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by 2045.
Among them, approximately one-third of patients with diabetes have osteoporosis [1,2].
The main causes of osteoporosis caused by type 1 diabetes mellitus (T1DM) are absolute insufficiency of insulin, growth factor-1 (IGF-1) deficiency, hyperglycemia, bone calcium loss due to osmotic diuresis, and damage to autoimmune and inflammatory
responses.
The increased risk of type 2 diabetes mellitus (T2DM) combined with osteoporosis and fracture is related to the course of diabetes, blood glucose fluctuations, insulin resistance, oxidative stress, non-enzymatic glycation of collagen, bone marrow fat accumulation, the musculoskeletal system effects of hypoglycemic drugs, and diabetes complications [1]
。
in predicting diabetic osteoporosis and fractures.
In a study of the association between rapid plasma glucose variability (FPG-CV) and hip fracture in elderly patients, it was found that 25.
4% of patients with FPG-CV > had a higher risk of hip fracture than 14.
3% of patients with FPG-CV<<b13>, suggesting that the stability of blood glucose was related to the occurrence of fractures in T2DM patients.
Another study also found that the risk of fracture was significantly increased in patients with T2DM glycated hemoglobin (HbA1c) of more than 9.
0%, and the two were linearly.
It suggests that glycemic control in elderly patients with T2DM is of great significance
for the prevention of fractures.
Other literature reports and risk factors associated with T2DM and osteoporosis and fractures are shown in Table 1 [3].
Note: bone density (BMD); Trabecular bone score (TBS); Spinal deformity index (SDI); fibroblast growth factor 23 (FGF23); Osteoinductive factor (OIF); Plasma fetuin-A (PFA).
- *: no correlation found; + **: Presence of associated risk factors
.
However, DXA bone density for clinical diagnosis of osteoporosis can only reflect 70% of bone mineral density, not bone mass, and often underestimates the fracture risk of
T2DM patients.
However, patients with diabetes can fracture at higher bone density than non-diabetic patients, fractures are more common in the hip, foot, and proximal femur, and severe vertebral fractures are also associated with
all-cause mortality.
Therefore, early intervention is critical to reduce the incidence of DOP and its fractures and to improve prognosis [4].
the World Health Organization is used (WHO) Diagnostic criteria for osteoporosis proposed in 1994:
When using FRAX to assess fracture risk in diabetic patients, rheumatoid arthritis is used to replace diabetes
.
▎ In 2018, the International Osteoporosis Foundation (IOF) Bone and Diabetes Working Group recommended the use of DXA lumbar or hip bone density T value -2.
0 as the threshold for fracture intervention in diabetic patients, but this cut point may be more suitable for European populations
.
It is recommended that patients with diabetes be assessed annually for fracture risk, monitored for bone density every 2 years, and considered to start osteoporosis if 2 consecutive bone density tests show bone loss of ≥5% or a T-value close to -2.
0
.
In cases where DXA bone density testing underestimates the fracture risk of diabetics, clinically available methods to assess fracture risk in diabetics include:
5
.
.
.
Healthy lifestyle:
2.
Basic supplements for bone health:
The intake of calcium and vitamin D is recommended to be the same as that of patients with primary osteoporosis, but patients with diabetes complications such as proton pump inhibitors, diuretics, malabsorption and diabetic nephropathy can increase
their daily calcium requirements accordingly.
Epidemiological studies of postmenopausal T2DM patients have found that patients are more likely to develop osteoporosis when the serum 25(OH)D 3 level < 18.
5ng/ml.
Therefore, adequate vitamin D should be supplemented; Patients with DOP should have their vitamin D levels corrected to the normal range<b20> before anti-osteoporosis therapy.
3.
Select appropriate hypoglycemic drugs:
comprehensively evaluate the general condition of patients including age, whether female patients are menopausal, nutritional status, diabetes course, diabetes complications and comorbidities, etc.
, and select appropriate hypoglycemic drugs to reduce blood sugar
steadily.
