June 2, 2023

Osteoporosis is less common in men but the risk of dying from complications of hip, vertebral, and other major fractures is higher in them than in women.
This is partly related to the older age and the presence of other illnesses (so-called co-morbid conditions) at the time that the fractures occur in men. Studies have also shown that men are less likely to be evaluated or given medications that prevent bone loss after a hip fracture.
The decision to start drug therapy for osteoporosis in men is done carefully by the physician and after a thorough explanation to the patient.
Selection of patients for drug therapy is based on the risk for fracture, presence of risk factors, and/or bone mineral density. Fracture Risk Assessment (FRAX) criteria and Osteoporosis Guidelines are used. Underlying diseases or conditions that cause or aggravate osteoporosis in males will be considered, like hypogonadism, tumor of the pituitary gland, or history of surgical removal of testicles as part of management cancer of the prostate. The level of the male hormone testosterone is tested if indicated.
Likewise in postmenopausal women, co-morbid conditions and risk factors are identified before drug therapy is started. For the most part, the treatment approach in both genders is similar. There are no high quality studies that made head-to-head drug comparisons of the individual drugs so that the choice is based upon efficacy, safety, cost, convenience, and patient-related factors. These drugs have an effect on bone mineral density and/ or inhibition of bone resorption.
Drugs for osteoporosis could be taken orally or by injection. Treatment is always individualized.
Biphosphonates – considered the first line of treatment for most patients at risk for fracture. They have proven efficacy, favorable cost, and long-term safety information. These include alendronic acid, risedronic acid, etidronic acid, ibandronic acid, and zoledronic acid;
Hormonal therapy – estrogen with progesterone and testosterone;
Parathyroid hormone – teriparatide, which is approved for the treatment of postmenopausal osteoporosis and for men at high risk for fractures, with severe osteoporosis, and not responding to other drugs; and
Selective estrogen receptor modulator – raloxifene, lasofoxifene, bazedoxifene, denosumab, romosozumab, strontium ranelate, tibolone, and calcitonin.
The list may be long and the names may sound foreign but it is good to be familiar with the name of the drugs and to know that there are options.
Monitoring of response to treatment includes BMD measurement; laboratory tests for bone turnover markers when deemed necessary, not routinely done.
Vertebral imaging/x-ray is done if there is documented loss of height, presence of vertebral pain (pain in the back), changes in posture, chest x-ray abnormalities, re-evaluation of treatment, presence of fracture of the vertebrae while patient is not on drug therapy.
Discuss with your doctor how your response and progress will be monitored. Ask about the side effects of the drugs, drug interactions, and when and how to take the medication.
Surgery is considered when acute symptomatic vertebral fractures are not responsive to conservative treatment. It can relieve pain. It is not, however, a first-line treatment for fracture of the vertebrae (backbones) because the adjacent ones are also osteoporotic and are themselves at high risk of fracture.
Osteopenia and osteoporosis are silent ailments until pain or fractures occur. Treatment starts at an early age, when we lay the foundation for strong bones until the third decade of our life. After this period, as studies have shown, bone density loss and bone thinning can occur.

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