Fractures in type 2 diabetes confer excess mortality: The Dubbo osteoporosis epidemiology study

The effect of oral colchicine and vitamin K1 on bone metabolism in patients with diabetes mellitus: A post-hoc analysis of a 2 × 2 factorial randomized controlled trial with 18F-sodium fluoride positron emission tomography

PURPOSE

Diabetes mellitus (DM) confers an increased risk of fracture. Fracture risk stratification techniques are imperfect, and preventative therapies are sparse. We aimed to describe features associated with a dysfunctional bone metabolism determined by 18F-Sodium Fluoride Positron Emission Tomography (18F-NaF PET) in patients with DM and test the effects of vitamin K1 and colchicine therapy on vertebral 18F-NaF activity.

METHODS

This is a post-hoc analysis of a 2 × 2 factorial randomized double-blind placebo-controlled trial. Participants aged 50-80 with DM underwent 18F-NaF PET/CT imaging at baseline, 3 months of therapy with vitamin K1 (10mg/daily) or placebo, and colchicine (0.5 mg/day) or placebo and repeat 18F-NaF PET/CT. The 18F-NaF vertebral mean standardized uptake value (SUVmean) and the CT estimated bone mineral density (BMD) (in Hounsfield units) was evaluated from thoracic vertebra.

RESULTS

In total, 149 individuals (66.4 % male, mean age 65.5 ± 6.8 years) were included. Male sex (β -1.421, 95 % CI [-1.826, -1.016], p < 0.001), duration of DM in years (-0.021 [-0.039, -0.002], p = 0.030) and CT estimated vertebral BMD (0.011 [0.006, 0.015], p < 0.001) were independently associated with the SUVmean. The change in the SUVmean was similar between vitamin K1 or placebo groups (-0.07 ± 0.64 v 0.07 ± 0.69, p = 0.20). Participants receiving colchicine therapy had a greater reduction in the SUVmean, compared with placebo (-0.12 ± 0.72 v 0.11 ± 0.60, p = 0.039).

CONCLUSION

18F-NaF PET may be a useful measure of vertebral bone metabolism in people with DM. Three months of oral colchicine reduced the 18F-NaF vertebral SUVmean, whereas Vitamin K1 had no effect. The findings should be considered hypothesis generating.

TRIAL REGISTRATION

www.anzctr.org.au (ACTRN12616000024448).

Adolescent Girls With Type 1 Diabetes Develop Changes in Bone Prior to Evidence of Clinical Neuropathy

CONTEXT

Neuropathy and fracture are prevalent complications of type 1 diabetes (T1D). Although correlated in the clinical literature, it remains unknown whether neuropathy contributes to the initiation of bone loss at the earliest stages of disease.

METHODS

We performed a single-center, cross-sectional study to quantify parameters of nerve and bone health in adolescent girls with T1D (n = 21) and associated controls (n = 12). Groups were well matched for age, height, strength, and physical activity.

RESULTS

By high-resolution peripheral quantitative computed tomograpy, participants with T1D had lower trabecular bone volume fraction at the distal radius (-14.6%, P-adj = .095) and the tibia (-12.8%, P-adj = .017) and decreased trabecular thickness (-8.3% radius, P-adj = .007; -7.5% tibia, P-adj = .034) after adjustment for body size. In the tibia only, cortical bone mineral density was increased by 8.6% (P-adj = .024) and porosity was decreased by 52.9% with T1D (P-adj = .012). There were no significant differences in bone density by dual-energy x-ray absorptiometry. Participants with T1D also had lower circulating levels of osteocalcin (-30%, P = .057), and type I collagen cross-linked C-telopeptide (-36%, P = .035), suggesting low bone formation and turnover in T1D. Based on the Michigan Neuropathy Screening Instrument, 9.5% of those with T1D had clinical evidence of diabetic peripheral neuropathy. However, consideration of neuropathy status failed to explain the widespread T1D-associated changes in bone.

CONCLUSION

Our study defines early deficits in trabecular bone microarchitecture, decreased cortical porosity in the tibia, and suppression of biomarkers of bone turnover in adolescent girls with T1D, prior to the onset of symptomatic peripheral neuropathy. These findings inform our understanding of the rapid progression of skeletal disease in young girls with T1D and suggests that early detection and management strategies may help to prevent fracture and related comorbidities later in life.

