A 71-year-old man comes to the physician for routine follow-up. He has no current health concerns or complaints. His medical problems include moderate chronic obstructive pulmonary disease, prostate cancer, hypothyroidism, and type 2 diabetes mellitus. He also reports a humeral fracture after falling off a 10-foot ladder about 5 years ago. His medications include tiotropium, leuprolide, levothyroxine, and metformin. His last HbA1c was 7.5% and thyroid-stimulating hormone level was 4.2 µU/mL about 6 months ago.
Which of the following is this patient's strongest risk factor for osteoporosis?

Question

A 71-year-old man comes to the physician for routine follow-up.  He has no current health concerns or complaints.  His medical problems include moderate chronic obstructive pulmonary disease, prostate cancer, hypothyroidism, and type 2 diabetes mellitus.  He also reports a humeral fracture after falling off a 10-foot ladder about 5 years ago.  His medications include tiotropium, leuprolide, levothyroxine, and metformin.  His last HbA1c was 7.5% and thyroid-stimulating hormone level was 4.2 µU/mL about 6 months ago.
Which of the following is this patient's strongest risk factor for osteoporosis?

Quizplus · Accepted Answer

11ec193a_97c7_e4b4_853d_05c997a0c288_MD0002_00 Although men have a lower incidence of osteoporosis compared to women, they are still at risk. Common osteoporosis risk factors in men are shown in the table. Hypogonadism is the best known risk factor as it increases bone turnover and decreases bone density. Congenital hypogonadism can be due to conditions such as Klinefelter syndrome or cryptorchidism. Acquired hypogonadism is usually due to organic disorders (eg, mumps, cirrhosis, chronic renal failure, HIV), localized radiation, androgen deprivation therapy (eg, leuprolide), or surgical orchiectomy. Androgen deprivation therapy can decrease bone mineral density within 6-9 months of starting the drug. Osteoporotic skeletal fractures occur in up to 20% of men within 5 years of starting androgen deprivation therapy. Therefore, all patients on hypogonadism-inducing agents should take daily calcium (1200 mg) and oral vitamin D therapy for osteoporosis prevention. Routine osteoporosis screening in men is controversial. Most guidelines do not recommend routine screening unless men have the risk factors shown in the table. Testosterone therapy is usually recommended for patients with symptomatic hypogonadism, osteoporosis, and no contraindications to testosterone therapy. Pharmacologic therapy (eg, bisphosphonates) is recommended as first-line treatment for men with osteoporosis (T-score < -2.5 or fragility fracture) and no symptomatic hypogonadism or for hypogonadal men with contraindications to testosterone therapy. (Choice A) Chronic obstructive pulmonary disease and other chronic respiratory diseases are not known to increase a man's risk for osteoporosis by themselves. However, corticosteroids used for treating these conditions can increase osteoporosis risk. (Choice B) The association between diabetes and osteoporosis is controversial as no current evidence shows a definite link between diabetes and increased fracture risk. (Choice D) Fractures that occur with minimal trauma, especially in the elderly, are often associated with osteoporosis. However, this patient's fracture occurred after significant trauma and is less likely to correlate with low bone mineral density. (Choice E) Untreated hyperthyroidism is a clinical risk factor for osteoporosis. Similarly, hypothyroidism treated with excessive thyroid replacement therapy can also increase osteoporosis risk. However, this patient's thyroid-stimulating hormone is in the euthyroid range, making this less likely. Educational objective: Routine screening for osteoporosis in men remains controversial. However, osteoporosis screening and potential treatment should be pursued in men with risk factors (eg, androgen deprivation therapy, chronic corticosteroid use, low-trauma fractures). Osteoporotic skeletal fractures occur in up to 20% of men within 5 years of starting androgen deprivation therapy. __________ References: Male osteoporosis: diagnosis and fracture risk evaluation. (http://www.ncbi.nlm.nih.gov/pubmed/19176288) Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. (http://www.ncbi.nlm.nih.gov/pubmed/18458281)

A 71-Year-Old Man Comes to the Physician for Routine Follow-Up