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[EXCERPTS]

Major Recommendations 

Evaluation

• The Task Force suggests testing men at increased risk for osteoporosis by measurement of bone mineral density (BMD). Age 70 is a sufficient risk factor. Younger men (aged 50–69) should be tested if additional risk factors are present. A history of fracture after age 50 is a particularly important indication for evaluation. Other reasons for testing men aged 50–69 include diseases/conditions such as delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, or chronic obstructive pulmonary disease; drugs such as glucocorticoids or gonadotropin-releasing hormone (GnRH) agonists; life choices such as alcohol abuse or smoking; or other causes of secondary osteoporosis. FRAX, Garvan, or other fracture risk calculators can improve the assessment of fracture risk and the selection of patients for treatment. (2|++OO)
• The Task Force recommends dual-energy x-ray absorptiometry (DXA) of the spine and hip in men at risk for osteoporosis. (1|++OO)
• The Task Force suggests measuring forearm DXA (1/3 or 33% radius) when spine or hip BMD cannot be interpreted and for men with hyperparathyroidism or receiving androgen-deprivation therapy (ADT) for prostate cancer. (2|++OO)
• The Task Force suggests a complete history and physical examination for men being evaluated for osteoporosis or considered for pharmacological treatment (e.g., those with low BMD and/or high fracture risk). Important information includes medications used, chronic diseases, alcohol or tobacco abuse, falls and/or fractures as an adult, and family history of osteoporosis. Physical examination should assess patient height in comparison with maximum height, kyphosis, balance, mobility, overall frailty, and evidence of causes of secondary osteoporosis, including testicular atrophy, signs of hyperthyroidism, and evidence of chronic obstructive pulmonary disease. Men for whom bisphosphonate therapy is considered should have an examination of the teeth. (2|++OO)
• The Task Force suggests measuring serum calcium, phosphate, creatinine (with estimated glomerular filtration rate), alkaline phosphatase, liver function, 25-hydroxyvitamin D (25[OH]D), total testosterone, complete blood count, and 24-h urinary calcium (creatinine and sodium) excretion in men being evaluated for osteoporosis or considered for pharmacological treatment with bone-active agents. (2|++OO)
• If history or physical examination suggests a specific cause of osteoporosis, further testing should be done. Depending on the findings of the history and physical examination, such testing may include (but is not limited to) calculated free or bioavailable testosterone (using measurements of sex hormone-binding globulin [SHBG]), serum protein electrophoresis with free κ and λ light chains and/or urine protein electrophoresis, tissue transglutaminase antibodies (for celiac disease), thyroid function tests, and parathyroid hormone (PTH) levels. (2|++OO)
• In men with low bone mass (osteopenia) or osteoporosis who might have previously undiagnosed vertebral fractures, the Task Force recommends vertebral fracture assessment (VFA) using DXA equipment. If VFA is not available or is technically limited, lateral spine radiographs should be considered. (1|++OO)

Lifestyle

• The Task Force recommends that men with or at risk for osteoporosis consume 1000–1200 mg calcium daily, ideally from dietary sources, with calcium supplements added if dietary calcium is insufficient. (1|+++O)
• The Task Force suggests that men with low vitamin D levels (<30 ng/ml [75 nmol/liter]) receive vitamin D supplementation to achieve blood 25(OH)D levels of at least 30 ng/ml (75 nmol/liter). (2|+++O)
• The Task Force suggests that men at risk of osteoporosis participate in weight-bearing activities for 30–40 min per session, three to four sessions per week. (2|+OOO)
• The Task Force suggests that men at risk of osteoporosis who consume three or more units of alcohol per day reduce their alcohol intake. (2|+OOO)
• The Task Force recommends that men at risk of osteoporosis who smoke cease smoking. (1|++OO)

Treatment

Selection of Men for Treatment

All Men

The Task Force recommends pharmacological therapy for men at high risk for fracture including, but not limited to:

• Men who have had a hip or vertebral fracture without major trauma. (1|+++O)
• Men who have not experienced a spine or hip fracture but whose BMD of the spine, femoral neck, and/or total hip is 2.5 standard deviations (SD) or more below the mean of normal young white males. (1|++OO)
• In the United States, men who have a T-score between –1.0 and –2.5 in the spine, femoral neck, or total hip plus a 10-yr risk of experiencing any fracture ≥20% or 10-yr risk of hip fracture ≥3% using FRAX; further studies will be needed to determine appropriate intervention levels using other fracture risk assessment algorithms. For men outside the U.S., region-specific guidelines should be consulted. (1|++OO)
• Men who are receiving long-term glucocorticoid therapy in pharmacological doses (e.g., prednisone or equivalent >7.5 mg/d), according to the 2010 guidelines of the American Society of Rheumatology. (1|++OO)

Management of Hypogonadal Men at High Risk of Fracture

• For men at high risk of fracture who are receiving testosterone therapy, the Task Force suggests adding an agent with proven antifracture efficacy (e.g., a bisphosphonate or teriparatide). (2|+OOO)
• The Task Force suggests testosterone therapy in lieu of a "bone drug" for men at borderline high risk for fracture who have serum testosterone levels below 200 ng/dl (6.9 nmol/ liter) on more than one determination, if accompanied by signs or symptoms of androgen deficiency (e.g., low libido, unexplained chronic fatigue, loss of body hair, hot flushes, etc.) or "organic" hypogonadism (e.g., due to hypothalamic, pituitary, or specific testicular disorder). If testosterone treatment does not alleviate symptoms of androgen deficiency after 3–6 months, it should be discontinued and other therapy considered. (2|++OO)
• The Task Force suggests testosterone therapy for men at high risk for fracture with testosterone levels below 200 ng/dl (6.9 nmol/liter) who lack standard indications for testosterone therapy but who have contraindications to approved pharmacological agents for osteoporosis. (2|++OO)

Men with Prostate Cancer Receiving ADT

The Task Force recommends pharmacological treatment for osteoporosis for men with prostate cancer receiving ADT who have a high risk of fracture. (1|+++O)

Monitoring Therapy

• The Task Force suggests that clinicians monitor BMD by DXA at the spine and hip every 1–2 yr to assess the response to treatment. If BMD appears to reach a plateau, the frequency of BMD measurements may be reduced.(2|+++O)
• The Task Force suggests that clinicians consider measuring a bone turnover marker (BTM) at 3–6 months after initiation of treatment using a bone resorption marker (such as serum C-telopeptide of type I collagen [CTX] or serum or urine N-telopeptide of type I collagen [NTX]) for antiresorptive therapy and a bone formation marker (such as serum procollagen I N-propeptide [PINP]) for anabolic therapy. (2|+++O)

[Definitions – Strength of Recommendation available online]

[Link to free full-text Guideline Summary at NGC online | PubMed® abstract]