I enjoyed reading Parts I and II of “Health Issues in Men.”^1,2 It is great to see the journal focus on men's issues. The authors did a really good job of covering all of the major issues, with the exception of one issue: male osteoporosis. Just as postmenopausal osteoporosis has been underdiagnosed in the past, osteoporosis in older men is grossly underdiagnosed and undertreated.

We now have new treatments for male osteoporosis. Alendronate (Fosamax) has been used to treat men with osteoporosis for some time, and risedronate (Actenol) has recently been introduced for this indication. These therapies are long overdue, considering the morbidity, mortality and huge Medicare costs associated with hip fractures in older men.

In addition to the aging process, several factors predispose men to osteoporosis. These factors include hypogonadism, alcoholism, chronic steroid use, previous gastrectomy, chronic lung disease, pernicious anemia and disorders of movement and balance that increase the risk of immobility. Disorders of movement and balance may include the neurologic conditions that lead to hemiparesis/hemiplegia (stroke, Parkinson's disease and dementia).

In particular, chronic steroid use appears to be a big problem that leads to compression fractures. The good news is that the currently available bisphosphonates (alendronate and risedronate) are indicated for the treatment of steroid-induced osteoporosis. Additional administration of calcium (1,500 mg) and vitamin D (400 to 800 IU) are also necessary when treating men with osteoporosis. The key to successful treatment is prompt institution of therapy when the attending physician determines that the patient will need longterm administration.

in reply: We appreciate Dr. Cefalu's response to our articles on men's health issues.^1,2 As one can imagine, it proved difficult to summarize all of the pertinent health issues of men in two brief reviews. As such, some health concerns could not be covered. Osteoporosis is one example. We wholeheartedly agree with Dr. Cefalu that osteoporosis in older men is a grossly underdiagnosed and undertreated disease. The diagnosis and management of osteoporosis in men is even more clinically relevant in light of recent epidemiologic data and advances in the treatment of osteoporosis.

The National Osteoporosis Foundation³ estimates that 2 million men have osteoporosis in the United States, with an additional 3 million men at risk. Although much less common in men than in women, it is estimated that between one fifth to one third of all hip fractures occur in men. In fact, almost 20 percent of men will have had a hip fracture from osteoporosis by age 90. Almost one half of all symptomatic vertebral fractures occur in men.

Risk factors for osteoporosis in men include medication (glucocorticoids, anticonvulsants and chemotherapeutic agents), tobacco use, excessive alcohol use, chronic inactivity, hypogonadism, hyperparathyroidism, hyperthyroidism, malabsorptive intestinal disorders, certain malignancies and heredity.³ No uniform recommendation exists for the routine screening of men for osteoporosis, leaving physicians to decide who should undergo a bone mineral density study based on risk factor assessment and pretest suspicion for the disease.

Prevention of osteoporosis in men should center on ensuring adequate calcium intake and appropriate vitamin D levels. Men should be cautioned against physical inactivity, tobacco use and excessive alcohol consumption. Medications like glucocorticoids should be used with caution in men for as brief a period as possible.

Treatment of men with osteoporosis should first focus on the identification and modification of any predisposing condition. Screening men for hypogonadism must be conducted and treatment with testosterone initiated regardless of the presence of symptomatology. Disorders of the thyroid and parathyroid glands should be excluded. If possible, medications such as glucocorticoids should be discontinued. Patients should also be advised to stop intake of tobacco and alcohol, and to increase weight-bearing physical activity. The second stage of treatment should focus on ensuring adequate calcium and vitamin D intake. Supplementation to ensure a daily minimum of 1,200 to 1,500 mg of calcium and 400 to 800 IU of vitamin D is indicated.³

The final stage in treating men with osteoporosis involves the use of medications such as the bisphosphonates (alendronate and risedronate). Specifically, alendronate has already shown efficacy in increasing bone density in men with glucocorticoid-induced osteoporosis and has been approved by the U.S. Food and Drug Administration for the treatment of persons with steroid-induced osteoporosis.⁴ Results from another recent study demonstrates a significant reduction in pathologic fractures secondary to osteoporosis in men treated with alendronate.5 The bisphosphonates are reasonable and safe medications to use in the treatment of men with osteoporosis.