Kebijakan Pelayanan Pasien Risiko Tinggi Dengan BHD Dll Afif Fanny GP



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  Osteoporosis in Men Abstract Osteoporosis is a significant threat to aging bone in men Thirtypercent of hip fractures occur in men; during initial hospitalizationand the first year after fracture, the mortality rate is twice that ofwomen Nevertheless, osteoporosis in men is grossly underdiag-nosed and undertreated The most frequent factors associated withosteoporosis in men are age >75 years, low baseline body mass in-dex (<24 kg/m 2 ), weight loss >5% over 4 years, current smoking,and physical inactivity Osteoporosis in men is either secondary toa primary disease or is idiopathic It exhibits a bimodal age distri-bution, with peaks at age 50 years (secondary disease) and at age70 years (idiopathic) Prevention and early detection currently arethe best forms of management Alone or in combination, calcium,vitamin D, bisphosphonates, and human parathyroid hormone areall effective management options In the acute setting of fragilityfracture, the orthopaedic surgeon is key in identifying patients atrisk because the surgeon provides primary care and may initiateprophylactic measures to prevent future fractures I t is estimated that more than 2million men in the United Statescurrently have osteoporosis 1,2 Al-though a threat to successful aging,this issue is largely unrecognizedOsteoporosis in men silentlyprogresses, with initial diagnosistypically made after hip or spinefracture Even after such fragilityfractures, osteoporosis in men isgrossly underdiagnosed and under-treated 3 As the primary physiciantreating fractures, the orthopaedicsurgeon can play a greater role inidentifying men with osteoporosisfor targeted intervention to preventthe possibility of future fracturesThirtypercentofhipfracturesoc-cur in men, and during the initialhospitalization and in the first yearfollowing fracture, men have twicethe mortality rate of women 3 Lossof independence often is a result ofhip fracture; consequently, one thirdof men in this population move intoa nursing facility or the home of arelative 4 With the potential for 77million men entering the at-risk agegroup in the next 15 to 20 years, theprevention,diagnosis,andtreatmentof men with osteoporosis is crucialto prevent fragility fractures Etiology Although osteoporosis historicallyhasbeenperceivedasadiseaseofag-ing women, in 1992, the Framing-ham study indicated that loss offemoral neck bone density was lin-ear with age and equivalent in menand women 5 In fact, osteoporosis isadiseaseofbothyoungandoldmen,with a prevalence of 4% to 6% inmen older than age 50 years An ad-ditional33%to47%ofmenhaveos-teopenia 1 Inabsoluteterms,23mil-lion men in the United Statescurrently have osteoporosis, and118 million have low bone densi- Vonda J Wright, MD Dr Wright is Fellow, Sports Medicineand Shoulder Services, Hospital forSpecial Surgery, New York, NY, andClinical Instructor, Department ofOrthopaedic Surgery, University ofPittsburgh, Pittsburgh, PANeither Dr Wright nor the departmentwith which she is affiliated has receivedanything of value from or owns stock in acommercial company or institutionrelated directly or indirectly to thesubject of this articleReprint requests: Dr Wright, Suite1010, 3471 5th Avenue, Pittsburgh, PA15213 J Am Acad Orthop Surg  2006;14:347-353Copyright 2006 by the AmericanAcademy of Orthopaedic SurgeonsVolume 14, Number 6, June 2006  347  ty 2 Evaluated according to race, theprevalence of osteoporosis in theUnited States is highest in Cauca-sian men (7%), followed by African-American men (5%) and Hispanicmen (3%) 6 The World Health Or-ganizationdefinitionofosteoporosisis a T-score of at least 25 standarddeviations below the mean bonemineral density (BMD) of youngmen (age 30 years) Although thisstandard was developed for women,it is currently being used in diagnos-ing osteoporosis in men However,controversy exists as to whether theuseofastandarddevelopedforwom-enaccuratelyreflectsthemeasureofBMD loss necessary for diagnosis ofosteoporosis in men 7 As many as 85% of all hip frac-tures and 90% of all vertebral frac-tures in men are attributed to os-teoporosis 8 Unlike the usualsituation in women, however, os-teoporosis in men typically is undi-agnosed until the patient sustains afragility fracture Because men startwith a higher peak BMD, they beginto experience fragility fractures10 years later than the age at whichwomen do (ie, 75 years) Thus, at ap-proximately age 85 years, absoluteBMD in a man generally is the sameas that of a woman who began tosustain fragility fractures at approx-imately age 75 years This is true forhip, vertebral, and distal radius frac-turesThe incidence of fracture be-comes similar between men andwomen with advancing age 9 Olderage at fracture and increased age-related medical comorbidities resultin men dying at twice the rate ofwomen after hip fracture 10 Morethan 50% of the remaining menhave chronic pain and require assis-tive devices for walking at 6months 2 After age 50 years, theprevalence of osteoporosis fragilityfractures in men increases by 5%These data are based on male life ex-pectancy and comorbidity factorsthat may produce osteoporosis 11 One recent study 3 found the careof men with osteofragility to be lim-ited Conducted at a large tertiarymedical center, the study comparedthe diagnosis and treatment of os-teoporosis in men and women afterhip fracture Although both groupswere matched for age, fracture, andfracturecare,only45%ofmenwerereferredfortreatmentofosteoporosisat the time of discharge versus 27%of women At 1- to 5-year follow-up,treatment of men continued to lagbehindwomenatarateofmorethan25:1 Further, most of the men whowere treated received only calciumand vitamins without antiresorptivetherapytoreduceosteoclastactivityAt 