• University of Texas, School of Nursing, Family Nurse Practitioner Program. Risk factor assessment for osteoporosis and/or increased fracture risk in men. Austin (TX): University of Texas, School of Nursing; 2008 May. 14 p. [35 references]

This is the current release of the guideline.

Strength of recommendations (A, B, C, D, I) and quality of evidence (good, fair, poor) are defined at the end of the "Major Recommendations" field.

Risk Assessment

Assess male patients for the following risk factors during history taking.  The following have been identified as being associated with increased risk of osteoporosis in men:

1. Medications
   1. Glucocorticoid use of 5 mg or greater for 3 months or longer (Rosen, 2006; Mauck & Clarke, 2006) Good Evidence; (Campion & Maricic, 2003) Fair Evidence
   2. Anticonvulsants including phenobarbital, phenytoin, and carbamazepine (Rosen, "Drugs that affect bone metabolism," 2007) Good Evidence; (Campion & Maricic, 2003) Fair Evidence
   3. Past chemotherapy including methotrexate, ifosfamide and/or imatinib or radiation treatment (Rosen, "Drugs that affect bone metabolism," 2007) Good Evidence; (Grey et al., 2006) Fair Evidence

   4. Hormone deprivation therapy being used for greater than one year as treatment for prostate cancer (Bruder et al., 2006; Greenspan et al., 2005) Fair Evidence; (Finkelstein, 2007) Good Evidence
   5. There is mixed evidence of several drugs which may have negative impact on bone density/fracture risk which need further research including:
      • Warfarin use for greater than or equal to one year (Rosen, "Drugs that affect bone metabolism," 2007; Gage, Birman-Deych, & Radford, 2006) Good Evidence
      • Selective serotonin reuptake inhibitors (SSRIs) (Busko, 2007) Fair Evidence; (Haney et al., 2007; Rosen, "Drugs that affect bone metabolism," 2007) Good Evidence
      • Long term use of retinoid and vitamin A supplementation >5000 units of vitamin A/day (Rosen, "Drugs that affect bone metabolism," 2007) Good Evidence
      • Proton pump inhibitors long-term use greater than 1 year (Rosen, "Drugs that affect bone metabolism," 2007; Yang et al., 2006; Vestergaard, Rejnmark, & Mosekilde, 2006) Good Evidence
      • Excessive use of antacids (Vestergaard, Rejnmark, & Mosekilde, 2006) Good Evidence
      • Aggressive treatment of hypothyroidism with overuse of thyroxine (Ross, 2007) Good Evidence

2. Modifiable Lifestyle
   1. Body weight <70 kg (Shepherd et al., 2007; Mauck & Clarke, 2006) Good Evidence
   2. Heavy tobacco or ≥14 drinks of alcohol/wk use (Campion & Maricic, 2003) Fair Evidence; (Cawthon et al., 2006; Finkelstein, 2007) Good Evidence
   3. Sedentary lifestyle (Michaelsson, Olofsson, & Jensevik, 2007) Good Evidence
   4. Nutritional deficits (vitamin D or calcium deficits) (Mauck & Clarke, 2006) Good Evidence; (Vondracek & Hansen, 2004) Fair Evidence

3. Non-modifiable Lifestyle
   1. Race (Caucasian & Asian at higher risk) (Vondracek & Hansen, 2004) Fair Evidence
   2. Genetic propensity (Finkelstein, 2007) Poor Evidence; (Mauck & Clarke, 2006) Fair Evidence
   3. Increasing age (Shepherd et al., 2007; Skedros, Sybrowsky, & Stoddard, 2007) Good Evidence
   4. Mobility impairments (hemiplegic, wheelchair bound) (Mauck & Clarke, 2006) Good Evidence; (Khosla, 2008) Fair Evidence
   5. Height loss of 1.5 inches or greater (Finkelstein, 2007) Good Evidence

4. Medical Conditions
   1. Pulmonary - Asthma, chronic obstructive pulmonary disease (COPD) (Mineo, 2005; Shepherd et al., 2007) Good Evidence
   2. Gastrointestinal (GI) - Inflammatory bowel disease (especially Crohn's), celiac disease, gastric resection, gastrectomy (Siffledeen et al., 2007; Rosen, "Metabolic bone disease," 2007) Good Evidence
   3. Nephrology - Hypercalciuria, renal insufficiency or failure (Vondracek & Hansen, 2004; Khosla, 2008) Fair Evidence; (Rosen, "Drugs that affect bone metabolism," 2007) Good Evidence
   4. Hepatic - Chronic liver disease (especially primary biliary cirrhosis) (Campion & Maricic, 2003) Fair Evidence; (American Gastroenterological Association [AGA], 2003) Good Evidence
   5. Endocrine - Hypogonadism (Bruder et al., 2006; Greenspan et al., 2005; Campion & Maricic, 2003) Fair Evidence; hyperthyroidism, hyperparathyroidism (Grey et al, 2006) Fair Evidence; diabetes (Vestergaard, Rejnmark, & Mosekilde,2006) Good Evidence; Cushing's disease (Vondracek & Hansen, 2004) Fair Evidence
   6. Hematology - Rheumatoid arthritis (Vondracek & Hansen, 2004) Fair Evidence
   7. Musculoskeletal disorders - Osteogenesis imperfecta, ankylosing spondylitis, (Khosla, 2008) Fair Evidence; prior history of low impact fractures (Mauck & Clarke, 2006) Fair Evidence
   8. Neuro - Parkinson's Disease (Fink et al., 2005) Fair Evidence; dementia, blindness, multiple sclerosis, cerebral vascular accident, (Mauck & Clarke, 2006) Good Evidence
   9. Immunosuppression related to organ transplant, cancer, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (Brown et al., 2004; Mauck & Clarke, 2006; Vondracek & Hansen, 2004) Fair Evidence

