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Review Outlines Algorithm for Managing Diabetes With Increased Fracture Risk


Fragility fractures are a serious complication of type 1 and type 2 diabetes, but many clinicians who treat patients with diabetes are not aware of the increased risk of these fractures.

Fragility fractures are a serious complication of type 1 and type 2 diabetes, but many clinicians who treat patients with diabetes are not aware of the increased risk of these fractures. A new review, published by the International Osteoporosis Foundation Bone and Diabetes Working Group, summarized research and outlined an algorithm for identifying and managing diabetic patients with their increased fractured risk.

The review considered clinical characteristics of bone fragility in adults with diabetes and included findings from recent studies that assessed bone mineral density (BMD), bone microstructure and material properties, biochemical markers, and fracture prediction algorithms (FRAX) in patients with diabetes. Also, the authors evaluated the impact of diabetes drugs on bones, in addition to the efficacy of osteoporosis treatments in this population.

"The link between diabetes and skeletal health is complex and the optimal approach to the management of bone health in patients with diabetes is not yet definitive and may change over time as findings of new clinical studies become available,” Serge Ferrari, MD, chair of the International Osteoporosis Foundation (IOF) Committee of Scientific Advisors and of the IOF Bone and Diabetes Working Group, said in a statement.

The main messages of the review included:

  • The pathophysiology of bone fragility in patients with diabetes is likely to be multifactorial.
  • FRAX and BMD T-score can predict the fracture risk in type 2 diabetes patients, however, there must be an adjustment for diabetes to avoid an underestimation.
  • Patients, with an indication for therapy based on criteria developed for non-diabetes patients, should be treated with osteoporosis drugs. Because these medications would be used in the absence of established osteoporosis, they should be used with caution because the effects of the drugs in situations where bone fragility is due to alterations in bone quality have not been fully studied.

“This new review will inform clinicians about the current state of knowledge, and, importantly, the clear algorithm will facilitate the clinical assessment and management of fragility fracture risk in their patients according to current best practice," Ferrari said.

The authors suggested the need for future studies in order to continue the evaluation of the structural determinants of bone fragility and to refine fracture prediction algorithms by including disease-specific determinants of fracture. Specifically, they suggested that new trials must prospectively investigate the efficacy and safety of osteoporosis treatments in those with diabetes with and without low BMD.

Furthermore, the researchers noted that this type of algorithm, that the review outlines, represents a consensus among some experts and will adapt overtime as more evidence is found.


Ferrari SL, Abrahamsen B, Napoli N, et al. Diagnosis and management of bone fragility in diabetes: an emerging challenge. [published online July 31, 2018]. Osteoporos Int. doi: 10.1007/s00198-018-4650-2.

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