Use of antiresorptives: increased risk of complications?

Abstract

In recent years, it has become evident that both type 1 diabetes (DM1) and type 2 diabetes (DM2) are associated with a higher risk of fracture, which increases as the duration of diabetes increases and is associated with a greater morbidity and mortality. It was observed that in DM1 there is a decrease in bone density, but that in DM2 bone density may still be increased. In diabetes, there is an alteration in bone quality associated, among other causes, with a lower bone turnover that can be evidenced as a decrease in biochemical markers of bone turnover and as an alteration of the bone structure due to the action of the advanced glycation end-products. Given the distinctive characteristics of the effect of diabetes on bone, a fracture risk stratification for the evaluation and therapeutic management of fracture risk in DM2 patients was recently proposed by a committee of experts, which presents some differences with respect to risk stratification of the non-diabetic population¹. They suggested that fracture risk stratification in patients with diabetes should be based on the presence of a previous fragility fracture and the individual risk profile, with the inclusion of specific risk factors for T2DM (more than 10 years of duration, presence of chronic complications of DM2, use of insulin or thiazolidinediones, and persistent HbA1c levels greater than 8% for at least 1 year). Due to the low bone turnover in diabetic patients, doubts arose regarding the effectiveness of antiresorptive drugs and no clinical trials have been carried out with antiresorptive drugs specifically in diabetic patients. The strongest evidence for the effectiveness of antiresorptive drugs comes from the pooled analysis of individual participants in clinical trials of antiresorptive drugs published between 1985 and 2018². It was observed that T2DM did not affect the efficacy of the treatment, with a similar reduction in the fracture rate. and increase in BMD and reduction in formation and resorption markers in DM2 and non-diabetic patients2. Different population studies could not associate a higher incidence of atypical fractures in diabetic patients treated with bisphosphonate treatment. Data on osteonecrosis of the jaw related to antiresorptive therapy in diabetic patients are inconclusive³.