Julien Paccou

Osteoporosis in men is under-recognized and under-treated despite a substantial disease burden and poorer fracture-related outcomes than in women. Secondary osteoporosis is highly prevalent in men, making the identification and management of underlying causes essential. BMD and fracture risk are influenced by sex-specific patterns of skeletal growth and age-related bone loss, with men typically exhibiting greater cortical thickness, larger bone size, and trabecular thinning rather than loss of trabecular number. Although randomized controlled trials in men are fewer than in postmenopausal women, bisphosphonates, denosumab, teriparatide, abaloparatide, and romosozumab have all been shown to significantly increase BMD. Fracture outcome data remain limited; however, reductions in vertebral fracture risk have been demonstrated for zoledronate, alendronate, risedronate, denosumab, and teriparatide. Treatment should be individualized according to fracture risk, comorbidities, and patient preferences. In men at very high fracture risk, osteoanabolic therapy should be considered as first-line treatment, followed by antiresorptive therapy to consolidate and maintain BMD gains. Goal-directed (treat-to-target) management, including long-term maintenance therapy, and careful discontinuation strategies, particularly following denosumab, is essential for optimizing long-term skeletal health. This narrative review and position statement by The ECTS Clinical Action Group provides an updated overview of current and emerging treatment options and offers practical, evidence-based recommendations for the long-term management of osteoporosis in men.

Objective: To evaluate and compare the efficacy of anti-osteoporotic-medications (AOM) for the prevention and treatment of glucocorticoid-induced-osteoporosis (GIOP). Design: Systematic review and network-meta-analysis conducted in accordance with PRISMA-NMA guidelines (ProsperoID: CRD42024502298). Methods: MEDLINE, Embase, and Web of Science were searched from inception to December 2025 to identify randomized-controlled-trials and comparative-observational-studies evaluating AOM in adults receiving oral glucocorticoids (GC). Outcomes included percentage change in areal bone- mineral-density (aBMD) at the lumbar-spine (primary), femoral-neck, and total-hip. A random effects network-meta-analysis was performed, integrating direct and indirect comparisons across AOM. Certainty of evidence was assessed using the CINeMA framework. Results: Thirty-one studies (28 randomized-controlled-trials and 3 observational-studies) involving 5260 participants (age-range: 29.6-70.6 years, 72.5% females) were included. All AOM were superior to placebo or calcium/vitaminD supplementation in increasing lumbar-spine aBMD. Teriparatide demonstrated the greatest efficacy compared with alendronate (effect-size: 3.8; 95% CI: 2.9-4.6), risedronate (4.0; 95% CI: 2.9-5.1), denosumab (1.5; 95% CI: 0.1-2.9), and zoledronate (2.4; 95% CI: 1.1-3.6), while no significant difference was observed with romosozumab (0.3; 95% CI: −2.1 to 1.4). Among antiresorptive-medications, zoledronate and denosumab showed greater efficacy than oral bisphosphonates, which demonstrated modest positive effects. In sensitivity analyses restricted to established GIOP, defined as GC users ≥3months, teriparatide and romosozumab remained superior to antiresorptive-medications. Evidence for total-hip and femoral-neck aBMD outcomes was limited by substantial network inconsistency (mostly missing data). Included studies were underpowered to assess difference in fracture outcomes. Conclusions: This network-meta-analysis demonstrates a clear gradient of efficacy among AOM in GIOP, with anabolic and potent antiresorptive-medications producing the largest gains in lumbar-spine aBMD supporting current ECTS recommendations advocating risk-stratified treatment selection.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have transformed obesity management through substantial weight loss and cardiometabolic benefits. However, their effects on musculoskeletal health, including bone, muscle, and joint outcomes, remain incompletely understood. This narrative review critically summarizes current evidence regarding the impact of GLP-1RAs and related incretin-based therapies on bone metabolism and fracture risk, muscle mass and function, osteoarthritis (OA), and inflammatory rheumatic diseases (IRDs) in people living with obesity (PwO). We reviewed preclinical, observational, and interventional studies, including randomized controlled trials evaluating musculoskeletal outcomes associated with GLP-1RA exposure. Obesity is associated with complex alterations in the musculoskeletal system, including increased bone mineral density (BMD) despite impaired bone quality, sarcopenia, OA progression, and greater incidence and severity of IRDs. Preclinical studies suggest potentially favorable effects of GLP-1RAs on bone metabolism and cartilage homeostasis. In humans, however, available evidence indicates largely neutral or modest adverse effects on bone turnover and BMD, mainly related to weight loss-associated skeletal unloading. In knee OA, GLP-1RAs appear to improve pain and physical function. These agents are also associated with reductions in lean mass, although the functional implications of these changes remain uncertain, particularly in individuals with sarcopenic obesity. Data regarding IRDs are limited, but findings from the PsA-TOGETHER trial showed that combined tirzepatide and ixekizumab therapy induced clinically meaningful weight loss accompanied by improvements in psoriatic arthritis disease activity, supporting a potential relationship between weight reduction and inflammatory disease control. Overall, incretin-based therapies may provide beneficial effects on selected musculoskeletal outcomes in PwO, particularly OA symptoms and inflammatory burden. Nevertheless, the long-term consequences of GLP-1RAs on bone metabolism, muscle mass, and physical performance remain uncertain. Dedicated mechanistic studies and adequately powered clinical trials are needed to better define their musculoskeletal safety profile and to develop strategies aimed at preserving bone mass, lean mass, and functional capacity, especially in older adults.

