk factors for both lumbar and femoral neck BMDs and risk factors and laboratory parameters (p>0.05). On the other hand, we observed in Group 2 a significant positive correlation between lumbar BMD and BMI, BMI at 25 years of age, and fT; in the same group, a negative correlation between lumbar BMD and deoxypyridinoline (p<0.05) was seen. We saw a significant positive correlation between femoral neck BMD and BMI, BMI at 25 years of age, and daily activities of life in Group 2. In addition, we saw a negative correlation between femoral neck BMD and height difference, fT, LH, and deoxypyridinoline in Group 2 (p<0.05). Risk factors for male osteoporosis were multifactorial: demographic and clinical data (difference of height, BMI, physical activity) together with biochemical and hormonal data (deoxypyridinoline, fT, LH) were significant, and most of the risk factors analyzed were related to bone loss in the proximal femur.

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.

Correlates of osteoporosis in chronic obstructive pulmonary disease: An underestimated systemic component

RATIONALE

Chronic obstructive pulmonary disease (COPD) patients are at increased risk of osteoporosis. Osteoporosis is under diagnosed and under treated in these patients and the underlying mechanisms remain unclear. To date, screening recommendations for osteoporosis in COPD patients are not available.

OBJECTIVES

To examine the prevalence of drug treatment of bone abnormalities as well as the clinical determinants of osteoporosis in COPD.

METHODS

COPD patients (n=554) consecutively entering pulmonary rehabilitation were included in this cross-sectional study. Medical history, current medication use, smoking status, lung function, bone mineral density, body composition and other clinical characteristics were assessed before entering pulmonary rehabilitation. Univariate- and multivariate multinomial logistic regression analyses were used to determine correlates of osteoporosis.

MAIN RESULTS

Twenty-one percent of patients had osteoporosis and 41% had osteopenia. Osteoporosis was pharmacologically under treated (82% of osteoporotic patients were not receiving bone medication). Independent predictors of osteoporosis were cachexia (OR: 12.1; 95%CI: 4.5-32.7; p<0.001), age between 55 and 65 years (OR: 6.0; 95%CI: 2.2-16.3; p<0.001) and over 65 years (OR: 11.7; 95%CI: 4.1-33.1; p=<0.001). Overweight (OR: 0.1; 95%CI: 0.05-0.4; p=0.001) and obesity (OR: 0.78; 95%CI: 0.02-0.4; p=0.002) showed a substantial protective effect.

CONCLUSIONS

The majority of COPD patients with osteoporosis entering pulmonary rehabilitation did not receive pharmacological treatment for osteoporosis. Cachectic COPD patients should be screened for osteoporosis, especially when over 55 years of age.

The relationship between testosterone deficiency and frailty in elderly men

The vulnerable health status usually preceding the onset of overt disability is often referred to as frailty. A stringent definition is elusive but it can be viewed as a physiological syndrome, characterized by decreased reserve and diminished resistance to stressors, resulting from a cumulative decline across multiple physiological systems and causing vulnerability to adverse outcomes. Elements of frailty are related to the neurological system, metabolism, joints, bones, and muscles. Sarcopenia seems to be the major determinant of frailty. Several components of the frailty syndrome are related to loss of physiological actions of testosterone (T). T and/or its aromatized metabolite, estradiol, are necessary for maintenance of bone mineral density. Furthermore, T stimulates erythrocyte formation. T has a profound effect on body composition. Androgens promote differentiation of mesenchymal pluripotent cells into the myogenic lineage and inhibit differentiation into the adipogenic lineage. Skeletal muscles of older men are as responsive to the anabolic effects of T as of younger men. Thus, although frailty is obviously a complex syndrome, some elements are androgen-associated and these can improve in men with subnormal T levels when treated with T. Evidence suggests that T treatment in frail elderly men with low T improves body composition, quality of life, and physical function, including increased axial bone mineral density and body composition. The data available to date strongly suggest a relationship between T-deficiency and frailty and warrant further basic and clinical investigations to extend these observations to the management of elderly men with frailty.

