What Is the Association Between Bone Fractures and Diabetes?

Individuals living with type 1 and type 2 diabetes (T1D and T2D, respectively) are at greater risk of bone fractures, according to a systematic review update published in Bone.

Diabetes is a major public health concern as 1.6 million deaths were directly caused by the disease in 2016. Fractures, meanwhile, also pose concern as up to 20% of patients die in the first year after a hip fracture and less than half regain their previous level of function. Individuals with diabetes also have a higher mortality after a hip fracture compared with people without diabetes, the authors wrote.

“Diabetes can cause a number of well-known complications including kidney problems, loss of eyesight, problems with your feet and nerve damage,” said Tatiane Vilaca, MD, an author of the study. “However, until now many people with diabetes and their doctors are unaware that they are also at greater risk of bone fractures.”

Researchers searched databases such as Medline, Embase, and Cochrane for observational studies with age and gender-adjusted risk of fractures in adults with diabetes compared with adults without diabetes, published through March 25, 2020.

A total of 48 studies met inclusion criteria and 2 separate meta-analyses were created: 1 for hip fractures (including 42 studies) and 1 for non-vertebral fractures (including 17 studies). Any studies that overlapped were included if they reported different aspects of the same population, so as to be included in subgroup analyses.

In total, the studies in the hip fracture analysis reported data from 17,571,738 participants with 319,652 fractures, while the studies in the non-vertebral fracture review reported data from 2,978,487 participants with 181,228 fracture.

The analyses revealed:

• An increase in the risk of fracture in those with diabetes for hip (relative risk [RR] 4.93, 3.06-7.95, in T1D and RR 1.33, 1.19-1.49, in T2D)
• An increase in the risk of fracture in those with diabetes for non-vertebral fractures (RR 1.92, 0.92-3.99, in T1D and RR 1.19, 1,11-1.28 inT2D)
• Risk of hip fractures was higher in the younger population in both T1D and T2D
• In those with T2D, the risk of hip fractures was higher in females than in males, in those using insulin compared to noninsulin users, and in those with longer disease duration (>10 years)

Researchers noted the mechanism for the increase in risk of fractures among those with diabetes is not understood. They hypothesized the association may be due to an increased risk of falls among insulin users, those with microvascular complications, and those with hypoglycemic episodes. Antidiabetic drugs may also be involved in those with T2D, as increased risk of fractures has been associated with sulfonylureas, thiazolidenediones, glucagon like peptide 1, and sodium glucose co-transporter 2 inhibitors. In addition, lower bone marrow density among those with T1D may also account for the greater fracture risk in this cohort.

However, there is currently no specific treatment for bone fragility in diabetes, and the skeleton is not widely recognized as a site for diabetes complications, authors wrote.

“We hope that by raising awareness about the greater risk people with diabetes face, bone density and bone strength will become something that doctors assess routinely in patients with the condition in the same way they do currently for other well-known complications,” said Richard Eastell, MD, a co-author of the study.

Reference:

Vilaca T, Schini M, Harnan S, et al. The risk of hip and non-vertebral fractures in type 1 and type 2 diabetes: a systematic review and meta-analysis update. Bone. Published online May 29, 2020. doi:10.1016/j.bone.2020.115457