For patients at high risk of fracture, metformin and glucagon-like peptide-1 (GLP-1) receptor agonists are recommended; Avoid the use of thiazolidinediones (TZD), especially the combination of sulfonylureas and TZD; Use caution with certain sodium-glucose cotransporter 2 (SGLT2) inhibitors
.
The risk of postoperative fracture is increased by 2~3 times in patients with metabolic surgery for weight loss, so the risk of fracture should be evaluated before and after surgery, and necessary interventions
should be given.
4.
Anti-osteoporosis treatment:
anti-bone resorption preparations or bone formation promoters can be used, and the principles, methods and treatment courses are the same as primary osteoporosis
.
Before the use of anti-bone resorption agents, renal function and the presence of diabetic gastrointestinal autonomic neuropathy should be evaluated in diabetic patients; When considering sequential anti-osteoporosis therapy, bone formation promoters should be selected to improve bone mass loss and lower bone turnover in patients with diabetes, followed by anti-bone resorption therapy to maintain efficacy, which can significantly reduce the risk of
fracture.
During treatment, the efficacy of osteoporosis treatment, patient compliance, progress of diabetes complications, and adjustment of anti-diabetic regimens should be regularly evaluated
.
5.
Reduce the risk of falls:
including the prevention of lower limb balance disorders caused by hyperglycemia, hypoglycemia and blood sugar fluctuations, the use of active vitamin D to improve the muscle strength of the lower limbs, effective treatment measures for deep sensory impairment caused by diabetic peripheral neuropathy, and corresponding measures to prevent falls for diabetic retinopathy
。
Developing gradual, regular and durable exercise prescriptions, including aerobic exercise, resistance versus exercise, or a combination of exercise and balance training, can not only help good blood sugar control, but also strengthen gait function, muscle strength in elderly patients, and effectively prevent falls
.
DOP is the most important metabolic bone disease of diabetes, and clinical attention is still far from enough
.
Early screening, strict monitoring of blood glucose, control of blood glucose and glycated hemoglobin within a reasonable range is the key to the prevention of the disease, standardized treatment to reduce the disability rate caused by fractures, improve the quality of life of diabetic patients, reduce the mortality caused by fractures has important clinical significance, should increase the management of diabetic osteoporosis, so that diabetic patients can receive more comprehensive care
.
This article is specially invited to write expert
Zhu Yikun, MD, the Second Hospital of Shanxi Medical University Director of the Department of Endocrinology, Scholar of Cosmology, Master Supervisor
-End -
"This article is intended solely to provide scientific information to healthcare professionals and does not represent the position of the platform"
One article to clarify!
by 2045.
Among them, approximately one-third of patients with diabetes have osteoporosis [1,2].
What is diabetic osteoporosis?
Diabeticosteoporosis (DOP) is a metabolic bone disease characterized by volumetric bone mass, increased bone fragility and increased risk of fracture on the basis of diabetes, and is one of the common chronic complications of
diabetes.
The main causes of osteoporosis caused by type 1 diabetes mellitus (T1DM) are absolute insufficiency of insulin, growth factor-1 (IGF-1) deficiency, hyperglycemia, bone calcium loss due to osmotic diuresis, and damage to autoimmune and inflammatory
responses.
The increased risk of type 2 diabetes mellitus (T2DM) combined with osteoporosis and fracture is related to the course of diabetes, blood glucose fluctuations, insulin resistance, oxidative stress, non-enzymatic glycation of collagen, bone marrow fat accumulation, the musculoskeletal system effects of hypoglycemic drugs, and diabetes complications [1]
。
What is the relationship between blood sugar and diabetic osteoporosis?
in predicting diabetic osteoporosis and fractures.
In a study of the association between rapid plasma glucose variability (FPG-CV) and hip fracture in elderly patients, it was found that 25.
4% of patients with FPG-CV > had a higher risk of hip fracture than 14.
3% of patients with FPG-CV<<b13>, suggesting that the stability of blood glucose was related to the occurrence of fractures in T2DM patients.
