Endocrine Abstracts

Introduction: Osteoporosis is a known complication of diabetes. Both type 1 and type 2 increase fracture risk, but type 3 c (pancreatogenic) diabetes can result in even more severe bone disease due to nutritional and metabolic challenges. Here, we present a case of a 44-year-old man with type 3 c diabetes and multiple comorbidities who developed severe osteoporosis, emphasising the importance of a multidisciplinary approach.

Case Presentation: A 44-year-old man with a history of reactivated tuberculosis was referred after a right proximal femoral fracture. His tuberculosis treatment caused chronic pancreatitis, leading to type 3 c diabetes requiring insulin and complicated by gastroparesis. Due to severe malnutrition (BMI 14 kg/m²), he was initiated on total parenteral nutrition two years ago. He also had long-standing suboptimal glycaemic control, a history of bowel surgery for Familial adenomatous polyposis, ankylosing spondylitis, past cannabis use, and a family history of osteoporosis. He was bedbound in a nursing home and required a stretcher for hospital visits. In 2017, his bone density scan confirmed osteoporosis (lumbar spine T-score -3.2), but no treatment was started. Calcium and renal function were satisfactory, but vitamin D was low (34 nmol/l;N-50-120 nmol/l), and ALP remained persistently elevated (394 U/l;N- 30-130 U/l). Because he could not tolerate oral bisphosphonates and preferred to avoid frequent injections due to the injection burden, annual zoledronate infusions were commenced. His vitamin D level was optimised, and his diabetes management was escalated with support from the community diabetes facilitator team.

Discussion: This case highlights the cumulative effects of multiple factors—type 3 c diabetes, malnutrition and malabsorption, low BMI, and immobility on bone health. The loss of insulin’s anabolic effects also contributes to higher fracture risk. Therefore, early screening and assessment in the metabolic bone clinics, and integrated multidisciplinary management, including gastroenterology, nutritional service, and diabetologists, are essential for improving outcomes in this high-risk population. Notably, there are currently no specific national guidelines for early evaluation of bone health in people living with diabetes.

Reference: Tomasiuk JM, Nowakowska-Płaza A, Wisłowska M, Głuszko P. Osteoporosis and diabetes - possible links and diagnostic difficulties. Reumatologia. 2023;61(4):294-304. doi: 10.5114/reum/170048. Epub 2023 Sep 3. PMID: 37745139; PMCID: PMC10515121.