OsteoEd

Male Osteoporosis

A 72-year-old white man presents for follow-up after a visit to the Emergency Department, where he was seen after a fall at home. He is bruised but recovering. He has chronic obstructive pulmonary disease that has required a 2-week course of prednisone twice in the past 3 years. Otherwise, his disease has been well managed with an inhaled bronchodilator. He has no known history of persistent back pain or fracture. Except for mowing his lawn, he does minimal exercise. You gather the following information:

• Medications:
  • Ipratropium bromide metered dose inhaler
  • 2 puffs QID
• Habits:
  • Cigarettes, 60 pack-year history, currently smoking
  • Alcohol, less than 1 drink per week
• Family History:
  • His mother died of complications of a hip fracture at age 77
• Exam:
  • Weight 166 pounds
  • height 69 inches
  • pulse 80
  • blood pressure 150/90
• Neck:
  • Thyroid not palpable
• Chest:
  • Bilateral gynecomastia, 3 cm, non-tender
• Lung:
  • Prolonged expiratory phase
• GU:
  • Normal testicles
• Rectal:
  • Prostate smooth, somewhat enlarged

You are concerned about the fall and the possibility that he may be at risk for osteoporosis.

Click an answer under each question.

1. How many risk factors for osteoporosis does this patient have?

   • Option A One or two
   • Option B Three or four
   • Option C Four or more

2. What is the relative prevalence of osteoporosis in men as compared with women?

   • Option A Equal
   • Option B 1/3
   • Option C 1/5

3. Should you screen this patient for osteoporosis with a dual X-ray absorptiometry (DXA) scan?

   • Option A Yes
   • Option B No

4. What is this patient's 10 year risk of a major osteoporotic fracture?

   • Option A 5%
   • Option B 10%
   • Option C 15%

5. On further questioning, this patient reports decreased libido and reduced erections for the past year. The onset of his symptoms was gradual, and he denies fatigue or sleep disturbance, aside from nocturia two to three times a night. Based on the patient's clinical presentation, you suspect testosterone deficiency. How should you test for this?

   • Option A Free and total testosterone levels
   • Option B Random total testosterone level
   • Option C Morning total testosterone level
   • Option D Random luteinizing hormone level
   • Option E Pooled random total testosterone levels

6. A random total testosterone level is 150 ng/dL and a follow-up luteinizing hormone level is 40 mIU/mL. You diagnose primary hypogonadism, i.e., testicular failure. What additional work-up should be considered?

   • Option A Testicular ultrasound
   • Option B DXA scan of lumbar spine and hip
   • Option C DXA scan of distal radius
   • Option D Follicle-stimulating hormone level

7. The patient's DXA scan at the lumbar spine shows a T-score of -3.36 and a Z-score of -1.8. Which of the following studies should be done?

   • Option A Thyroid-stimulating hormone (TSH)
   • Option B Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP)
   • Option C Complete metabolic panel, including calcium and phosphate
   • Option D 24-hour urine calcium
   • Option E All of the above

8. What treatment should be offered to this patient?

   • Option A Estrogen supplementation
   • Option B Testosterone replacement
   • Option C Calcium, 2,000 mg per day
   • Option D Vitamin D, 400 IU per day
   • Option E Hydrochlorothiazide

9. What is the best strategy for beginning androgen replacement in this patient?

   • Option A Testosterone in hydroalcoholic gel, 25 mg per day
   • Option B Testosterone enanthate, 150 mg intramuscularly every 14 days
   • Option C Methyltestosterone, 20 mg p.o. daily
   • Option D Transdermal testosterone system, 5 mg per day
   • Option E Any of the above

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