A 65-year-old man comes to the office a month after sustaining a nondisplaced left femoral neck fracture in a ground-level fall. He underwent internal fixation of the left hip and was discharged to a skilled nursing facility. The patient is now able to ambulate with a cane. He has no bone pain, previous fractures, diarrhea, or loss of height. Medical history is significant for hypertension treated with hydrochlorothiazide. The patient does not use tobacco or alcohol. There is no family history of osteoporosis or thyroid disorders. Since hospital discharge, the patient has taken adequate amounts of calcium and vitamin D via diet and oral supplementation.
Vital signs are normal. The surgical scar has healed well and physical examination is unremarkable.
Laboratory tests show normal complete blood count, basic metabolic panel, hepatic function tests, TSH, 24-hour urinary calcium, and 25-hydroxyvitamin D. DXA reveals T-scores of −2.0 in the femoral neck and −2.5 in the lumbar spine. Plain radiograph of the spine is normal.
Which of the following is the most appropriate next step in evaluation of this patient?

Question

A 65-year-old man comes to the office a month after sustaining a nondisplaced left femoral neck fracture in a ground-level fall.  He underwent internal fixation of the left hip and was discharged to a skilled nursing facility.  The patient is now able to ambulate with a cane.  He has no bone pain, previous fractures, diarrhea, or loss of height.  Medical history is significant for hypertension treated with hydrochlorothiazide.  The patient does not use tobacco or alcohol.  There is no family history of osteoporosis or thyroid disorders.  Since hospital discharge, the patient has taken adequate amounts of calcium and vitamin D via diet and oral supplementation.
Vital signs are normal.  The surgical scar has healed well and physical examination is unremarkable.
Laboratory tests show normal complete blood count, basic metabolic panel, hepatic function tests, TSH, 24-hour urinary calcium, and 25-hydroxyvitamin D.  DXA reveals T-scores of −2.0 in the femoral neck and −2.5 in the lumbar spine.  Plain radiograph of the spine is normal.
Which of the following is the most appropriate next step in evaluation of this patient?

Quizplus · Accepted Answer

11ec193a_97d3_a49e_853d_65068be105ff_MD0002_00 In contrast to women, in whom osteoporosis is usually due to physiologic bone loss following menopause, osteoporosis in men is more likely due to secondary causes (eg, glucocorticoid use, excessive alcohol intake). As many as two-thirds of elderly men with hip fractures have hypogonadism, which is often not associated with other specific symptoms of testosterone deficiency (eg, changes in body hair, loss of libido). This patient with osteoporosis (low bone mineral density [BMD] on DXA) and a fragility fracture has no clear etiology for his low BMD; therefore, an early-morning serum testosterone assay is indicated. Some men with hypogonadism who have osteoporosis may benefit from testosterone replacement therapy, which increases BMD. Additional tests for men with osteoporosis should include blood cell counts, serum chemistries (eg, electrolytes, calcium, phosphorus), liver function tests, albumin and total serum protein, alkaline phosphatase, TSH, and 25-hydroxyvitamin D. A 24-hour urine calcium assay can also be considered during initial testing, but vitamin D deficiency must be corrected before this test is ordered. Some experts also recommend a parathyroid hormone level (especially in patients with hypercalcemia) and a tissue transglutaminase antibody assay (especially in patients with evidence of malabsorption). (Choice A) A common cause of osteoporosis is excess glucocorticoids. However, screening for hypercortisolism with a 24-hour urine cortisol assay is necessary only for those with clinical features of Cushing syndrome. Cushing syndrome (Choice B) Hyperprolactinemia in men typically presents with central hypogonadism due to suppression of GnRH (and subsequently LH) secretion. Common symptoms include erectile dysfunction and loss of libido. Osteoporosis is a possible manifestation, due to low testosterone production. However, serum testosterone levels should be obtained first because, if serum testosterone is normal, hyperprolactinemia is unlikely and there is no need to measure prolactin. (Choice C) In addition to localized osteolytic lesions, multiple myeloma can cause generalized bone loss. However, this is a less common cause of osteoporosis, and testing with serum and urine protein electrophoresis is needed only for those with additional features suggestive of myeloma (eg, anemia, parathyroid hormone-independent hypercalcemia, vertebral fracture). (Choice E) Bone turnover markers (eg, urine N-telopeptide) can assess ongoing bone loss and may be useful if the need for antiresorptive therapy is uncertain. However, antiresorptive therapy is indicated for this patient due to established osteoporosis with a fragility fracture; measurement of bone turnover markers would not further improve his care. Educational objective: Osteoporosis in men is often due to secondary causes. Elderly men with hip fractures frequently have hypogonadism and should be screened with an early-morning serum testosterone assay. __________ References: Osteoporosis in men. (http://www.ncbi.nlm.nih.gov/pubmed/24019112)

A 65-Year-Old Man Comes to the Office a Month After