Osteoporosis in women with diabetes

Abstract

Diabetes mellitus (DM) has a significant impact on bone health, substantially increasing the risk of fractures. In type 1 DM, the risk of hip fracture increases 6 to 7 times, associated with a deficit in bone mass and quality. In type 2 DM, the risk increases 1.3 to 1.7 times, even in patients with normal or high bone mineral density (BMD), indicating poor bone quality. Fractures of other areas, such as the humerus, forearm, and ankle, are also common in patients with DM, with significantly higher mortality following hip fracture. Factors such as the duration of diabetes, high HbA1c levels, microvascular complications, the need for insulin therapy, and frailty are strongly associated with an increased risk of fractures.

The pathophysiology behind these bone effects includes alterations in collagen quality, caused by the effect of advanced glycation end products (AGEs), which generate an altered matrix with reduced toughness and resistance, and a decrease in the generation of both osteoblasts and osteoclasts. This results in low bone turnover, unrepaired microdamage to the bone material, and an increased risk of fracture.

Fracture risk assessment using standard osteoporosis diagnostic parameters in diabetic patients is often underestimated. Bone mineral density (BMD) measurement by DXA does not adequately reflect bone quality. Risk assessment tools such as FRAX® do not include diabetes as an input variable, which can distort the interpretation of results. Specific adjustments are recommended for both interpreting BMD and calculating FRAX risk in the context of diabetes mellitus (DM).

Regarding the treatment of osteoporosis, post-hoc studies of various pivotal trials and some real-world studies have shown that antiresorptive agents and osteoanabolic agents are effective in this patient group. It should be emphasized that fall prevention, glycemic control, and adequate calcium and vitamin D supplementation are crucial strategies for maintaining bone health in patients with diabetes.