Risk factors for developing osteoporosis in diabetic kidney disease and its correlation with calcium-phosphorus metabolism, FGF23, and Klotho

BACKGROUND

The progression of diabetic kidney disease (DKD) affects the patient's kidney glomeruli and tubules, whose normal functioning is essential for maintaining normal calcium (Ca) and phosphorus (P) metabolism in the body. The risk of developing osteoporosis (OP) in patients with DKD increases with the aggravation of the disease, including a higher risk of fractures, which not only affects the quality of life of patients but also increases the risk of death.

AIM

To analyze the risk factors for the development of OP in patients with DKD and their correlation with Ca-P metabolic indices, fibroblast growth factor 23 (FGF23), and Klotho.

METHODS

One hundred and fifty-eight patients with DKD who were admitted into the Wuhu Second People's Hospital from September 2019 to May 2021 were selected and divided into an OP group (n = 103) and a normal bone mass group (n = 55) according to their X-ray bone densitometry results. Baseline data and differences in Ca-P biochemical indices, FGF23, and Klotho were compared. The correlation of Ca-P metabolic indices with FGF23 and Klotho was discussed, and the related factors affecting OP in patients with DKD were examined by multivariate logistic regression analysis.

RESULTS

The OP group had a higher proportion of females, an older age, and a longer diabetes mellitus duration than the normal group (all P < 0.05). Patients in the OP group exhibited significantly higher levels of intact parathyroid hormone (iPTH), blood P, Ca-P product (Ca × P), fractional excretion of phosphate (FeP), and FGF23, as well as lower estimated glomerular filtration rate, blood Ca, 24-hour urinary phosphate excretion (24-hour UPE), and Klotho levels (all P < 0.05). In the OP group, 25-(OH)-D3, blood Ca, and 24-hour UPE were negatively correlated with FGF23 and positively correlated with Klotho. In contrast, iPTH, blood Ca, Ca × P, and FeP exhibited a positive correlation with FGF23 and an inverse association with Klotho (all P < 0.05). Moreover, 25-(OH)-D3, iPTH, blood Ca, FePO4, FGF23, Klotho, age, and female gender were key factors that affected the lumbar and left femoral neck bone mineral density.

CONCLUSION

The Ca-P metabolism metabolic indexes, FGF23, and Klotho in patients with DKD are closely related to the occurrence and development of OP.

Bone Fragility in Diabetes and its Management: A Narrative Review

Bone fragility is a serious yet under-recognised complication of diabetes mellitus (DM) that is associated with significant morbidity and mortality. Multiple complex pathophysiological mechanisms mediating bone fragility amongst DM patients have been proposed and identified. Fracture risk in both type 1 diabetes (T1D) and type 2 diabetes (T2D) continues to be understated and underestimated by conventional risk assessment tools, posing an additional challenge to the identification of at-risk patients who may benefit from earlier intervention or preventive strategies. Over the years, an increasing body of evidence has demonstrated the efficacy of osteo-pharmacological agents in managing skeletal fragility in DM. This review seeks to elaborate on the risk of bone fragility in DM, the underlying pathogenesis and skeletal alterations, the approach to fracture risk assessment in DM, management strategies and therapeutic options.

Bone metabolism in diabetes: a clinician's guide to understanding the bone-glucose interplay

Skeletal fragility is an increasingly recognised, but poorly understood, complication of both type 1 and type 2 diabetes. Fracture risk varies according to skeletal site and diabetes-related characteristics. Post-fracture outcomes, including mortality risk, are worse in those with diabetes, placing these people at significant risk. Each fracture therefore represents a sentinel event that warrants targeted management. However, diabetes is a very heterogeneous condition with complex interactions between multiple co-existing, and highly correlated, factors that preclude a clear assessment of the independent clinical markers and pathophysiological drivers for diabetic osteopathy. Additionally, fracture risk calculators and routinely used clinical bone measurements generally underestimate fracture risk in people with diabetes. In the absence of dedicated prospective studies including detailed bone and metabolic characteristics, optimal management centres around selecting treatments that minimise skeletal and metabolic harm. This review summarises the clinical landscape of diabetic osteopathy and outlines the interplay between metabolic and skeletal health. The underlying pathophysiology of skeletal fragility in diabetes and a rationale for considering a diabetes-based paradigm in assessing and managing diabetic bone disease will be discussed.

