Table 5: Suggested approach for diagnosis and management of male osteoporosis in COPD patients.

Initial evaluation
(i) Detailed medical history and physical examination
(ii) Documentation of height, weight, and BMI
(iii) Assessment of COPD severity
(iv) Definition of major risk factors associated with low BMD and fractures
(v) Exclusion or treatment of other secondary causes of bone loss in men
(vi) Assessment of serum 25-OHD. Additional laboratories tests, as suggested by results of clinical evaluation
(vii) Confirmation with lateral spinal radiography of possible vertebral fracture in patients with back pain, height loss, or kyphosis

BMD measurement with DEXA
(i) Recommendations:
All COPD men with 3 minor (BMI < 21 kg/m2, current smoking, use of ethanol  >3 units/day, age > 65 years, parent hip fracture, rib fracture, inactivity, FEV1 < 50% predicted) or 1 major [systemic corticosteroids (3 months/year), major fragility fracture (spine-hip)]
(ii) Sites: hip and lumbar spine
(iii) Diagnostic categories of BMD according to WHO: definition of osteopenia (low bone mass) as BMD T-score between −1.0 and −2.5 SD and definition of osteoporosis as BMD T-score ≤−2.5 SD
(iv) Measurement interval:
  (1) 2 years or more to follow loss or treatment effect
  (2) 1 year if use of OGCSs without antiresorptive therapy

Fracture risk estimation
(i) Fracture risk assessment tool (FRAX), is a useful supplement to BMD assessments, as it helps physicians to decide which patients might require prolonged treatment to reduce the risk of future fractures

Prevention and treatment of osteoporosis
(i) Lifestyle measures and nutritional recommendations
  (1) Smoking cessation or avoidance.
  (2) Reduction of alcohol consumption, if excessive
  (3) Weight-bearing and strengthening exercise
  (4) Counselling on fall prevention
  (5) Rehabilitation programs in moderate to severe COPD
  (6) Calcium and vitamin D supplementation (1000 mg and 800 IU, respectively) to everyone COPD man
(ii) Management of COPD treatment based on the use of limited CS doses.
(ii) Drug therapy
  (1) Bisphosphonates
 (2) Anabolic drugs (teriparatide)

OGCS: oral glucocorticosteroids; CS: corticosteroids; ICS: inhaled corticosteroids; BMI: body mass index; WHO: World Health Organization; FEV1: forced expiratory volume in 1 second; FVC: forced vital capacity; COPD: chronic obstructive pulmonary disease; BMD: bone mineral density; DEXA: dual energy X-ray absorptiometry.