Diabetes fracture risk: men who have their glucose in control could be facing another challenge as a result.
A recent study conducted by Duke University researchers has shown that type 2 diabetes mellitus is tied to higher bone density, but ironically also linked to increased fracture risk.
A retrospective study was conducted which included 652,901 veterans that were at least 65 years of age and have received most of their healthcare from the Veterans Health Administration from 2000-2010. All subjects had to be diagnosed with type 2 diabetes and baseline A1c that reflected their diagnosis. Exclusion criteria included men who were diagnosed with osteoporosis or have had any fractures within 3 years from the start of the study.
Risk factors associated to fractures were assessed in each patient. Some of these risk factors include: race, age, weight, tobacco or alcohol use, corticosteroid use, hyperparathyroidism, as well as other risk factors that were used to better explain how some of the fractures occurred. There were some types of fractures that were not included in the study, such as fractures that included fingers, toes, and skull. Subjects were also assessed for other comorbidities related to diabetes. Some of these comorbidities include peripheral neuropathy, congestive heart failure, chronic kidney disease, cardiovascular-related diseases, and others.
According to the results, men who sustained a fracture were usually older compared to the men who did not get any fractures. The mean age of the men who received fractures was 76.4 years old, while the men who did not get any fractures had a mean age of 73.9 years old. Another trend that was noticed in the men who suffered a fracture was that they typically used insulin and/or sulfonylureas more than those who did not suffer from a fracture. It was also shown that men who sustained fractures typically had more comorbidities and complications. Some of the more common complications include peripheral neuropathy, congestive heart failure, and chronic kidney disease. The most common fracture that was seen in the study was hip fractures. Other common fractures included spine, ribs, and lower leg related fractures. According to the results of the study, it was seen that men who had an HbA1c of less than 6.5% were at a higher risk of fractures compared to men who had an HbA1c between 7.5-8.5%.
It was noted that some medications played a role in whether a subject experienced a fracture or not. Metformin, for instance, was shown to decrease fracture risk, whereas thiazolidinediones significantly increased the risk of fractures. Sulfonylureas were also shown to increase fracture risk in those who had an HbA1c of less than 6.5%.
There were some limitations to the study. Certain medications were excluded from the study because they were not used enough clinically to determine if they played a role in whether a person suffered a fracture. Some of the medications that were not included in the study included DPP-4 inhibitors, GLP-1 agonists, and SGLT2 inhibitors. Another limitation was that some of the data was not measured, which included some laboratory values (e.g. parathyroid hormone levels) and fracture-related risk factors (e.g. falls outside of healthcare setting, hip fracture history).
There were also many strengths in this study. This was the largest study that observed the association between glucose control and fracture risk in older men with diabetes. There was also a large sample size that showed good sensitivity and specificity. Since the study was able to link to the Medicare database, the researchers were able to obtain a thorough background on all the subjects that they included in the study.
- Older men with a diagnosis of diabetes usually have increased bone density but are somehow also more prone to suffering from a fracture.
- It has been shown that older men with diabetes who have their HbA1c under control are more at risk of experiencing a fracture than those who have an HbA1c that is higher.
- Certain medications can increase the risk of fractures in older men with diabetes despite a tight glycemic control. Some of these medications include insulin, sulfonylureas, and thiazolidinediones.
Lee, Richard H., et al. “Glycemic Control and Insulin Treatment Alter Fracture Risk in Older Men with Type 2 Diabetes Mellitus – Lee – – Journal of Bone and Mineral Research – Wiley Online Library.” Journal of Bone and Mineral Research, John Wiley & Sons, Ltd, 3 July 2019, https://onlinelibrary.wiley.com/doi/10.1002/jbmr.3826.
Joel John, Pharm.D. Candidate, Florida A&M University, College of Pharmacy & Pharmaceutical Sciences