Endocrine Abstracts

Given the increasingly accepted increase in fracture risk that occurs in patients with type 2 diabetes, a number of strategies need to be considered reflecting the multiple factors underlying the fracture risk. These comprise measures to improve falls risk, the avoidance of treatments that may be detrimental to skeletal health and the use of treatments to maintain or improve bone strength.

Older people with diabetes are at high risk of falls, recurrent falls and fractures. Risks factors for falls in older persons with diabetes include polypharmacy, muscle weakness, previous stroke, motor and sensory neuropathy, poor glycaemic control, hypoglycaemia, insulin use, cognitive dysfunction, orthostatic hypotension, and visual impairment. Lower HbA1c has been associated with higher risk of falls frail elderly people and hip fracture, especially in those treated with insulin. Falls risk should be assessed in all patients as many studies using techniques such as gait, balance, and strength training have shown reduced risk of falls for people with diabetes. No studies have shown a reduction in fracture risk.

The significant side effect profile of thiazolidinediones includes concerns over an increase in the risk of fractures. This and other potential side effects has significantly decreased the enthusiasm for their use, despite their potential convenience in older people. The majority of the fractures have occurred in the limbs and guidance suggests that the risk of fracture should be considered in the care of patients, especially female patients, treated with such agents.

The evidence base for the use of agents developed for the treatment of osteoporosis in the setting of increased fracture risk in type 2 diabetes is lacking. The majority of studies have either excluded diabetes directly or indirectly by the requirement of low BMD at study entry. The decrease in bone turnover markers observed in type 2 diabetes raises a question mark over the use of antiresorptive therapies. Furthermore, post-hoc analyses of Phase 3 studies suggest that some anti-resorptive agents are less effective in the presence of a high BMI. In contrast, epidemiological studies suggest that diabetes does not seem to affect the fracture preventive potential of bisphosphonates or raloxifene.