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Diabetes Important Factor In
Osteoporosis Management
posted 04/05/04
Diabetes plays a role on the incidence of
osteoporosis in older women, and care of patients with diabetes should include a
careful assessment of bone health.
Sue A. Brown, MD and Julie Sharpless, MD, assistant professors of medicine at the University of North Carolina, Chapel Hill, United States, note that "it is now clear patients with type 1 diabetes have lower bone mineral density (BMD) and higher risk of fractures." There is also increasing evidence that patients with type 2 diabetes are at greater risk of osteoporotic fractures despite having a higher BMD than those with type 1 diabetes.
Hip fractures are recognized as a major cause of morbidity and mortality. Women with type 1 diabetes had a 6.9- to 12-fold increase in relative risk. The data are less clear in type 2 diabetes.
The question then becomes whether osteoporosis is a complication of poor glycemic control. No correlation between BMD, diabetes duration or current glycemic control has been shown in postmenopausal women.
Complications of diabetes are also indicators of long-term control issues. The presence of severe peripheral neuropathy correlates with decreased BMD at all sites. Others have found decreased BMD in the cortical bone of the hip and a greater decrease at the distal limb with neuropathy.
"Increasing evidence suggests that type 1 diabetes in particular may impede new bone formation possibly because of defective functioning of osteoblasts, the primary cells responsible for bone formation," say the authors. Lower levels of insulin-like growth factor 1, an anabolic hormone that maintains bone formation, are seen in patients with type 1 diabetes.
Other factors outside of metabolic control may also play a role. Women who are young at disease onset may not reach the same peak BMD and cross osteoporotic thresholds earlier. Oestrogen dysfunction may also play an important role in earlier onset osteoporosis.
Among these are vision problems, poor balance, orthostatic hypotension or the vision impairments, poor coordination and muscle control seen in both hypo- and hyperglycemia may increase to the risk of falling, as well.
There are currently no screening recommendations specific to this population, according to the authors. They suggest BMD screening for patients with type 1 diabetes, women or men with any complications and thin women with complications.
Treatment regimens are basically the same as in non-diabetic women. Bisphosphonates, selective oestrogen receptor modulators, and calcitonin have not been found to impair glycemic control.
"It has become clear that patients with type 1 diabetes have lower BMD and higher risk of fractures. Evidence is accumulating that patients with type 2 diabetes and complications, who were once thought to be protected from osteoporosis due to higher BMD and obesity, may in fact be at higher risk for fracture," conclude Dr. Brown and Dr. Sharpless.
Source: Diabetes In Control.com: Clin Diabetes 2004;22:10-20.
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