Another study also found that the risk of fracture was significantly increased in patients with T2DM glycated hemoglobin (HbA1c) of more than 9.
0%, and the two were linearly.
It suggests that glycemic control in elderly patients with T2DM is of great significance
for the prevention of fractures.
Other literature reports and risk factors associated with T2DM and osteoporosis and fractures are shown in Table 1 [3].
Note: bone density (BMD); Trabecular bone score (TBS); Spinal deformity index (SDI); fibroblast growth factor 23 (FGF23); Osteoinductive factor (OIF); Plasma fetuin-A (PFA).
- *: no correlation found; + **: Presence of associated risk factors
.
However, DXA bone density for clinical diagnosis of osteoporosis can only reflect 70% of bone mineral density, not bone mass, and often underestimates the fracture risk of
T2DM patients.
However, patients with diabetes can fracture at higher bone density than non-diabetic patients, fractures are more common in the hip, foot, and proximal femur, and severe vertebral fractures are also associated with
all-cause mortality.
Therefore, early intervention is critical to reduce the incidence of DOP and its fractures and to improve prognosis [4].
Indications for the use of osteoporosis treatment drugs in patients with diabetes mellitus
the World Health Organization is used (WHO) Diagnostic criteria for osteoporosis proposed in 1994:
- T values of ≤-2.
5 standard deviations (SD) for osteoporosis; - -2.
5SD - A T-value ≥-1.
0SD is normal
.
- vertebral or hip fragility fractures;
- DXA (lumbar spine, femoral neck, total hip, or distal radial 1/3) bone density T ≤-2.
5; - low bone mass (-2.
5< T <-1.
0) with fragility fractures (upper humerus, distal forearm or pelvis); - and/or FRAX calculates a 10-year hip fracture probability ≥ 3% or any major osteoporotic fracture probability ≥ 20%.
When using FRAX to assess fracture risk in diabetic patients, rheumatoid arthritis is used to replace diabetes
.
▎ In 2018, the International Osteoporosis Foundation (IOF) Bone and Diabetes Working Group recommended the use of DXA lumbar or hip bone density T value -2.
0 as the threshold for fracture intervention in diabetic patients, but this cut point may be more suitable for European populations
.
It is recommended that patients with diabetes be assessed annually for fracture risk, monitored for bone density every 2 years, and considered to start osteoporosis if 2 consecutive bone density tests show bone loss of ≥5% or a T-value close to -2.
0
.
Bone quality assessment in patients with diabetes
In cases where DXA bone density testing underestimates the fracture risk of diabetics, clinically available methods to assess fracture risk in diabetics include:
■1.
FRAX fracture risk assessment:
5
.
■2.
TBS trabecular score:
.
■3.
High-resolution peripheral quantitative computed tomography (HR-pQCT):
.
Comprehensive management of osteoporosis and fracture risk in diabetic patients
Healthy lifestyle:
This includes long-term adherence to a good lifestyle, dietary management, exercise management, and weight management
.
Increase milk and other calcium-rich foods; Sufficient sunshine; Reduce sodium intake; Quit smoking and limit alcohol, etc
.
2.
Basic supplements for bone health:
The intake of calcium and vitamin D is recommended to be the same as that of patients with primary osteoporosis, but patients with diabetes complications such as proton pump inhibitors, diuretics, malabsorption and diabetic nephropathy can increase
their daily calcium requirements accordingly.
Epidemiological studies of postmenopausal T2DM patients have found that patients are more likely to develop osteoporosis when the serum 25(OH)D 3 level < 18.
5ng/ml.
Therefore, adequate vitamin D should be supplemented; Patients with DOP should have their vitamin D levels corrected to the normal range<b20> before anti-osteoporosis therapy.
3.
Select appropriate hypoglycemic drugs:
comprehensively evaluate the general condition of patients including age, whether female patients are menopausal, nutritional status, diabetes course, diabetes complications and comorbidities, etc.
, and select appropriate hypoglycemic drugs to reduce blood sugar
steadily.