Management of osteoporosis in the aging male: focus on zoledronic acid

Osteoporosis in the aging male remains an important yet under-recognized and undertreated disease. Current US estimates indicate that over 14 million men have osteoporosis or low bone mass, and men suffer approximately 500,000 osteoporotic fractures each year. Men experience fewer osteoporotic fractures than women but have higher mortality after fracture. Bisphosphonates are potent antiresorptive agents that inhibit osteoclast activity, suppress in vivo markers of bone turnover, increase bone mineral density, decrease fractures, and improve survival in men with osteoporosis. Intravenous zoledronic acid may be a preferable alternative to oral bisphosphonate therapy in patients with cognitive dysfunction, the inability to sit upright, or significant gastrointestinal pathology. Zoledronic acid (Reclast) is approved in the US as an annual 5 mg intravenous infusion to treat osteoporosis in men. The zoledronic acid (Zometa) 4 mg intravenous dose has been studied in the prevention of bone loss associated with androgen deprivation therapy.

MicroRNAs and micromanaging the skeleton in disease, development and evolution

MicroRNAs (miRNAs) are short, non-protein-encoding RNAs that effect post-transcriptional gene regulation by targeting messenger RNAs. miRNAs are associated with specific human diseases and help regulate development. Here we review recent advances in understanding the roles of miRNAs in skeletal malformations, including cleft palate, and in the evolution of skeletal morphologies. We propose the hypothesis that evolutionary variation in miRNA expression patterns or structural variation in miRNA binding sites in messenger RNAs can help explain the evolution of craniofacial variation among species, the development of human craniofacial disease and physiological changes leading to osteopenia that increases with ageing.

Undertreatment of osteoporosis in the oldest old? A nationwide study of over 700,000 older people

SUMMARY: We analysed data from elderly people registered in the Swedish Prescribed Drug Register to investigate whether age is associated with use of osteoporosis drugs in a nationwide population. Our results indicate an undertreatment of osteoporosis, particularly with bisphosphonates, in the oldest old in Sweden. INTRODUCTION: The aim of this study was to investigate whether age is associated with use of osteoporosis drugs in a large population of older people. METHODS: We analysed data on age, sex, type of residential area (urban/rural) and dispensed drugs for people aged >/=75 years registered in the Swedish Prescribed Drug Register from October to December 2005 (n = 731,105). Multivariate logistic regression was used to analyse whether age was associated with use of osteoporosis drugs, after adjustment for type of residential area and number of other drugs (a proxy for comorbidity). RESULTS: Osteoporosis drugs were used by 16.1% of the women and 3.4% of the men. The probability of use of bisphosphonates declined with increasing age [ORwomen = 0.36 (95% CI 0.34-0.38) and ORmen = 0.46 (95% CI 0.37-0.56) for age >/=90 years vs. 75-79 years]. Raloxifene was also negatively associated with age. Calcium + vitamin D supplements, however, showed a divergent pattern regarding age. In women, the lowest likelihood of use of calcium + vitamin D supplements occurred in the oldest old (>/=90 years). CONCLUSIONS: Our results indicate an undertreatment of osteoporosis, particularly with bisphosphonates, in the oldest old in Sweden. Future research is needed for understanding the mechanisms behind this age effect.

High risk of osteoporosis in male patients with eating disorders

OBJECTIVE

Osteoporosis has traditionally been considered a female problem. This study's purpose is to evaluate bone mineral density (BMD) in males with eating disorders.

METHOD

Charts of 70 consecutive males admitted to an eating disorder program were reviewed. Females admitted during the same time period were used for comparison. BMD was measured by dual-energy X-ray absorptiometry.

RESULTS

Thirty-six percent (19/53) had osteopenia and 26% (14/53) had osteoporosis at the lumbar spine. A disproportionate number of males with anorexia restricting or binge/purge subtype (ANR/ANB) had osteoporosis, as well as those of older age, lower weights, and longer illness duration. BMD for ANR and ANB males was significantly lower than females (p = .02 and p = .03, respectively). In multivariate stepwise linear and logistic regression, lowest BMI and illness duration predicted lumbar Z-scores.