1- to 5-year follow-up, only 11%of men had a BMD measurement,compared with 27% of womenThe economic costs of fragilityfracture are high, for the individualpatient as well as to the health caresystem in general It is estimatedthat 25 billion is spent annually inthe United States in caring for menwith osteoporotic fractures 12 Morehospital days are used to care formen with osteoporotic fracturesthan those with prostate cancer 13 The number of hip fractures in menis expected to increase 310% by2050, versus 240% in women 14 Table 1 compares osteoporosisand fragility fracture occurrence inmen and women The prevalence ofosteoporosis in men is lower thanthat in women for four primary rea- Table 1Comparison of Osteoporosis and Fracture Occurrence in Men and Women Factor Men WomenLifetime risk of osteoporosis 7 13%-25% 50%Usual presentation Fragility fracture, backpain, loss of heightAsymptomaticvia DXA scanOnset of osteoporosis 7 10 years later than inwomen; bimodalprevalence (at ages 50and 70 years)Prevalenceskewed towardlater yearsPrevalence of osteopeniaafter age 50 years 7,15 33%-47% 50%Prevalence of osteoporosisafter age 50 years 15 3%-6% 13%-18%Causes of osteoporosis 50% idiopathic,50% secondaryMost idiopathicPeak bone mass 10% greater than in women —Lifetime risk of hipfracture at age 50 years 16 6% 17%Incidence of hip fractureafter age 65 years 16 5/1,000 10/1,000Mortality within 1 yearafter hip fracture 17 31% 17%Number of patientsreceiving treatment forosteoporosis 1-5 yearsafter fragility fracture 1 27% 71%Prevalence of osteoporoticspine fractureAfter age 50 years, 5% 11 By age 60 years,116%; by age 90 years,517% 18 DXA = dual-energy x-ray absorptiometry Osteoporosis in Men  348  Journal of the American Academy of Orthopaedic Surgeons  sons First, men accumulate morebonemassduringdevelopmentSec-ond, men do not experience thesame abrupt hormone decline thatwomen do at approximately age50 years; rather, men experience aslow, steady decline in testosteroneand bioavailable estrogen Third,men historically have had shorterlife spans than women and thereforehave had less time to develop fragil-ity fractures 19 With increased lifeexpectancy, however, more men arenow living long enough to developosteofragilityFinally,althoughbothmen and women with age lose can-cellousboneatperipheralsites,menbegin with greater bone mass; thus,over their lifetimes, women losemore central trabecular bone andcortical bone than do men 20,21 Risk Factors Multiple risk factors have been at-tributed to the development of os-teoporosis in men Approximatelyhalfofthesefactorsarearesultofei-ther genetics or age, with the re-mainder secondary to modifiablevariables (Table 2) Bakhireva et al 22 prospectively examined the predic-tors of bone loss in older men (aged45 to 92 years) and determined thatthe most important factors were age>75 years, low baseline body massindex (<24 kg/m 2 ), weight loss >5%over 4 years, current smoking, andphysical inactivity Sedentary menhad greater BMD loss in the femoralneck and lumbar spine than didphysically active men Fracture riskincreases, not only with low BMD(<185 kg/m 2 ) but also with historyofpreviousfracture,maternalhisto-ry of hip fracture, and weight loss>10% 23 Classification MendeveloposteoporosisasaresultofprimaryorsecondarycausesThisresults in a bimodal prevalence overtime Cross-sectional studies haveshown that men have two distincttime frames for presenting with os-teoporosis The first, resulting fromsecondary or disease-related causes,occurs at approximately age 50years; the second wave—idiopathicor age-related osteoporosis—occursafter age 70 years 19 Secondary Osteoporosis It is more common for men thanwomen to develop osteoporosis sec-ondary to an underlying disease ormetabolic derangement At least50% of the causes of osteoporosis inmenareascribedtootherdiseasesorto lifestyle choices 1 Categorically,these include genetic disorders, life-style choices, drug-induced boneloss, malabsorptive diseases, and en-docrinedisordersOfthese,themostfrequent causes of secondary os-teoporosisinmenareexcessivealco-hol consumption, corticosteroidtherapy, and hypogonadism 1 Genetic Causes The genes predisposing men toosteoporosis have not yet been iden-tified Several case reports, however,have implicated estrogens as keyplayers in the regulation of peakBMD in men In these case reports,in which each patient was os-teoporotic, estrogen was not avail-able to bone, either because of a mu-tation in the estrogen receptor geneor an inability to convert androgenstoestrogen 24,25 Severalgeneticdisor-ders, including homocystinuria,Marfan syndrome, and osteogenesisimperfecta, are known to cause os-teoporosis and osteopenia 26,27 Lifestyle Factors Lifestyle choices can have a pro-found impact on bone healthChronic alcohol use (>7 oz/wk) di-rectlysuppressesosteoblastactivitySmoking lowers BMD and increasesthe risk of hip and vertebral frac-ture 28,29 Smoking also increases therisk of hip fracture by 40% Low cal-cium and vitamin D levels, as wellas insufficient sun exposure, alsocontributetothedevelopmentofos-teoporosis Although the literatureshows mixed results, in general, in-activity is thought to contribute toloss of BMD Table 2Risk Factors for the Development of Osteoporosis in Men 7,22 Modifiable lifestyle risk factors Excessive alcohol use (>7 oz/wk)Tobacco useSedentary lifestyleLow body mass indexLow calcium and vitamin D intakeMedicationAnticonvulsantsOral glucocorticoidsCyclosporinMethotrexateHeparin Nonmodifiable risk factors AgeFamily history of fragility fracturesProstate cancer with luteinizing hormone–releasing hormone analogue useTestosterone and estrogen deficiencyPeptic ulcer diseaseRheumatoid arthritisHyperthyroidHyperparathyroidHypercalciuria Vonda J Wright, MDVolume 14, Number 6, June 2006  349