ReviewManagement of osteoporosis in men on androgen deprivation therapy
Introduction
Prostate cancer is very common in older men, with about 300,000 new cases diagnosed in the United States every year. For local and distant metastases, androgen deprivation therapy (ADT) is a commonly used therapy, consisting of short or long term androgen receptor blocking drugs plus an analog of gonadotropin releasing hormone that leads to suppression of pituitary gonadotropin secretion. While prostate cancer occurs at a time when serum testosterone levels are decreasing in men, ADT causes profound hypogonadism, a consequence of which is bone and muscle loss. The man with localized or metastatic prostate cancer may be treated with ADT, often if the serum PSA rises after primary treatment (surgery or radiation). Such men have a generally good prognosis, but an under-appreciated fact is that their fracture risk rises quickly. It has been estimated that the chance of a fracture in men on ADT is as high as 20% by 5 years of treatment [1]. Older men and those with osteoporosis risk factors in addition to age are at the highest risk [2]. Many men on ADT and thus at risk for osteoporotic fractures will likely not have any evaluation or treatment for osteoporosis, nor will preventive measures be instituted. The purpose of this review is to provide suggestions for assessing the risk in a given man on ADT and determining the best course of action.
Section snippets
Importance of general measures and vitamin D
It has generally been assumed that there are a number of non-pharmacologic ways to prevent fractures in elders, and such methods can be applied to men receiving ADT. Thus, prevention of falls through weight-bearing exercise and home safety can be almost universally recommended. Reduction of risk factors for falls and fractures also makes sense: smoking cessation, avoidance of excess alcohol (defined as >3 units daily), minimization of medications that can alter mental functioning, avoiding oral
Clinical evaluation of men on ADT
All of the above can be applied to all older men with or at risk for prostate cancer and with or at risk for osteoporosis. What specifically should be done for the man about to start ADT or who is receiving ADT? An evaluation should include history and physical examination to look for risk factors and secondary causes of osteoporosis [11]. Routine laboratory tests such as a complete blood count and serum chemistries (particularly calcium and creatinine) are important as well. Measurement of
Bisphosphonate treatment – efficacy and safety
For such cost-effectiveness, the treatment must be effective. There are studies with several different bisphosphonates that demonstrate the surrogates for fracture are affected appropriately. As shown in Table 1, there are several studies [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], including randomized controlled trials, that demonstrate that bisphosphonates increase bone mineral density in men on ADT. For these studies, alendronate, risedronate, pamidronate, and
Provenance and peer review
Commissioned and externally peer reviewed.
Contributor
As the sole author of this manuscript, I, Robert A. Adler, MD, am completely responsible for all aspects. Dr. Adler is an employee of the Department of Veterans Affairs. The opinions expressed are his and not necessarily those of the Department of Veterans Affairs.
Competing interests
Robert A. Adler, MD has received recent research funding from: Eli Lilly, Novartis, Amgen, Genentech, and Merck
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2021, Journal of Clinical DensitometryCitation Excerpt :It is therefore recommended to include distal radius DXA measurements in patients with primary hyperparathyroidism (30,31). Similar observations and recommendations have been made for men on androgen deprivation therapy (32,33). Likewise, we found reduced BMD and T-score of the distal radius in PD which may suggest an increased cortical porosity (34), but with no between-group differences in TBS which evaluates bone trabecular microarchitecture in the lumbar spine (20–22).
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2020, Molecular and Cellular EndocrinologyCitation Excerpt :This finding is clinically relevant, as men treated with androgen deprivation therapy and at increased risk for secondary osteoporosis often have a low dietary calcium and vitamin D intake (Varsavsky et al., 2011; Greenspan et al., 2005; Davison et al., 2012). Treatment with bisphosphonates might thus be less effective under circumstances of combined hypogonadism and low dietary calcium (Adler, 2011). Very few data are available with respect to the effects of androgens on renal phosphate handling.
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2018, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :Speculatively, OAs might have a protective role in a subset of patients with clinically localized diseases who are at high risk for developing bone metastases (e.g. PSA 8 g/dl, PSA doubling time less than 10 months [64]) and for decreased bone mineral density and osteoporosis due to a long-term treatment with ADT. For assessment and stratification of bone loss risk, dual energy X-ray absorptiometry as well as validated fracture risk assessment tools such as the FRAX questionnaire can be used and are recommended by current expert opinions [65]. Since evidence focusing on this patient cohort is still missing, further studies are welcomed.
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2013, Journal of Clinical DensitometryCitation Excerpt :DXA is a covered benefit for Medicare for a man who has already had a fracture, is on glucocorticoids, or has hyperparathyroidism. Despite the very high incidence of fracture in men on ADT (16), DXA reimbursement for these men is problematic in the United States. Now that generic alendronate is inexpensive, a case could be made to simply treat the high-risk men, perhaps using the World Health Organization (WHO) fracture risk calculator (FRAX), with or without DXA, to estimate 10-yr fracture risk.