Bone Health in Patients With Type 2 Diabetes

The association between type 2 diabetes mellitus (T2DM) and skeletal fragility is complex, with effects on bone at the cellular, molecular, and biomechanical levels. As a result, people with T2DM, compared to those without, are at increased risk of fracture, despite often having preserved bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). Maladaptive skeletal loading and changes in bone architecture (particularly cortical porosity and low cortical volumes, the hallmark of diabetic osteopathy) are not apparent on routine DXA. Alternative imaging modalities, including quantitative computed tomography and trabecular bone score, allow for noninvasive visualization of cortical and trabecular compartments and may be useful in identifying those at risk for fractures. Current fracture risk calculators underestimate fracture risk in T2DM, partly due to their reliance on BMD. As a result, individuals with T2DM, who are at high risk of fracture, may be overlooked for commencement of osteoporosis therapy. Rather, management of skeletal health in T2DM should include consideration of treatment initiation at lower BMD thresholds, the use of adjusted fracture risk calculators, and consideration of metabolic and nonskeletal risk factors. Antidiabetic medications have differing effects on the skeleton and treatment choice should consider the bone impacts in those at risk for fracture. T2DM poses a unique challenge when it comes to assessing bone health and fracture risk. This article discusses the clinical burden and presentation of skeletal disease in T2DM. Two clinical cases are presented to illustrate a clinical approach in assessing and managing fracture risk in these patients.

Traditional Chinese medicine in osteoporosis: from pathogenesis to potential activity

Osteoporosis characterized by decreased bone density and mass, is a systemic bone disease with the destruction of microstructure and increase in fragility. Osteoporosis is attributed to multiple causes, including aging, inflammation, diabetes mellitus, and other factors induced by the adverse effects of medications. Without treatment, osteoporosis will further progress and bring great trouble to human life. Due to the various causes, the treatment of osteoporosis is mainly aimed at improving bone metabolism, inhibiting bone resorption, and promoting bone formation. Although the currently approved drugs can reduce the risk of fragility fractures in individuals, a single drug has limitations in terms of safety and effectiveness. By contrast, traditional Chinese medicine (TCM), a characteristic discipline in China, including syndrome differentiation, Chinese medicine prescription, and active ingredients, shows unique advantages in the treatment of osteoporosis and has received attention all over the world. Therefore, this review summarized the pathogenic factors, pathogenesis, therapy limitations, and advantages of TCM, aiming at providing new ideas for the prevention and treatment of OP.

Diagnosing Osteoporosis in Diabetes-A Systematic Review on BMD and Fractures

PURPOSE OF REVIEW

Recently, the American Diabetes Association updated the 2024 guidelines for Standards of Care in Diabetes and recommend that a T-score of - 2.0 in patients with diabetes should be interpreted as equivalent to - 2.5 in people without diabetes. We aimed to evaluate the most recent findings concerning the bone mineral density (BMD)-derived T-score and risk of fractures related to osteoporosis in subjects with diabetes.

RECENT FINDINGS

The dual-energy X-ray absorptiometry (DXA) scan is the golden standard for evaluating BMD. The BMD-derived T-score is central to fracture prediction and signifies both diagnosis and treatment for osteoporosis. However, the increased fracture risk in diabetes is not sufficiently explained by the T-score, complicating the identification and management of fracture risk in these patients. Recent findings agree that subjects with type 2 diabetes (T2D) have a higher T-score and higher fracture risk compared with subjects without diabetes. However, the actual number of studies evaluating the direct association of higher fracture risk at higher T-score levels is scant. Some studies support the adjustment based on the 0.5 BMD T-score difference between subjects with T2D and subjects without diabetes. However, further data from longitudinal studies is warranted to validate if the T-score treatment threshold necessitates modification to prevent fractures in subjects with diabetes.

Insights and implications of sexual dimorphism in osteoporosis

Osteoporosis, a metabolic bone disease characterized by low bone mineral density and deterioration of bone microarchitecture, has led to a high risk of fatal osteoporotic fractures worldwide. Accumulating evidence has revealed that sexual dimorphism is a notable feature of osteoporosis, with sex-specific differences in epidemiology and pathogenesis. Specifically, females are more susceptible than males to osteoporosis, while males are more prone to disability or death from the disease. To date, sex chromosome abnormalities and steroid hormones have been proven to contribute greatly to sexual dimorphism in osteoporosis by regulating the functions of bone cells. Understanding the sex-specific differences in osteoporosis and its related complications is essential for improving treatment strategies tailored to women and men. This literature review focuses on the mechanisms underlying sexual dimorphism in osteoporosis, mainly in a population of aging patients, chronic glucocorticoid administration, and diabetes. Moreover, we highlight the implications of sexual dimorphism for developing therapeutics and preventive strategies and screening approaches tailored to women and men. Additionally, the challenges in translating bench research to bedside treatments and future directions to overcome these obstacles will be discussed.

