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Health sense: Managing osteoporosis and bone-mineral density for men
Eddie, who is 70, had been suffering from constant low back pain
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Eddie, who is 70, had been suffering from constant low back pain. He took painkillers but the pain kept recurring. When he finally decided to consult his doctor, an X-ray showed a compression fracture in a vertebra in his lower spine.
This was the likely cause of his back pain. Eddie was puzzled, as he did not recall having suffered any direct injury to his spine.
His doctor sent Eddie for a bone mineral density assessment, a simple procedure, which confirmed that he has significant osteoporosis of his spine. Eddie was referred to me for further assessment.
Although osteoporosis is common in older women, this condition is unusual in men. Unlike women who begin to lose bone quite rapidly after menopause, the rate of bone loss in men as they grow older is much slower.
Apart from a healthy intake of calcium and vitamin D, adequate levels of sex hormones are also necessary to help maintain good bone quality.
On the other hand, conditions causing excessive levels of thyroid or parathyroid hormone can lead to bone loss.
Bone mineral density (BMD) may be assessed using dual X-ray bone absorptiometry, a simple inexpensive and non-invasive X-ray scan that assesses a person's bone quality in comparison to healthy young adults.
BMD results are expressed as normal, or osteopenia (or pre-osteoporosis, in layman's term) or osteoporosis.
However, it does not mean that a person classified as osteopenia is at low risk of sustaining a fracture. Other independent risk predictors include factors, such as frailty, small build, frequent falls, cigarette smoking, heavy alcohol consumption, a family history of fractures, the use of steroids (frequently found in traditional medicine) and diseases like rheumatoid arthritis.
Therefore, these must be considered in conjunction with a person's BMD result and the fracture risk estimated using a risk calculator designed for specific populations or communities, such as one developed by the WHO specifically for Indonesia.
It turned out that Eddie has been a heavy smoker for many years, puffing about 20 cigarettes daily, already a strong risk factor. Blood investigations also revealed that Eddie had low levels of vitamin D as well as testosterone, the essential sex hormone for men.
Besides vitamin D, the maintenance of good bone quality is highly dependent on testosterone. As testosterone declines with age, older men are at higher risk of bone loss and fractures.
Low testosterone also predisposes men toward loss of muscular strength and frailty, poorer sexual function and quality of life (becoming easily tired, lacking in stamina), development of diabetes and higher mortality from heart disease.
Although Eddie's bone density measurement placed him in the osteopenic category (i.e., not quite osteoporotic, but already poorer than expected), he is clearly at risk of further fractures as he has already had a vertebra fracture.
In Eddie's case, treatment has to be instituted from all fronts. While most people may be familiar with vitamin D3, which is dosed at 1,000 units daily, this will not be enough to overcome deficiency.
Instead, Eddie was started on high-dose vitamin D2 at 50,000 units weekly for two months. His testosterone deficiency was treated with an injection of testosterone depot that can last up to three months.
This form of treatment ensures that none of the testosterone is wasted through poor absorption. Improvement in BMD can be seen six months after the start of testosterone therapy and continues to be well-sustained for as long as testosterone therapy is continued.
Eddie also experienced a dramatic improvement in his quality of life once his testosterone level has been restored. His stamina was better, he no longer felt sleepy in the afternoon, his back pain disappeared and his sexual interest returned. He also noticed that his waist line decreased.
Standard treatment for osteoporosis, such as bisphosphonates, must also be administered.
While bisphosphonates are commonly taken orally on a weekly basis, its efficacy in older persons may not be as good due to poorer absorption.
Zoledronate, one of several bisphosphonates, is available as a once-yearly intravenous infusion that can easily be administered in the clinic. Eddie, being a busy person who is fairly absent-minded as well, much preferred this convenient and cost-effective treatment.
As its effects are long-lasting, zoledronate could be stopped after 3-5 years of treatment, while testosterone therapy and maintenance vitamin D were continued to ensure that Eddie's restored BMD continues to be well-maintained.
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The writer is a consultant physician and endocrinologist at Glen Arden Endocrinology Specialist Clinic at the Gleneagles Medical Centre in Singapore and a previous president of the Endocrine & Metabolic Society of Singapore. For more information, visit klinikdiabetessingapura.com.
