Critical review of bone health, fracture risk and management of bone fragility in diabetes mellitus

Abstract

The risk of fracture is increased in both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). However, in contrast to the former, patients with T2DM usually possess higher bone mineral density. Thus, there is a considerable difference in the pathophysiological basis of poor bone health between the two types of diabetes. Impaired bone strength due to poor bone microarchitecture and low bone turnover along with increased risk of fall are among the major factors behind elevated fracture risk. Moreover, some antidiabetic medications further enhance the fragility of the bone. On the other hand, antiosteoporosis medications can affect the glucose homeostasis in these patients. It is also difficult to predict the fracture risk in these patients because conventional tools such as bone mineral density and Fracture Risk Assessment Tool score assessment can underestimate the risk. Evidence-based recommendations for risk evaluation and management of poor bone health in diabetes are sparse in the literature. With the advancement in imaging technology, newer modalities are available to evaluate the bone quality and risk assessment in patients with diabetes. The purpose of this review is to explore the pathophysiology behind poor bone health in diabetic patients. Approach to the fracture risk evaluation in both T1DM and T2DM as well as the pragmatic use and efficacy of the available treatment options have been discussed in depth.

Keywords: Diabetes; Fracture risk; Bone mineral density; Microarchitecture; Antidiabetic drugs; Antiosteoporosis therapy

Core Tip: Diabetes mellitus, either type 1 or type 2, has adverse effects on bone that translate into an elevated fracture risk. Different pathophysiological mechanisms contribute to poor bone health in patients with diabetes. Diagnosis of bone fragility in diabetic patients is challenging as traditional fracture predictors underestimate fracture risk in this population, contributing to the concept that diabetes affects bone quality. While waiting for further evidence, the prevention and management of bone fragility in diabetes should include identification of patients at risk, correction of modifiable risk factors, appropriate choice of antidiabetic medications and use of antiosteoporosis drugs with proven efficacy.