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Osteoporosis and Diabetes: Pros and Cons to Antidiabetic Regimens

Jul 8, 2017

Study aims to distinguish different antidiabetic drugs and their effect on osteoporosis in people with diabetes.

Osteoporosis and type 2 diabetes have recently been the focus of study in recent years. Osteoporosis is a bone condition defined by low bone mass, increased fragility, decreased bone quality, and an increased fracture risk. Research has shown that people with tyope 2 diabetes are at risk for developing osteoporosis and fractures. The incidence of fractures increases with age and therefore osteoporosis is most likely seen in individuals 50 years or older. The increase in fractures poses an increased mortality rate among patients with osteoporosis. This mortality rate is increased when people with type 2 diabetes develop osteoporosis.


There are many risk factors of osteoporosis and bone fractures. According to the World Health Organization, individuals with low bone mass and increased fragility are most susceptible to fractures and osteoporosis. The Nord-Trondelag Health Survey from Norway showed a dramatic increase in hip fractures among type 1 females. As such, the longer an individual is diagnosed with diabetes, the lower his or her bone mineral density (BMD) becomes. In addition, it has been reported that women with type 1 diabetes are more prone to developing fractures and ultimately osteoporosis when compared to females without diabetes. It is suggested that insulin plays a role in diabetic bone metabolism. Moreover, diabetic neuropathy and retinopathy have also been associated with increased fractures and increase in falls due to impairment in gait caused by visual defects.

In past studies, type 2 diabetes was perceived to provide bone protection and increased BMD. However, when other risk factors are taken into consideration, patients with diabetes tend to have an increased risk of falling due to their diabetic neuropathy and retinopathy causing visual deficits. In addition, obese individuals with type 2 diabetes who have a high bone mass are more susceptible to fractures than a person with a lower BMI. Researchers also believe that microvascular events also cause changes in bone quality and those with poorly controlled diabetes have an increased risk of bone loss and fractures.

Reviewers of the article Type 2 Diabetes and Osteoporosis: a Guide to Optimal Management, conducted a systematic literature search in the following databases: PubMed, Cochrane and EMBASE. They attempted to seek preventative and treatment measures for individuals with diabetes who had osteoporosis. They discovered that the use of anti-diabetic agents like metformin, sulfonylureas, DPP-4 inhibitors and GLP-1 receptor antagonists should be the main treatment options used in the treatment of osteoporosis. They also suggested that thiazolidinediones (TZDs) and canagliflozin should be avoided and insulin be administered with caution to avoid hypoglycemic incidences. Despite these hypoglycemic effects, insulin therapy is suggested as the preferred method in achieving glycemic control in hospitalized patients with type 2 diabetes and fractures.

Moreover, the reasoning behind why TZDs should be avoided is that they are shown to cause secondary osteoporosis by promoting bone loss and increasing fracture risk. It is known that TZD release their antidiabetic effects by releasing peroxisome proliferator-activated receptor-y (PPAR-y) which aide in glucose control and fatty acid metabolism. However, the PPAR-y also causes unbalanced bone remodeling causing an increase in bone resorption and decreasing bone formation.

Osteoporosis and diabetes go hand in hand, however, patients with this co-existing condition should be monitored daily and managed appropriately. Prevention of osteoporosis involves recognizing individuals at risk and conducting BMD screenings such as DXA scans, as well as quantitative ultrasounds and computed tomography. Non-pharmacological measures, including administration of 1,200 mg/day of elemental calcium and 400-800 IU/day of Vitamin D should be taken into consideration, in conjunction with pharmacological measures mentioned previously. In addition to this, exercises are shown to have clinical improvements by strengthening muscle tone in those affected by osteoporosis.

Osteoporosis is a long-standing disease with harmful effects. If preventative measures are performed and both non-pharmacological and pharmacological therapies are administered, one’s risk for fractures becomes significantly diminished. Moreover, recognizing at risk populations like those with either type 1 or type 2 diabetes increases a patient’s risk for developing osteoporosis. Administering appropriate anti-diabetics, as well as performing preventative measures, ensures better clinical outcomes.

Practice Pearls:

  • Osteoporosis is a long standing disease affecting many individuals primarily the elderly.
  • Type 2 diabetes is a major risk factor to the development of secondary osteoporosis.
  • Antidiabetic agents should be examined closely as some drugs like thiazolidinediones promote bone loss and increase fracture risk.


Chau, Diane L., and Steven V. Edelman. “Osteoporosis and Diabetes.” Clinical Diabetes. American Diabetes Association, 01 July 2002. Web. 05 July 2017.

Paschou, Stavroula Α., Anastasia D. Dede, Panagiotis G. Anagnostis, Andromachi Vryonidou, Daniel Morganstein, and Dimitrios G. Goulis. “Type 2 Diabetes and Osteoporosis: A Guide to Optimal Management.” The Journal of Clinical Endocrinology & Metabolism. Oxford University Press, 21 June 2017. Web. 05 July 2017


Nuha Awad, Doctor of Pharmacy Candidate: Class of 2018; ACCP FSHP