The strength of evidence (High, Moderate, Low) and the strength of the recommendations (Strong or Weak) are defined at the end of the "Major Recommendations" field.
Recommendation 1: The American College of Physicians recommends that clinicians should periodically perform individualized assessment of risk factors for osteoporosis in older men. (Grade: strong recommendation, moderate-quality evidence.)
The appropriate age to start risk assessment is uncertain. However, by age 65 years, at least 6% of men have dual-energy x-ray absorptiometry (DXA)-determined osteoporosis, therefore, assessment of risk factors before this age is reasonable. Factors that increase the risk for osteoporosis in men include age (>70 years), low body weight (body mass index <20 to 25 kg/m2), weight loss (>10% [compared with the usual young or adult weight or weight loss in recent years]), physical inactivity (participates in no physical activities on a regular basis [walking, climbing stairs, carrying weights, housework, or gardening]), corticosteroid use, androgen deprivation therapy, and previous fragility fracture. Risk assessments should be updated periodically for men who choose not to be screened.
Recommendation 2: The American College of Physicians recommends that clinicians should obtain DXA for men who are at increased risk for osteoporosis and are candidates for drug therapy. (Grade: strong recommendation, moderate-quality evidence.)
Bone density measurement with DXA is the accepted reference standard for diagnosing osteoporosis in men. Men who are at increased risk for osteoporosis are candidates for DXA. Little evidence about alternatives to DXA exists. The two most studied methods are quantitative ultrasonography (usually of the calcaneus) and the osteoporosis self-assessment screening tool (OST). Available evidence indicates that neither alternative is sufficiently sensitive or specific at predicting DXA-determined bone mass to be recommended as a substitute for DXA.
No studies have evaluated the optimal intervals for repeated screening by using bone mineral density (BMD) measurement with DXA.
The evidence review showed that calcaneal ultrasonography predicts DXA-determined osteoporosis only modestly well. However, more important, it was a strong predictor of fracture in men. This may be because ultrasonography identifies other bone properties, such as bone quality, which may not be identified on DXA. Because treatment trials have not measured the effectiveness of therapy for osteoporosis diagnosed by ultrasonography rather than DXA, the role of ultrasonography in diagnosis remains uncertain.
Recommendation 3: The American College of Physicians recommends further research is needed to evaluate osteoporosis screening tests in men.
A major limitation of existing osteoporosis screening studies is the use of BMD measurement (DXA) as the primary outcome rather than fracture occurrence. Although there is a large body of evidence about risk factors for osteoporosis in women, more research is needed to understand whether these risk factors also apply to men. Therapy should be evaluated in terms of fracture occurrence because of the significant disability, morbidity, mortality, and expenses that are associated with osteoporotic fractures. Furthermore, the harms of screening in this age group, such as radiation exposure and false-positive results, should also be studied. In addition, more research is needed in evaluating other screening tests, such as quantitative computed tomography, other types of questionnaires, or peripheral BMD measurements, which might also be useful as screening tests in men. Further research should explore whether acceptable substitutes for DXA exist (in terms of establishing the need for pharmacologic therapy). Research that explores the age at which men should begin to consider screening for osteoporosis and effective prevention measures for osteoporosis in men is also needed.
Definitions:
| The American College of Physicians' Guideline Grading System* |
| Quality of Evidence |
Strength of Recommendation |
| |
Benefits Clearly Outweigh Risks and Burden OR Risks and Burden Clearly Outweigh Benefits |
Benefits Finely Balanced with Risks and Burden |
| High |
Strong |
Weak |
| Moderate |
Strong |
Weak |
| Low |
Strong |
Weak |
| Insufficient evidence to determine net benefits or risks |
I-recommendation |
* Adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup.
