Screening men for osteoporosis
==============================

* Aliya A. Khan MD
* Anthony B. Hodsman, MB BS
* Alexandra Papaioannou, MSc MD
* David Kendler MD
* Jacques P. Brown MD
* Wojciech P. Olszynski, MD PhD

*   © 2007 Canadian Medical Association or its licensors

[The authors respond:]

We thank Dara Behroozi for raising an important point concerning our article.1 Unfortunately, the data currently available on the cost-effectiveness of bone densitometry in men are very limited. Schousboe and colleagues recently evaluated the cost-effectiveness of bone densitometry followed by 5 years of oral bisphosphonate therapy to prevent fractures among older men with osteoporosis in the United States.2 They concluded that bone densitometry for all men as young as 70 years of age may be cost-effective. This assumes a societal willingness to pay US$100 000 per quality-adjusted life-year gained in addition to drug costs. The Osteoporosis Society of Canada's guidelines emphasize assessing key clinical risk factors for fracture (e.g., previous fracture history and glucocorticoid use) in conjunction with bone mineral density testing to determine treatment thresholds.3 In our article, we recommend targeting those at high risk of developing a fragility fracture for pharmacological intervention, which would improve the cost- effectiveness of treatment.

On the basis of current expert opinion, the Osteoporosis Society of Canada's recommendations for bone mineral density testing and clinical risk factor assessment are appropriate. It is true that in the absence of a defining fracture event, a low bone mineral density alone places a man at less risk for fracture than a woman of similar age with a similar bone mineral density. White men at age 60 have a 29% risk of experiencing a fracture.4 One-third of all hip fractures occur in men; they are associated with equivalent morbidity and higher mortality compared with those occurring in women.5 Vertebral fractures are also associated with similar morbidity in men and women.6 More detailed Canadian studies will help to assess the cost-effectiveness of bone mineral density screening in men. The Osteoporosis Society of Canada is in the process of completing an exhaustive evidence-based review of osteoporosis in men, the results of which will be reflected in future guidelines.

## Footnotes

*   **Competing interests:** None declared by Wojciech Olszynski. Aliya Khan has received consultancy fees, research grants and/or honoraria from Aventis–Sanofi, Merck, Eli Lilly, Novartis, NPS Allelix, Servier and Proctor & Gamble. Anthony Hodsman has received consultancy fees, research grants and honoraria from Eli Lilly, Merck Frosst, NPS Allelix, Zelos Therapeutics, Servier, Proctor & Gamble and Sanofi–Aventis. Alexandra Papaioannou has been a consultant to, has conducted clinical trials for and has received unrestricted grants from Eli Lilly, Merck Frosst, Procter & Gamble and Aventis–Sanofi. She has also been a consultant to and has received unrestricted grants from Amgen and has conducted clinical trials for Novartis. David Kendler has served on the advisory board and speakers' bureau of and/or has received research grants from Alliance, Merck, Servier, Eli Lilly, Wyeth, Takeda, Zelos, Roche, Novartis and Pfizer. Jacques Brown has received consultancy and speaker's fees from Eli Lilly, Merck Frosst, Novartis, Sanofi–Aventis, Procter & Gamble Pharmaceuticals, Amgen and Wyeth.

## REFERENCES

1.  1. Khan A, Hodsman AB, Papaioannou A, et al. Management of osteoporosis in men: an update and case example. CMAJ 2007;176:345-8.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNzYvMy8zNDUiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTc3LzkvMTA2OS4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  2. Schousboe JT, Taylor BC, Fink HA, et al. Cost- effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA 2007; 298: 629-37.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/jama.298.6.629&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=17684185&link_type=MED&atom=%2Fcmaj%2F177%2F9%2F1069.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000248574800023&link_type=ISI) 

3.  3. Brown JP, Josse RG; Scientific Advisory Council of the Osteoporosis Society of Canada. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada [published errata in CMAJ 2003;168:400, 2003;168:544 and 2003;168:676]. *CMAJ* 2002;167(Suppl 10):S1-34.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjgvNC80MDAiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTc3LzkvMTA2OS4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  4. Mussolino ME, Looker AC, Madans JH, et al. Risk factors for hip fracture in white men: the NHANES I Epidemiologic Follow-up Study. J Bone Miner Res 1998;13:918-24.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1359/jbmr.1998.13.6.918&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9626622&link_type=MED&atom=%2Fcmaj%2F177%2F9%2F1069.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000073958600002&link_type=ISI) 

5.  5. Trombetti A, Herrmann F, Hoffmeyer P, et al. Survival and potential years of life lost after hip fracture in men and age-matched women. Osteoporos Int 2002;13:731-7.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1007/s001980200100&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12195537&link_type=MED&atom=%2Fcmaj%2F177%2F9%2F1069.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000178083900007&link_type=ISI) 

6.  6. Jackson SA, Tenenhouse A, Robertson L. Vertebral fracture definition from population-based data: preliminary results from the Canadian Multicenter Osteoporosis Study (CaMos). Osteoporos Int 2000; 2:680-7.