Rescuing SERCA2 pump deficiency improves bone mechano-responsiveness in type 2 diabetes by shaping osteocyte calcium dynamics

Type 2 diabetes (T2D)-related fragility fractures represent an increasingly tough medical challenge, and the current treatment options are limited. Mechanical loading is essential for maintaining bone integrity, although bone mechano-responsiveness in T2D remains poorly characterized. Herein, we report that exogenous cyclic loading-induced improvements in bone architecture and strength are compromised in both genetically spontaneous and experimentally-induced T2D mice. T2D-induced reduction in bone mechano-responsiveness is directly associated with the weakened Ca2+ oscillatory dynamics of osteocytes, although not those of osteoblasts, which is dependent on PPARα-mediated specific reduction in osteocytic SERCA2 pump expression. Treatment with the SERCA2 agonist istaroxime was demonstrated to improve T2D bone mechano-responsiveness by rescuing osteocyte Ca2+ dynamics and the associated regulation of osteoblasts and osteoclasts. Moreover, T2D-induced deterioration of bone mechano-responsiveness is blunted in mice with osteocytic SERCA2 overexpression. Collectively, our study provides mechanistic insights into T2D-mediated deterioration of bone mechano-responsiveness and identifies a promising countermeasure against T2D-associated fragility fractures.

Femoral bone mineral density at the time of hip fracture is higher in women with versus without type 2 diabetes mellitus: a cross-sectional study

PURPOSE

To compare femoral bone mineral density (BMD) levels in hip-fracture women with versus without type 2 diabetes mellitus (T2DM). We hypothesized that BMD levels could be higher in the women with T2DM than in controls and we aimed to quantify the BMD discrepancy associated with the presence of T2DM.

METHODS

At a median of 20 days after the occurrence of an original hip fracture due to fragility we measured BMD by dual-energy x-ray absorptiometry at the non-fractured femur.

RESULTS

We studied 751 women with subacute hip fracture. Femoral BMD was significantly higher in the 111 women with T2DM than in the 640 without diabetes: mean T-score between-group difference was 0.50, (95% CI from 0.30 to 0.69, P < 0.001). The association between the presence of T2DM and femoral BMD persisted after adjustment for age, body mass index, hip-fracture type, neurologic diseases, parathyroid hormone, 25-hydroxyvitamin D and estimated glomerular filtration rate (P < 0.001). For a woman without versus with T2DM, the adjusted odds ratio to have a femoral BMD T-score below the threshold of - 2.5 was 2.13 (95% CI from 1.33 to 3.42, P = 0.002).

CONCLUSIONS

Fragility fractures of the hip occurred in women with T2DM at a femoral BMD level higher than in control women. In the clinical assessment of fracture risk, we support the adjustment based on the 0.5 BMD T-score difference between women with and without T2DM, although further data from robust longitudinal studies is needed to validate the BMD-based adjustment of fracture risk estimation.

Associations of Type 2 Diabetes, Body Composition, and Insulin Resistance with Bone Parameters: The Dubbo Osteoporosis Epidemiology Study

Type 2 diabetes (T2D) may be associated with increased risk of fractures, despite preserved bone mineral density (BMD). Obesity and insulin resistance (IR) may have separate effects on bone turnover and bone strength, which contribute to skeletal fragility. We characterized and assessed the relative associations of obesity, body composition, IR, and T2D on bone turnover markers (BTMs), BMD, and advanced hip analysis (AHA). In this cross-sectional analysis of Dubbo Osteoporosis Epidemiology Study, 525 (61.3% women) participants were grouped according to T2D, IR (homeostasis model assessment insulin resistance [HOMA-IR] Collapse

Key Words

• BIOCHEMICAL MARKERS OF BONE TURNOVER
• BONE‐FAT INTERACTIONS
• DUAL‐ENERGY X‐RAY ABSORPTIOMETRY
• FRACTURE RISK ASSESSMENT
• STATISTICAL METHODS

