New Review Identifies Diabetes Patients at Increased Fracture Risk

A newly devised algorithm can help clinicians identify and manage diabetic patients at increased fracture risk, according to a new study.

An expert review by the International Osteoporosis Foundation Bone and Diabetes Working Group outlines key research and provides valuable insights and clinical guidance for the diagnosis and treatment of bone fragility in diabetes.

Fragility fractures are a serious yet neglected complication of both type 1 and type 2 diabetes mellitus (T2DM), with fracture risk that increases with disease duration and poor glycemic control. However, identification and management of fracture risk in these patients remains challenging, the reviewers note.

The expert review summarizes key research, highlights clinical issues, and provides a helpful decision-tree style algorithm for the identification and management of diabetic patients at increased fracture risk.

“The link between diabetes and skeletal health is complex and the optimal approach to the management of bone health in patients with diabetes is not yet definitive and may change over time as findings of new clinical studies become available,” stated Professor Serge Ferrari, MD, chair of the IOF Committee of Scientific Advisors and of the IOF Bone and Diabetes Working Group. “This new review will inform clinicians about the current state of knowledge, and, importantly, the clear algorithm will facilitate the clinical assessment and management of fragility fracture risk in their patients according to current best practice.”

The researchers published their review online July 31, 2018 in Osteoporosis International.

The review outlines the clinical characteristics of bone fragility in adults with diabetes and highlights recent studies that have evaluated bone mineral density (BMD), bone microstructure and material properties, biochemical markers, and fracture prediction (FRAX). It also looks at the impact of diabetes drugs on bone, as well as the efficacy of osteoporosis treatments in these patients.

The key messages in the review include:

• The pathophysiology of bone fragility in diabetes is likely multifactorial.

• FRAX and BMD T-score predict fracture risk in those with T2DM, but both require adjustment for diabetes to avoid underestimation of risk.

• If a patient has indication for therapy based on criteria developed for nondiabetic patients, they should be treated with osteoporosis drugs. In the absence of established osteoporosis, these medications may be used, although with caution as the effects of these drugs in situations where bone fragility is mainly due to alterations in bone quality remain to be thoroughly evaluated.

• Future studies should continue to evaluate the structural determinants (eg, microstructure and material properties) of bone fragility and refine fracture prediction algorithms by including disease-specific determinants of fracture.

• New trials will have to prospectively investigate the efficacy and safety of osteoporosis treatment in diabetics with and without low areal BMD.

“The optimal approach to management of patients with diabetes has not yet been established based on prospective clinical studies. Hence, our currently proposed algorithm should be considered as a consensus among some experts which may change over time as more evidence will be gathered,” stated the reviewers.

References:

Ferrari SL, Abrahamsen B, Napoli N, et al. Diagnosis and management of bone fragility in diabetes: an emerging challenge. Osteoporos Int. 2018.