Osteoporosis in men: symptoms and treatment. Features of the development of osteoporosis in men and methods of treatment Osteoporosis in young men

ABOUT Steoporosis and osteoporetic fractures are usually considered as pathologies characteristic of postmenopausal and elderly women. However, osteoporosis often occurs in men. In fact, 30% of all osteoporetic hip fractures affecting the world's population occur in males (Table 1). Among all cases of osteoporosis, its frequency in men is 20%. Obviously, since osteoporosis occurs without symptoms until the moment of skeletal bone fracture, it is necessary to assess the risk of osteoporosis not only in women, but also in men, and in the presence of risk factors, carry out active prevention and treatment.

In both women and men, bone mass peaks around age 20. Peak bone mass depends on many factors, including heredity, nutrition, lifestyle, and environmental influences. Poor nutrition and especially low calcium intake in childhood and adolescence is one of the very important reasons for the development of osteoporosis in adulthood in both women and men. Men have longer and more “powerful” bones; in general, bone mass in men is higher than in women. At the same time, the thickness and number of bone trabeculae in women and men are approximately the same, so when adjusted for bone volume, they have approximately the same peak bone mass.

In both women and men, age-related bone loss begins after age 50. However, in men there is a bimodal distribution of the incidence of osteoporosis (Fig. 1), since before the age of 50, osteoporosis in men (usually secondary) develops much more often than in women. For example, in men, acute hypogonadism (usually the result of orchiectomy for prostate cancer) causes rapid bone loss at any age.

Rice. 1. Distribution of the incidence of osteoporosis depending on the age of men and women

Osteoporosis is detected in approximately 4-6% of men over the age of 50, and osteopenia is much more common - in 33-47% of cases. Since men still have higher bone mass than women, the incidence of osteoporotic fractures begins to increase approximately 10 years later, after age 75. Given the lower overall life expectancy in men than in women, the contribution of osteoporosis to morbidity is not as pronounced as in women. However, given the projected increase in life expectancy (at least in developed countries), a significant increase in the incidence of osteoporotic fractures in men is expected over the next decade (Table 1).

It should be especially emphasized that the consequences of femoral fractures in men are significantly more severe than in women, both in terms of short-term and long-term prognosis. For example, there is evidence that hospital mortality after hip fractures in men is 2 times higher than in women, and overall mortality during the first year after a fracture is 30-50%, while in women it is about 20%. The increase in mortality is associated with many reasons, and primarily with a higher incidence of comorbidities. In addition, more than half of men who suffer hip fractures are significantly disabled due to severe pain and require assistance with mobility.

Risk factors

Although the main cause of osteoporosis in men is old age and genetic factors, in 30-60% its development is associated with secondary risk factors (Table 2). Only about 40% of men, despite intensive testing, fail to detect at least one risk factor.

Among them, one of the leading places is occupied by glucocorticoid therapy, which is associated with every 1 in 6 cases of osteoporosis in men. Since the risk of developing osteoporosis during treatment with glucocorticoids in men is especially high, almost all patients should necessarily receive anti-osteoporosis therapy if they take these drugs in a dose of more than 5 mg/day for more than 6 months. . The optimal treatment for glucocorticoid osteoporosis in men is the use of calcium and vitamin D supplements in combination with bisphosphonates.

Among them, one of the leading places is occupied by glucocorticoid therapy, which is associated with every 1 in 6 cases of osteoporosis in men. Since the risk of developing osteoporosis during treatment with glucocorticoids in men is especially high, almost all patients should necessarily receive anti-osteoporosis therapy if they take these drugs in a dose of more than 5 mg/day for more than 6 months. . The optimal treatment for glucocorticoid osteoporosis in men is the use of calcium and vitamin D supplements in combination with bisphosphonates.

Anticonvulsants

Anticonvulsants, especially phenytoin and phenobarbital, have multiple negative effects on bone metabolism. For example, anticonvulsants increase the metabolism of vitamin D and 25-hydroxyvitamin D in the liver, which in turn leads to decreased calcium absorption in the intestine. Men taking anticonvulsants should definitely receive calcium and vitamin D supplements, and if there is a significant decrease in bone mineral density (BMD), bisphosphonates.

Low levels of sex hormones

Androgens are essential for achieving peak bone mass and maintaining bone mass throughout life. In young men with hypogonadism, there is a clear correlation between decreased testosterone levels and BMD, and replacement therapy testosterone leads to an increase in bone mass. With age, testosterone levels progressively (but smoothly) decrease. This is probably why in older men there is no clear correlation between testosterone levels and BMD (unlike young men). Moreover, the administration of testosterone to elderly men is contraindicated, as it leads to severe side effects, primarily increases the risk of prostate cancer.