Age-related decline in sex hormones is the most frequent cause of primary osteoporosis; however, secondary causes contribute to osteoporosis in a substantial proportion of cases. These causes are diverse and often overlooked, ranging from endocrine diseases to chronic inflammatory conditions and medication use. The identification and exclusion of secondary causes of osteoporosis is crucial, because treatment typically begins by addressing the underlying condition. Investigation to exclude common secondary causes is recommended for everyone presenting with fractures indicative of osteoporosis. Advanced investigations are reserved for premenopausal individuals and those aged <50 years, and for older people in whom common risk factors, comorbidities or drugs predisposing to osteoporosis are absent. The risk of fracture can be underestimated by bone mineral density in some chronic diseases and overestimated in others. Specific adjustments can be made to the criteria in the online fracture risk FRAX calculator to provide a more accurate estimation of fracture risk in people with some forms of secondary osteoporosis. The response to conventional anti-osteoporosis treatments can be suboptimal if the underlying condition remains unrecognized and untreated. In most conditions, the evidence for antiresorptive or anabolic therapy is based on changes in bone mineral density rather than fracture. This Review covers the aetiology, pathogenesis, diagnosis and management of secondary osteoporosis, together with key areas for future research.

Introduction: Postoperative complications after metabolic and bariatric surgery (MBS) increase with age, yet data on bone health in older postmenopausal women remain limited. The 2022 European Calcified Tissue Society (ECTS) position statement recommend anti-osteoporotic medication (AOM) for patients with a T-score ≤ −2 and/or a fragility fracture within the past two years. This study evaluated the prevalence of AOM eligibility according to age (< 60 vs. ≥ 60 years) in postmenopausal women and identified associated risk factors. Materials and Methods: We conducted a cross-sectional, observational, single-center study at Lille University Hospital including postmenopausal women referred for bone health evaluation before or after MBS. AOM eligibility was defined according to the 2022 ECTS criteria. Results: Among 306 postmenopausal women, 173 were < 60 years (group 1) and 133 were ≥ 60 years (group 2). Overall, 69 patients (22.5%) were eligible for AOM, with a significantly higher prevalence in women ≥ 60 years (30.1% vs. 16.8%, p = 0.006). In multivariate analysis, independent predictors of AOM eligibility were age ≥ 60 years (OR = 2.34, 95% CI: 1.19–4.61), active smoking (OR = 2.98, 95% CI: 1.27–7.02), reduced appendicular lean mass index (ALMI < 5.5 kg/m ² ; OR = 3.72, 95% CI: 1.78–7.78), and elevated iPTH (OR = 1.15, 95% CI: 1.05–1.25 per 10 ng/mL increase). Conclusion: Nearly one in five postmenopausal women undergoing MBS were eligible for AOM based on the ECTS position statement, with prevalence doubling after 60 years (OR = 2.34). Active smoking, secondary hyperparathyroidism, and low ALMI were key independent risk factors. These findings underscore the importance of systematic bone health assessment and early implementation of lifestyle interventions, alongside AOM, to reduce fracture risk in this vulnerable population.