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Osteoporosis is often underdiagnosed and undertreated in men before and even after sustaining a fracture, according to research presented Saturday at ACR Convergence 2020.
“This is a major public health issue,” as fractures contribute significantly to morbidity and mortality, said Jeffrey Curtis, MD, MS, MPH, professor of medicine in the Division of Clinical Immunology and Rheumatology at the University. of Alabama in Birmingham.
Men are often overlooked, he said, “because it is misinterpreted as a disease that primarily, if not only, affects Caucasian women,” despite 20% -25% of fractures occurring in men.
Emerging evidence suggests that men who have bone fractures have worse outcomes than women, Curtis said.
Missing guidelines
There is also a lack of consistent guidelines for osteoporosis screening among men, leading to ambiguity and increased disease burden.
The researchers studied records for a random 5% sample of male Medicare service recipients (n = 9876) aged 65 or older with a closed fragility fracture between January 2010 and September 2014. The mean age for men with fractures was 77.9 years and the most common sites of the fracture were the spine, hip and ankle.
They looked back to see if these men had received effective screening and treatment.
Very few had done it.
“We found that 92.8 percent of them had no osteoporosis diagnosis or treatment at baseline,” Curtis said. Furthermore, less than 6% of the men had undergone any dual-energy X-ray absorptiometry [DEXA] o bone mineral tests in the 2 years prior to their fracture.
Men who had high-risk factors for falls, such as those using beta blockers, mobility problems, or a history of opioid use, were also unlikely to be screened, he said.
Curtis’ data shows that there was actually a decline in DEXA scans from 2012 to 2014, and that decline was especially high in men 75 years of age or older who are more likely to be at risk of fracture.
In addition to the under-screen and under-treatment before the fracture, Curtis said, “The treatment models after the fracture were not much better.” In the year following the fracture, “only about 10% of these men had BMD [bone mineral density] test. Only 9% were treated with an osteoporosis drug. “
“Importantly, about 7 percent of the men in this large cohort have had one or more fractures in the next year,” he added.
Reasons for insufficient treatment
The reasons for the low diagnosis and treatment rates may begin with patients who have no symptoms. Therefore, they do not enter doctors’ offices asking to be screened. “Even if they break their bones, they may not know enough to ask how to prevent the next fracture,” Curtis said.
There is also a financial obstacle, explained Curtis. “US legislation that provides for population screening for Medicare patients is actually quite dissimilar to nearly universal coverage for women for men. So many doctors fear they won’t get reimbursed if they order DEXA in men for screening.”
Additionally, post-fracture quality care guidelines that are reimbursed as part of the MACRA and MIPS program specifically exclude men, she noted.
Better management of male osteoporosis, including early identification of individuals at risk, is clearly warranted, he said, so that they can be examined and given effective therapy.
Sonali khandelwal, MD, a rheumatologist at Rush University Medical Center in Chicago who was not part of the research, agrees.
She said Medscape Medical News that part of the problem is that diagnosis and treatment could come from a variety of specialists – endocrinologists, rheumatologists, orthopedists, primary care physicians – and each would think that it falls within the realm of another.
In Rush and other sites nationwide, he said, a warning is recorded in electronic health records that alerts any patient who may need a bone density screening based on age, medication, or history.
Rush University also has a fracture liaison service whereby all patients admitted to Rush who may have had a history of a fracture or who have been hospitalized with a fracture are followed up with screening and treatment, “to catch those patients. that may not have passed through the system otherwise. “
He said the guidelines called for DEXA screening for men by age 70, but said clinical screening should start younger – starting at age 50 – for patients with conditions like lupus, the rheumatoid arthritis, hypogonadism or those on chronic steroids.
Khandelwal he said that even when an insurance company typically doesn’t cover bone density screening for men, doctors can often file a lawsuit for reimbursement if the patient has a history of falls or fractures.
“In the long run, preventing a fracture means saving a lot more than when you get a fracture and end up in a hospital and have to go to a nursing home,” he said.
Curtis has reported relationships with AbbVie, Amgen, Bristol-Myers Squibb, Corrona, Janssen, Lilly, Myriad, Pfizer, Regeneron, Roche, UCB, Gilead Sciences Inc, and Sanofi. Khandelwal did not report any significant financial relationships.
American College of Rheumatology (ACR) 2020 Annual Meeting: Abstract 0533. Presented November 7, 2020.
Marcia Frellick is a Chicago-based freelance journalist. She previously wrote for the Chicago Tribune, Science News, and Nurse.com and was an editor of the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.
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