Interestingly, according to a number of researchers in men, a decrease in BMD correlates more clearly with a decrease in estradiol levels than testosterone. However, what are the pharmacological prospects for the use of estradiol in men with osteoporosis is currently unclear.

Smoking and drinking alcohol

Smoking and alcoholism are significant independent risk factors for osteoporetic fractures in both men and women. Negative influence Smoking is associated with a decrease in body weight, a decrease in calcium absorption and estradiol levels, as well as a direct toxic effect on bone tissue, and depends on the duration and intensity of smoking. Alcohol in moderate doses, on the contrary, has a “protective” effect on bone metabolism, but its excessive use leads to bone loss. It is believed that in high doses, alcohol directly inhibits the activity of osteoblasts.

In addition, there are numerous other risk factors for osteoporosis, and the more of these factors identified at the same time, the higher the risk of osteoporotic fractures in men.

Diagnosis of osteoporosis in men

Unlike women, in whom osteoporosis is often detected during a routine densitometric examination, in men the presence of osteoporosis, as a rule, becomes obvious only after the development of fractures of the spine or hip. This is largely due to the fact that internationally accepted recommendations regarding indications for screening men for osteoporosis have not yet been developed.

Age over 70 years;

History of any non-traumatic fractures;

Identification of radiological signs of osteopenia during X-ray examination;

Long-term use of glucocorticoids;

Hypogonadism;

Hyperparathyroidism;

The presence of other obvious factors leading to impaired bone metabolism.

It is obvious that the fastest implementation in clinical practice These recommendations appear to be extremely important to reduce the risk of developing complications of osteoporosis in men.

To diagnose osteoporosis, use bienergetic X-ray densitometry method (DEXA). Although the WHO recommendations regarding densitometric criteria for osteoporosis are developed for women, it is believed that a decrease in BMD below 2-2.5 standard deviations from peak bone mass is associated with a significant increase in the risk of fractures in men (to the same extent as in women) and dictates the need to prescribe antiosteoporetic therapy. It should be especially emphasized that the decision on the appropriateness of treatment should be based not only on densitometry data, but also on an assessment of other risk factors for osteoporetic fractures (Table 2).

In patients with osteoporosis (based on densitometry), an attempt should be made to identify the causes of osteoporosis. Commonly accepted methods for routine assessment of men with osteoporosis are summarized in Table 3.

Recommendations regarding the need for regular exercise, quitting smoking and drinking alcohol are of undoubted importance. For example, a recent controlled trial in older men found that regular exercise was associated with a 25% reduction in the risk of accidental loss of balance (and therefore fracture) by 25% (Evidence Level C).

However, the cornerstone of treatment for osteoporosis in men (as in women) is undoubtedly prescribing calcium and vitamin D supplements in adequate doses . This is especially important because only about half of men consume adequate dietary calcium, according to epidemiological studies. In addition, in older men there is a significant impairment in the biosynthesis of vitamin D in the skin, a decrease in vitamin D intake from food and its gastrointestinal absorption. Of particular interest are drugs containing both calcium salts and vitamin D. Among the drugs presented on the Russian pharmaceutical market, one of the most adequate dosage forms is Calcium-D 3 from the pharmaceutical company Nycomed ( Calcium-D 3 Nycomed ), containing 500 mg of calcium and 200 IU of vitamin D in the form of chewable tablets with orange flavor and Calcium-D 3 Nycomed Forte , containing 500 mg calcium and 400 IU vitamin D in lemon-flavored chewable tablets. Taking 1-2 tablets of the drug provides the body's daily need for calcium and vitamin D. According to experts from the National Osteoporosis Society (USA), for the prevention and treatment of osteoporosis in males, especially over the age of 70, it is necessary to prescribe vitamin D in a dose of 400 -800 IU/day. Calcium-D 3 Nycomed Forte fully complies with international standards for the treatment of osteoporosis.

An adequate treatment method for patients with definite osteoporosis is to prescribe bisphosphonates . The only bisphosphonate approved for use in men with osteoporosis is alendronate (level A evidence). In men receiving glucocorticoids, along with alendronate, it is possible to use risedronate, but this drug, unfortunately, has not yet been registered in Russia. Recently, recombinant parathyroid hormone, teriparatide, which has anabolic activity, has been used to treat osteoporosis in men (and postmenopausal women).

For patients who require diuretics (due to the presence of concomitant diseases), it is advisable to prescribe thiazides, which reduce calcium loss in the urine. It has been established that they long-term use(over 10 years) is associated with a reduced incidence of hip fractures.

Thus, osteoporosis in men is an important medical problem, no less significant in its negative impact on the health of the population of our planet than osteoporosis in women. In fact, osteoporosis in men can be considered the most common form of secondary osteoporosis. Active diagnosis, identification of secondary causes, prevention and treatment are important tasks of modern medicine.