CONCLUSION

Males with ANR/ANB often have severe bone disease, which is worse than females, and is best predicted by a patient's lowest BMI and illness duration.

Characteristics of males over 50 years who present with a fracture: epidemiology and underlying risk factors

Osteoporosis and fragility fractures in men constitute a considerable burden in healthcare. We have reviewed 2035 men aged over 50 years with 2142 fractures to clarify the epidemiology of these injuries and their underlying risk factors. The prevalence of osteoporosis ranged between 17.5% in fractures of the ankle and 57.8% in those of the hip. The main risk factors associated with osteoporosis were smoking (47.4%), alcohol excess (36.2%), body mass index < 21 (12.8%) and a family history of osteoporosis (8.4%). Immobility, smoking, self-reported alcohol excess, a low body mass index, age >/=72 and loss in height were significantly more common among men with fractures of the hip than in those with fractures elsewhere.

Are cancer survivors/patients knowledgeable about osteoporosis? Results from a survey of 285 chemotherapy-treated cancer patients and their companions

OBJECTIVE

This study assessed osteoporosis knowledge deficits among cancer patients and their spouses/partners.

DESIGN

Single-institution survey (modified version of the Osteoporosis Knowledge Assessment Tool).

SETTING

The Mayo Clinic in Rochester, Minnesota.

PARTICIPANTS

Consecutive chemotherapy-treated cancer patients (n = 285) with their spouses/partners (n = 101).

OUTCOME MEASURES

The main outcome was the percentage of cancer patients who incorrectly conveyed that 1) cancer treatment strengthens bones (or did not know) and/or 2) male cancer patients are not at risk for osteoporosis (or did not know).

ANALYSES

Test scores and 95% confidence intervals (CI) as well as the correlation between patient and spouse/partner scores, are reported.

RESULTS

39% of patients (95% CI, 32% - 48%) thought cancer treatment strengthened bones or did not know, and 39% (95% CI, 32% - 48%) either answered that osteoporosis almost never occurred in men or did not know. The mean correct score on the modified Osteoporosis Knowledge Assessment Tool was 6.7 (95% CI, 6.7, 7.9), and scores from patients correlated with companion scores (r = 0.42; P < .001).

CONCLUSIONS AND IMPLICATIONS

Chemotherapy-treated cancer patients and their companions have knowledge deficits concerning osteoporosis. Educational initiatives to increase awareness may be of value.

Risks of cancer among a cohort of 23,935 men and women with osteoporosis

Low hormone levels among persons with osteoporosis may decrease risk of some cancers. Other osteoporosis risk factors, such as smoking and alcohol consumption, however, may increase risk. As these deleterious factors are more often associated with osteoporosis diagnosed prior to age 70 years, cancer risk may be higher in these younger persons than in the general population. To examine this hypothesis, a cohort study of 23,935 persons with osteoporosis was conducted in Denmark. Patients hospitalized with osteoporosis between 1978 and 1993 were identified in the Danish Inpatient Register. Linkage to the Danish Cancer Registry identified all cancer outcomes through 2003. Standardized incidence ratios (SIR) and 95% confidence intervals (95%CI) were calculated to compare cancer incidence in the cohort with that in the general population. Persons diagnosed prior to age 70 years were at increased cancer risk (women: SIR = 1.11, 95%CI = 1.04-1.19; men: SIR = 1.31, 95%CI = 1.13-1.50) due, in part, to increased risks of cancers of the buccal cavity, esophagus, liver, pancreas and lung. Persons diagnosed at ages 70 and older were at decreased risk (women: SIR = 0.91, 95%CI = 0.87-0.96; men: SIR = 0.89, 0.77-1.01) due, in part, to decreased risks of breast, endometrial, colon, rectal and brain cancers in women and prostate cancer in men. These results suggest that risk factors associated with earlier onset osteoporosis may be associated with increased risk of cancer. Conversely, factors associated with later onset osteoporosis may be related to a decreased risk of cancer.