Diagnosis and management of bone fragility in diabetes: an emerging challenge

Abstract

Fragility fractures are increasingly recognized as a complication of both type 1 and type 2 diabetes, with fracture risk that increases with disease duration and poor glycemic control. Yet the identification and management of fracture risk in these patients remains challenging. This review explores 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 algorithms (i.e., FRAX) in these patients. It further reviews the impact of diabetes drugs on bone as well as the efficacy of osteoporosis treatments in this population. We finally propose an algorithm for the identification and management of diabetic patients at increased fracture risk.

Keywords: Diabetes; Diabetes-related bone disease; Fracture; Osteoporosis.

Fig. 1

Fracture risk evaluation in patients with diabetes. * In diabetes, fracture risk at T-score < −2 equivalent for non-diabetes at T-score < −2.5 (see text). ** Depending on country-specific guidelines for therapies. *** For example, with TBS and/or “RA” – yes. ⁺ Diabetes-specific CRFs are listed in Table 3. ¹In certain countries, humerus or pelvis fractures are also sufficient to initiate therapy; otherwise, more than non-vertebral non-hip fragility fracture could be required to initiate therapy; alternatively, a non-vertebral non-hip fragility fracture should prompt further exams to evaluate fracture risk