Even though we are facing an aging population with an expected rise in cases of osteoporotic hip fractures, there is still poor awareness regarding osteoporosis. Male osteoporosis, being less common than female osteoporosis, continues to receive little attention in terms of screening, diagnosis and treatment. This can hopefully be remedied by increased clinical data in the field of osteoporosis. There is increasing interest in the field of osteoporosis in Malaysia. The Malaysian clinical guidance for the management of osteoporosis included some data regarding the incidence and treatment for male osteoporosis16. A study from Malaysia examined the age-related changes in bone health in men and women > 50 years old using quantitative ultrasound (QUS), and the authors found significant age-related decline of bone health indices observed in females but not in males17. Yeap et al examined the depth and sources of osteoporosis knowledge among the public in Malaysia using a self-administered questionnaire distributed among attendees of health forums18. They found that 87.1% of attendees have heard of osteoporosis, and significantly more women than men (p = 0.015) have heard of osteoporosis. Data from other Asian countries are available as well, with the Asian Osteoporosis comparing hip fracture data from Hong Kong SAR, Singapore, Malaysia, and Thailand (Chiang Mai) in 199719. The study reported the age-adjusted incidence rate for men and women as follows (per 100,000): Hong Kong 180 and 459, Singapore 164 and 442, Malaysia 88 and 218, Thailand 114 and 289; compared with US Whites 187 men and 535 women. In our study, the incidence of male osteoporotic hip fracture was 28.6%, which was similar to other studies. In our study, as expected, the proportion of women with osteoporotic hip fractures outnumbered the men. Both groups have a mean age of > 70 years. However, there was no statistically significant difference in mortality rates among the men and women in our study. This may be due to both groups being in the elderly group with co-morbidities.
Our current study showed that 50% of our male patients and 13% of female patients had secondary osteoporosis. This finding is consistent with reported data of 30% of post-menopausal women and 50–80% of men were found to have secondary osteoporosis20. The osteoporosis treatment may differ for different underlying conditions, and certain conditions and medication prescription may prompt the clinician to consider bone health issues20. Ryan et al examined 234 men diagnosed with osteoporosis via DXA and measured 25-OH-vitamin D, testosterone, luteinizing hormone, follicular stimulating hormone (FSH), thyroid stimulating hormone (TSH), and spot urinary calcium-to-creatinine. 75% had secondary osteoporosis including hypogonadism, vitamin D deficiency, hypercalciuria, subclinical hyperthyroidism, and hyperparathyroidism21. The authors showed that a modest clinical and laboratory evaluation of osteoporotic men will provide useful information in identifying secondary osteoporosis. History, physical examination and basic laboratory investigation should be performed, and additional testing as appropriate. Colangelo et al proposed that after history and physical examination, a first-level laboratory test of full blood count, erythrocyte sedimentation rate (ESR), serum calcium, phosphorus, creatinine, alkaline phosphatase, total protein with electrophoresis and a 24-hour urinary calcium should be performed22. Following that, ionized calcium, parathyroid hormone (PTH), 25-OH-vitamin D, TSH, dexamethasone suppression test, serum and urinary immunofixation, anti-transglutamase antibodies, testosterone in men, serum tryptase and ferritin, should be considered clinically.
There were three men on glucocorticoids and one man on ADT in our study. Patients on these medications are recommended for osteoporosis evaluation (including Fracture Risk Assessment Tool (FRAX), BMD), calcium and vitamin D supplementation, and treatment with bisphosphonate, denosumab or teriparatide as appropriate22. Adler et al examined 115 men on ADT referred for DXA and found 33% would need osteoporosis treatment23. More clinicians need to be made aware of osteoporosis evaluation when prescribing medications such as ADT and glucocorticoids.
There has been much development in the treatment of post-menopausal osteoporosis, but data for male osteoporosis are notable as well. There is less evidence for treatment of male osteoporosis due to the smaller number of male participants in clinical trials. Evidence-based treatment for male osteoporosis are bisphosphonates (alendronate, risedronate, zoledronic acid), denosumab and teriparatide24–30. There is compelling evidence that current osteoporosis treatment is equally effective in men and women, not only to increase BMD but also to prevent osteoporotic fractures31. Effective treatment for GIOP for men and for male osteoporosis on ADT include bisphosphonates, denosumab and teriparatide 28,32−33. Testosterone replacement is indicated for symptomatic hypogonadal men, but data on its efficacy for fracture prevention is lacking. Thus, additional osteoporosis treatment may be needed, especially in men with very low testosterone who are at high risk of bone loss and/or men not able to receive testosterone replacement34.
However there still exists a treatment care gap between men and women. The Canadian Multicentre Osteoporosis Study found that between 1996 until 2002, 90% of men with fragility fractures remained undiagnosed and untreated for osteoporosis35. Yeap et al found that following a hip fracture, only 36.8% patients (men and women) received treatment, but out of these, 24.2% were on calcium and vitamin D only36.
There is a need to increase awareness of male osteoporosis among clinicians, so a diagnosis is made, and appropriate treatment administered, especially among those with fragility fractures and those at risk of secondary osteoporosis. Other guidelines also recommend personalized assessment, obtaining DXA and FRAX in those at risk of osteoporosis, and starting appropriate treatment37–38.The Canadian Osteoporosis Society recommends screening men > 65 years old for osteoporosis, while the National Osteoporosis Foundation and International Society for Clinical Densitometry and the Endocrine Society recommend screening all men > 70 years old or men aged 50–69 years old with risk factors38. Alswat et al analyzed the rate of osteoporosis screening between men and women in primary care, and men had a screening rate of 18.4% compared to females screening rate of 60%39. De Martinis and colleagues also highlighted the gender bias in osteoporosis screening, and found that among those referred for osteoporosis screening at their center, 94.5% were women while only 5.4% were men. They also found that men were under-screened for osteoporosis, exhibit secondary osteoporosis more frequently, and had a higher calculated risk for hip fractures compared to women40.
The limitations in our study are:
The death outcome was collected at inpatient and at 3 month-follow up visit only. This may not reflect the one-year mortality rate.
Data collection was temporarily halted during the height of the Coronavirus Disease 2019 (COVID-19) pandemic as the fracture liaison services was temporarily stopped. The number of cases in this study may not reflect the true incidence of male osteoporotic hip fractures.
Some investigations results were not available for the secondary osteoporosis screening, and the number of secondary osteoporosis may not be truly reflected.