For patients at high risk of fracture, metformin and glucagon-like peptide-1 (GLP-1) receptor agonists are recommended; Avoid the use of thiazolidinediones (TZD), especially the combination of sulfonylureas and TZD; Use caution with certain sodium-glucose cotransporter 2 (SGLT2) inhibitors
.
The risk of postoperative fracture is increased by 2~3 times in patients with metabolic surgery for weight loss, so the risk of fracture should be evaluated before and after surgery, and necessary interventions
should be given.
4.
Anti-osteoporosis treatment:
anti-bone resorption preparations or bone formation promoters can be used, and the principles, methods and treatment courses are the same as primary osteoporosis
.
Before the use of anti-bone resorption agents, renal function and the presence of diabetic gastrointestinal autonomic neuropathy should be evaluated in diabetic patients; When considering sequential anti-osteoporosis therapy, bone formation promoters should be selected to improve bone mass loss and lower bone turnover in patients with diabetes, followed by anti-bone resorption therapy to maintain efficacy, which can significantly reduce the risk of
fracture.
During treatment, the efficacy of osteoporosis treatment, patient compliance, progress of diabetes complications, and adjustment of anti-diabetic regimens should be regularly evaluated
.
5.
Reduce the risk of falls:
including the prevention of lower limb balance disorders caused by hyperglycemia, hypoglycemia and blood sugar fluctuations, the use of active vitamin D to improve the muscle strength of the lower limbs, effective treatment measures for deep sensory impairment caused by diabetic peripheral neuropathy, and corresponding measures to prevent falls for diabetic retinopathy
。
Developing gradual, regular and durable exercise prescriptions, including aerobic exercise, resistance versus exercise, or a combination of exercise and balance training, can not only help good blood sugar control, but also strengthen gait function, muscle strength in elderly patients, and effectively prevent falls
.
epilogue
DOP is the most important metabolic bone disease of diabetes, and clinical attention is still far from enough
.
Early screening, strict monitoring of blood glucose, control of blood glucose and glycated hemoglobin within a reasonable range is the key to the prevention of the disease, standardized treatment to reduce the disability rate caused by fractures, improve the quality of life of diabetic patients, reduce the mortality caused by fractures has important clinical significance, should increase the management of diabetic osteoporosis, so that diabetic patients can receive more comprehensive care
.
This article is specially invited to write expert
Zhu Yikun, MD, the Second Hospital of Shanxi Medical University Director of the Department of Endocrinology, Scholar of Cosmology, Master Supervisor
- Member of the International Society for Clinical Bone Densitometry (ISCD).
- Member of the Science Popularization and Continuing Education Group of the Osteoporosis and Bone Mineral Salt Disease Committee of the Chinese Medical Association
- Member of the Physician Education and Training Committee of the Osteoporosis Branch of the Chinese Geriatrics Association
- Member of the Ophthalmology Group of the Diabetes Committee of the Chinese Research Hospital Association
- Chairman of the Endocrinology Committee of the Medical Branch of Shanxi Experts and Scholars Association
- Chairman of the Osteoporosis and Bone Mineral Salt Committee of Shanxi Medical Association
- Vice Chairman of the Diabetes Committee of Shanxi Medical Association
- Vice President of Shanxi Female Physicians Endocrinology Branch
- Vice Chairman of the Endocrinology Committee of Shanxi Medical Association
- Vice Chairman of the Basic Health Endocrinology Committee of Shanxi Province
References:
[1] Fu Mengfei et al.
, Meta-analysis of risk factors for osteoporosis in Chinese people with type 2 diabetes.
Journal of Huazhong University of Science and Technology, vol.
50, No.
1, P.
94, Feb2021
[2] IDF Global Diabetes Atlas 2021, 10th Edition
[3] Chin J Osteoporos，January 2017，Vol 23，No.
1
[4] CHIN J OSTEOPOＲOSIS ＆ BONE MINEＲ ＲES Vol．12 No．4 July 10，2019
-End -
"This article is intended solely to provide scientific information to healthcare professionals and does not represent the position of the platform"
