Mortality after fracture was higher for men than women, and some authors report that men have twofold mortality rates after hip fractures [ 42 , 43 ]. Male-specific determinants of bone mass like the peak bone mass occur later in life because of later onset of puberty. Males also have larger periosteal deposition of bone conferring a better resistance to mechanical forces [ 44 ]. Trabecular bone mass decreases with age in both sexes, but this loss is accelerated by menopause. Cortical bone mass remains stable until menopause for women and even later ages for men. Women mainly experience trabecular bone perfora- tion and loss of connectivity, while men predominantly expe- rience trabecular thinning. Perforation is structurally more det- rimental and could partially explain the higher fracture risks of women [ 41 ]. Two hundred thirty-two patients were studied to describe the etiology and characteristics of osteoporosis in men, and results revealed 57% had idiopathic osteoporosis, which was more common under the age of 60. Forty-three percent of men developed secondary osteoporosis, which was more frequent in individuals older than 60 years. The risk factors of osteo- porosis are similar despite sex; however, men with idiopathic osteoporosis have higher frequencies of hypercalciuria and family history [ 45 ]. Common secondary causes of osteoporosis in men are ex- cessive consumption of alcohol, hypogonadism, tobacco use, and prolonged treatment with corticosteroids [ 45 – 49 ]. Kanis et al. found up to 68% of both sexes suffering a hip fracture and 38% suffering any fragility fracture excessively consumed alcohol ( ≥ 3 units/day) [ 45 , 46 ]. A meta-analysis including 3,730,424 participants revealed that heavy alcohol consump- tion was associated with a trend toward increased hip fracture risk, but there was significant heterogeneity between studies ( P < 0.001, I 2 = 72.6%). Analyses based on amount of alcohol consumption revealed the RR of hip fractures was 0.88 (95% CI 0.83 – 0.89) with light alcohol consumption (0.01 – 12.5 g/ day), 1.00 (95% CI 0.85 – 1.14) with moderate consumption (12.6 – 49.9 g/day), and 1.71 (95% CI: 1.41 – 2.01) with heavy consumption ( ≥ 50 g/day) [ 47 ]. A meta-analysis of 59,232 participants found an associa- tion between smoking and the risk of any fracture (RR = 1.25, 95% CI 1.15 – 1.36). The relative risk (RR) of suffering a hip fracture was 1.84 (95% CI 1.52 – 2.22). The male subgroup (26% of the study population) had elevated risks of osteopo- rotic fractures at any site [ 48 ]. Another risk common in older men is androgenic hormone suppression in individuals with prostate cancer. Hormonal therapy is associated with a fracture risk of 20% in the first 5 years [ 49 ] and a rapid loss of bone mass after the first year of treatment (approximately 2 – 4% in the lumbar spine and hip) [ 50 ]. Clinically, we assume that BMD scores ( T -scores ≤ − 2.5) can be used similarly in both men age 50 and older and postmenopausal women; however, fractures in men have been Table 4 Recommendations for antiresorptive drugs Drug Zoledronic acid Risedronate Alendronate Ibandronate Raloxifene Denosumab Dose 5 mg/year (EV) 5 mg/day 35 mg/week 10 mg/day 70 mg/week 2.5 mg/day 150 mg/month
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