Men with the following risk factors are strongly recommended for screening for osteoporosis:

• All men with a height loss of 1.5 inches or greater (Finkelstein, 2007) Good Evidence; Recommendation A
• All men 65 years and older who have been on glucocorticoid therapy for greater than 3 months at doses greater than or equal to 5 mg/day (Mauck & Clarke, 2006; Rosen, 2006; Sinnott, Kukreja, & Barengolts, 2006) Good Evidence; Recommendation A
• All men 65 years and older who have a personal or first degree family member history of non traumatic fracture in adulthood (Mauck & Clarke, 2006; Lewiecki, 2007; Kanis, Borgstrom, & De Laet, 2005) Good Evidence; Recommendation A
• All men 65 years and older who have a history of hypogonadism for at least 5 years (Barclay, 2008) Fair Evidence; (Mauck & Clarke, 2006; Lie, 2008, Finkelstein, 2007) Good Evidence; Recommendation A
• All men 65 years and older be calculated for risk using the following formula adapted from the Osteoporosis Screening Tool (OST)

  [Wt (kg) – age (yrs)] x 0.2

  If results are -1 or less, the man is recommended for screening for osteoporosis, especially if he has a history of COPD and/or a gastrectomy. (Sinnott, Kukreja, & Barengolts, 2006; Adler, Tran, & Petkov., 2003; Skedros, Sybrowsky, & Stoddard, 2007; Zimering et al., 2007; Lynn et al., 2005; Shepherd et al., 2007) Good Evidence; Recommendation A

Men with the following risk factors are recommended for screening:

• Men 70 years and older with any of the medical conditions or long term medication use noted in the risk factor list (Mauck & Clarke, 2006; International Society for Clinical Densitometry [ISCD], 2007) Good Evidence; Recommendation C
• All men 70 years and older with low body weight (<70 kg) combined with a history of long term alcohol use, smoking >5 years, or immobility >6 months. (Finkelstein, 2007; Cawthon et al., 2006; Kanis, Borgstrom, & De Laet, 2005; Shepherd et al., 2007; ISCD, 2007) Good Evidence; (Khosla, 2008) Fair Evidence; Recommendation B

Men with the following risk factors may be considered for screening:

• All men 70 years and older (Campion & Maricic, 2003) Fair Evidence; (ISCD, 2007) Good Evidence; Recommendation C
• All men who have a history of hypogonadism for at least 5 years (Finkelstein, 2007; Cawthon et al., 2006) Good Evidence; (Khosla, 2008) Fair Evidence; Recommendation B

Screening methods may include but are not limited to dual energy X-ray absorptiometry (DEXA), testosterone levels, 25-hydroxyvitamin D (Vitamin D 25-OH) levels, urinary calcium/creatinine ratio. The method for screening should be utilized based upon the mechanism of how the drug and/or disease/condition cause poor bone quality and/or osteoporosis.

Definitions:

Strength of Recommendations (Based on U.S. Preventive Services Task Force [USPSTF] Ratings)

A. There is good evidence that the recommendation improves important health outcomes. Benefits substantially outweigh harms.

B. There is at least fair evidence that the recommendation improves important health outcomes. Benefits outweigh harms.

C. There is at least fair evidence that the recommendation can improve health outcomes but the balance of benefits and harms is too close to justify a general recommendation.

D. There is at least fair evidence that the recommendation is ineffective or that harms outweigh benefits.

I. Evidence that the recommendation is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Quality of Evidence (Based on USPSTF Ratings)

• Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes
• Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
• Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

None provided

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

• University of Texas, School of Nursing, Family Nurse Practitioner Program. Risk factor assessment for osteoporosis and/or increased fracture risk in men. Austin (TX): University of Texas, School of Nursing; 2008 May. 14 p. [35 references]

Not applicable: The guideline was not adapted from another source.

2008 May

University of Texas at Austin School of Nursing, Family Nurse Practitioner Program - Academic Institution

University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program

Practice Guidelines Committee

Authors: Terri Bagwell, RN, MSN; Megan Banks, RN, BSN; Debbie Butz, RN, MSN

Expert Consultant: Sharon Hausman-Cohen, MD

None stated

This is the current release of the guideline.

Electronic copies: None available.

Print copies: Available from the University of Texas at Austin, School of Nursing. 1700 Red River, Austin, Texas, 78701-1499

None available

None available

This NGC summary was completed by ECRI Institute on September 18, 2008.

This NGC summary is based on the original guideline, which may be subject to the guideline developer's copyright restrictions.