Common Questions
What are treatment options for osteoporosis in men?
Non-pharmacologic treatments, such as adequate calcium (1,200 mg per day), vitamin D (1,000 IU per day, with the goal of a serum 25-hydroxy vitamin D level of 30 ng/mL or higher), and exercise, are required in elderly men with osteoporosis. Currently accepted pharmacologic therapies include testosterone replacement therapy for hypogonadal men and alendronate.
Testosterone replacement therapy. Overt hypogonadism has been associated with osteoporosis in men (1). Androgen replacement in hypogonadal men decreases bone resorption and increases bone mass (2-5). In one study, bone mineral density (BMD) increased by 5 percent over the 12- to 18-month treatment of young hypogonadal men (median age 58) (6).
In elderly men with age-related declines in testosterone, one study showed that only those with a serum testosterone level below 300 ng/dL had an increase in BMD with testosterone treatment that was statistically significant (7). Another study of elderly hypogonadal men demonstrated an increase of BMD in the lumbar spine of 10.2% and 2.7% of the hip after 36 months of testosterone therapy in those with initial testosterone levels < 350 ng/dl) (8). Presently, there are no studies of the effect of androgen therapy on fracture rates in any group of osteoporotic men.
Alendronate and risedronate. Alendronate's ability to improve bone density and reduce vertebral fractures has been demonstrated in a randomized controlled trial (9). The subjects were men with mean T-scores of -2.0 or less and were randomized to receive alendronate 10 mg daily or placebo for two years. Findings of this study include:
- Statistically significant increase in BMD at the lumbar spine versus placebo (7.1 percent versus 1.8 percent)
- Statistically significant increase in BMD at the femoral neck versus placebo (2.5 percent versus 0.1 percent)
- Significantly reduced spine fractures in the alendronate group (measured by quantitative methods)
- Equivalent response in men with both normal and hypogonadal testosterone levels
A meta-analysis has also shown a benefit for alendronate therapy (10). Risedronate shows a similar benefit (11). The U.S. Food and Drug Administration has approved the use of alendronate daily (10 mg a day) or once weekly (70 mg weekly) and risedronate (35 mg weekly) for the treatment of osteoporosis in men. Among hypogonadal men, alendronate is usually reserved for those with a contraindication to testosterone replacement (11). Ibandronate is not FDA approved for use in men.
Zoledronic acid. Zoledronic acid was FDA approved in 2008 for the treatment of osteoporosis in men. This was based on a 2 year double-blind head-to-head randomized trial of >300 men (ages 25-86) with osteoporosis. The men were randomized to either zoledronic acid 5 mg IV/year or a weekly oral bisphosphonate (active control group). The increase in BMD of the spine was similar in both groups (6.1% in the zoledronic acid group and 6.2% in the active control group) demonstrating that zoledronic acid was not inferior to oral bisphosphonates.
Teriparatide. Teriparatide (parathyroid hormone) is also FDA approved for treatment of osteoporosis in men that is either primary or due to hypogonadism. It increases bone density but its effect on fracture risk in men is not known. Due to concerns about safety (e.g., risk of osteosarcoma) and cost, its role in treatment is uncertain (12). At this time, it is reserved for patients at very high risk for fracture who have not responded to a bisphosphonate.
- Kaufman JM, Johnell O, Abadie E, Adami S, Audran M, Avouac B, et al. Background for studies on the treatment of male osteoporosis: State of the art. Ann Rheum Dis 2000; 59(10): 765-72.
- Finkelstein JS, Klibanski A, Neer RM, et al. Increases in bone density during treatment of men with idiopathic hypogonadotropic hypogonadism. J Clin Endocrinol Metab 1989; 69: 776.
- Behre HM, Kliesch S, Leifke F, et al. Long-term effect of testosterone therapy on bone mineral density in hypogonadal men. J Clin Endocrinol Metab 1997; 82: 2386.
- Greenspan SL, Oppenheim DS, Klibanski A. Importance of gonadal steroids to bone mass in men with hyperprolactinemic hypogonadism. Ann Intern Med 1989; 110: 526.
- Sih R, Morley JE, Kaiser FE, Perry HM 3rd, Patrick P, Ross C. Testosterone replacement in older hypogonadal men: A 12 month randomized controlled trial. J Clin Endocrinol Metab 1997; 8: 1661-7.
- Katznelson L, Finkelstein JS, Schoenfeld DA, et al. Increase in bone density and lean body mass during testosterone administration in men with acquired hypogonadism. J Clin Endocrinol Metab 1996; 81: 4358.
- Snyder PJ, Peachey H, Hannoush P, Berlin JA, Loh L, Holmes JH, et al. Effect of testosterone treatment on bone J Clin Endocrinol Metab. mineral density in men over 65 years of age 1999; 84(6): 1966-72.
- Amory JK, Watts NB, Easley KA, Sutton PR, et al. Exogenous testosterone or testosterone with finasteride increases bone mineral density in older men with low serum testosterone. J Clin Endocrinol Metab 2004; 89: 503-510.
- Orwoll E, Ettinger M, Weiss S, Miller P, Kendler D, Graham J, et al. Alendronate for the treatment of osteoporosis in men. N Engl J Med 2000; 343: 604-10.
- Sawka AM, Papaioannou A, Adachi JD, Gafni A, Hanley DA, Thabane L. Does alendronate reduce the risk of fracture in men? A meta-analysis incorporating prior knowledge of anti-fracture efficacy in women. BMC Musculoskelet Disord 2005; 6: 39.
- Finkelstein JS. Diagnosis and treatment of osteoporosis in men. 2008. Available online.
- Orwoll ES, Scheele WH, Paul S, et al. The effect of teriparatide [human parathyroid hormone (1-34)] therapy on bone density in men with osteoporosis. J Bone Miner Res 2003; 18: 9.