In the JournalsPerspective

Osteoporosis treatment suboptimal in men, black adults

Men aged at least 70 years receive less treatment for osteoporosis than women of the same age, according to findings published in the Journal of Pharmaceutical Health Services Research. In addition, black adults are undertreated for osteoporosis compared with other populations.

Feng‐Hua Ellen Loh

“Osteoporosis is an asymptomatic disease and has long been seen as a women’s disease; therefore, men may not be aware of osteoporosis and its related bone fractures and thus do not pursue care,” Feng‐Hua Ellen Loh, PhD, BPharm, assistant professor in the department of social, behavioral and administrative sciences at Touro College of Pharmacy in New York, told Endocrine Today. “However, men diagnosed with osteoporosis have a higher risk of bone fracture compared to women and suffer more sever outcomes after having a bone fracture. Therefore, it is crucial to improve osteoporosis care in men.”

Using Medicare data from the Chronic Condition Data Warehouse, Loh and colleagues conducted a study investigating sex-based differences in osteoporosis treatment between 2006 and 2008. All study participants (n = 99,421; 91.4% women), which encompassed a 5% national random sample, were aged at least 70 years and diagnosed with osteoporosis before 2006. Participants were considered to be using osteoporosis medication if they had at least one prescription refill in a given year. Osteoporosis management was determined by the presence of bone mineral density testing.

More women in the cohort had osteoporosis than men (44% vs. 11%). Treatment rates were higher for women, with a range of 44.3% in 2006 to 42% in 2008 vs. a range of 25.2% and 24.5% for men in the same period, the researchers reported. Osteoporosis medication was less likely to be given to men when compared with women (RR = 0.2; 95% CI, 0.19-0.22). Nonbisphosphonates were more likely to be the medication choice for men who were treated (RR = 1.16; 95% CI, 1.16-1.17) compared with women who were treated.

Osteoporosis treatment was less likely for black men compared with white men (RR = 0.76; 95% CI, 0.68-0.85) and black women compared with white women (RR = 0.61; 95% CI, 0.59-0.63), according to the study. In addition, Hispanic women were less likely to be treated for osteoporosis compared with white women (RR = 1.36; 95% CI, 1.32-1.41).

“Such wide racial and ethnic differences raise important questions about osteoporosis education and access to care that deserve further research,” the researchers wrote.

The researchers also found a positive association between living in a nursing home and treatment probability in men (RR = 1.65; 95% CI, 1.44-1.9) and women (RR = 1.17; 95% CI, 1.15-1.2).

“Even though we already knew that elderly men were less likely to be treated for osteoporosis compared to elderly women from the literature, we were still surprised by the magnitude of the difference in treatment use,” Loh said. “The clinical implication of this study is that elderly men and their physicians should pay more attention to osteoporosis and manage it more appropriately.” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.

Men aged at least 70 years receive less treatment for osteoporosis than women of the same age, according to findings published in the Journal of Pharmaceutical Health Services Research. In addition, black adults are undertreated for osteoporosis compared with other populations.

Feng‐Hua Ellen Loh

“Osteoporosis is an asymptomatic disease and has long been seen as a women’s disease; therefore, men may not be aware of osteoporosis and its related bone fractures and thus do not pursue care,” Feng‐Hua Ellen Loh, PhD, BPharm, assistant professor in the department of social, behavioral and administrative sciences at Touro College of Pharmacy in New York, told Endocrine Today. “However, men diagnosed with osteoporosis have a higher risk of bone fracture compared to women and suffer more sever outcomes after having a bone fracture. Therefore, it is crucial to improve osteoporosis care in men.”

Using Medicare data from the Chronic Condition Data Warehouse, Loh and colleagues conducted a study investigating sex-based differences in osteoporosis treatment between 2006 and 2008. All study participants (n = 99,421; 91.4% women), which encompassed a 5% national random sample, were aged at least 70 years and diagnosed with osteoporosis before 2006. Participants were considered to be using osteoporosis medication if they had at least one prescription refill in a given year. Osteoporosis management was determined by the presence of bone mineral density testing.

More women in the cohort had osteoporosis than men (44% vs. 11%). Treatment rates were higher for women, with a range of 44.3% in 2006 to 42% in 2008 vs. a range of 25.2% and 24.5% for men in the same period, the researchers reported. Osteoporosis medication was less likely to be given to men when compared with women (RR = 0.2; 95% CI, 0.19-0.22). Nonbisphosphonates were more likely to be the medication choice for men who were treated (RR = 1.16; 95% CI, 1.16-1.17) compared with women who were treated.

Osteoporosis treatment was less likely for black men compared with white men (RR = 0.76; 95% CI, 0.68-0.85) and black women compared with white women (RR = 0.61; 95% CI, 0.59-0.63), according to the study. In addition, Hispanic women were less likely to be treated for osteoporosis compared with white women (RR = 1.36; 95% CI, 1.32-1.41).

“Such wide racial and ethnic differences raise important questions about osteoporosis education and access to care that deserve further research,” the researchers wrote.

The researchers also found a positive association between living in a nursing home and treatment probability in men (RR = 1.65; 95% CI, 1.44-1.9) and women (RR = 1.17; 95% CI, 1.15-1.2).

“Even though we already knew that elderly men were less likely to be treated for osteoporosis compared to elderly women from the literature, we were still surprised by the magnitude of the difference in treatment use,” Loh said. “The clinical implication of this study is that elderly men and their physicians should pay more attention to osteoporosis and manage it more appropriately.” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Rachel Pessah-Pollack

    Rachel Pessah-Pollack

    Osteoporosis is a disease characterized by reduced bone mass and skeletal fragility resulting in an increased risk for fractures. Despite the known increased risk of hip and vertebral fractures, studies suggest that there is a declining rate of treatment nationally of osteoporosis.

    This study looks at osteoporosis treatment patterns in a cross-sectional analysis of male and female Medicare Part D beneficiaries aged 70 years or older diagnosed from 2006 to 2008. Importantly, two agents used for osteoporosis treatment were not included in this analysis as they became available at a later date (denosumab in 2010 and abaloparatide in 2018.) As such, the data available for this time period would likely be different if the study were repeated today. 

    One main finding was that the prevalence of osteoporosis medication use in men was substantially less than in women (25.2% vs 44.3% in 2006.) Despite a diagnosis of osteoporosis, men are undertreated, and this is concerning since 28% of hip fractures in the United States occur in men, and treatment can reduce fracture risk and associated morbidity and mortality. Bisphosphonates were the treatment choice in both men and women during this time period, and a common contraindication to bisphosphonate use was chronic kidney disease, which may have resulted in fewer people being treated in this study. Denosumab, which is a RANK ligand inhibitor and has no renal dosing adjustment, would allow a potentially increased number of patients to be treated for osteoporosis compared with what was noted in this study. It would be beneficial to do a cross-sectional analysis over more recent years given the addition of newer FDA-approved bone treatment agents.

    Black men and women were much less likely to be treated for osteoporosis compared to white men and women. We need to better assess and address the reasons for both racial and gender disparities in treatment. With education and awareness regarding appropriate screening and treatment of osteoporosis, we can reduce the risk of fracture and improve the quality of life of our patients.

    • Rachel Pessah-Pollack, MD, FACD
    • Assistant Clinical Professor
      Icahn School of Medicine at Mount Sinai

    Disclosures: Pessah-Pollack reports that she is speaker/consultant for Boehringer Ingelheim/Eli Lilly and speaker for Radius Healthcare.

    Perspective
    John D. Kaufman

    John D. Kaufman

    The suboptimal awareness of osteoporosis in men has been an ongoing problem for many years. Osteoporosis is frequently thought of as a “women’s disease” and men fail to think about it or to take preventative measures to ensure their bone health. Many physicians also give osteoporosis screening or treatment in men a low priority.

    We know that about 20% of osteoporosis occurs in men, but, according to the International Osteoporosis Foundation, about one-third of all hip fractures worldwide are in men. Men also do not recover as well as women after a hip fracture and have a substantially higher mortality.

    As orthopedic surgeons, we need to consider osteoporosis as a factor in many of the men we encounter with fractures. Any older man sustaining a fracture in a fall from a standing height should be screened for osteoporosis. Treatment is easy and there are excellent drugs available that have been approved for men.

    The number of men over the age of 70 will increase as life expectancy rises. Hopefully, awareness among men and physicians will increase, as well.

    • John D. Kaufman, MD
    • Section Editor: Musculoskeletal Oncology & Metabolic Bone Disease
      Orthopedics Today

    Disclosures: Kaufman reports no relevant financial disclosures.