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Grants

• St. Vincent's Clinic Foundation

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Affiliation(s)

Angela Sheu Skeletal Diseases ProgramGarvan Institute of Medical ResearchSydneyNSWAustralia School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Faculty of Medicine and HealthUNSW SydneySydneyNSWAustralia Department of Endocrinology and DiabetesSt Vincent's HospitalSydneyNSWAustralia
Robert D. Blank Skeletal Diseases ProgramGarvan Institute of Medical ResearchSydneyNSWAustralia
Thach Tran Skeletal Diseases ProgramGarvan Institute of Medical ResearchSydneyNSWAustralia School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Faculty of Medicine and HealthUNSW SydneySydneyNSWAustralia
Dana Bliuc Skeletal Diseases ProgramGarvan Institute of Medical ResearchSydneyNSWAustralia School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Faculty of Medicine and HealthUNSW SydneySydneyNSWAustralia
Jerry R. Greenfield Skeletal Diseases ProgramGarvan Institute of Medical ResearchSydneyNSWAustralia School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Faculty of Medicine and HealthUNSW SydneySydneyNSWAustralia Department of Endocrinology and DiabetesSt Vincent's HospitalSydneyNSWAustralia
Christopher P. White School of Clinical Medicine, Prince of Wales Clinical Campus, Faculty of Medicine and HealthUNSW SydneySydneyNSWAustralia Department of Endocrinology and MetabolismPrince of Wales HospitalSydneyNSWAustralia
Jacqueline R. Center Skeletal Diseases ProgramGarvan Institute of Medical ResearchSydneyNSWAustralia School of Clinical Medicine, UNSW Medicine and Health, St Vincent's Clinical Campus, Faculty of Medicine and HealthUNSW SydneySydneyNSWAustralia Department of Endocrinology and DiabetesSt Vincent's HospitalSydneyNSWAustralia

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Factors associated with fragility fractures in type 2 diabetes: An analysis of the randomised controlled Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study

AIMS

Fracture risk is elevated in some type 2 diabetes patients. Bone fragility may be associated with more clinically severe type 2 diabetes, although prospective studies are lacking. It is unknown which diabetes-related characteristics are independently associated with fracture risk. In this post-hoc analysis of fracture data from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trial (ISRCTN#64783481), we hypothesised that diabetic microvascular complications are associated with bone fragility.

MATERIALS AND METHODS

The FIELD trial randomly assigned 9795 type 2 diabetes participants (aged 50-75 years) to receive oral co-micronised fenofibrate 200 mg (n = 4895) or placebo (n = 4900) daily for a median of 5 years. We used Cox proportional hazards models to identify baseline sex-specific diabetes-related parameters independently associated with incident fractures.

RESULTS

Over 49,470 person-years, 137/6138 men experienced 141 fractures and 143/3657 women experienced 145 fractures; incidence rates for the first fracture of 4∙4 (95% CI 3∙8-5∙2) and 7∙7 per 1000 person-years (95% CI 6∙5-9∙1), respectively. Fenofibrate had no effect on fracture outcomes. In men, baseline macrovascular disease (HR 1∙52, 95% CI 1∙05-2∙21, p = 0∙03), insulin use (HR 1∙62, HR 1∙03-2∙55, p = 0∙03), and HDL-cholesterol (HR 2∙20, 95% CI 1∙11-4∙36, p = 0∙02) were independently associated with fracture. In women, independent risk factors included baseline peripheral neuropathy (HR 2∙04, 95% CI 1∙16-3∙59, p = 0∙01) and insulin use (HR 1∙55, 95% CI 1∙02-2∙33, p = 0∙04).

CONCLUSIONS

Insulin use and sex-specific complications (in men, macrovascular disease; in women, neuropathy) are independently associated with fragility fractures in adults with type 2 diabetes.

Contributors to impaired bone health in type 2 diabetes

Type 2 diabetes (T2D) is associated with numerous complications, including increased risk of fragility fractures, despite seemingly protective factors [e.g., normal bone mineral density and increased body mass index(BMI)]. However, fracture risk in T2D is underestimated by current fracture risk calculators. Importantly, post-fracture mortality is worse in T2D following any fracture, highlighting the importance of identifying high-risk patients that may benefit from targeted management. Several diabetes-related factors are associated with increased fracture risk, including exogenous insulin therapy, vascular complications, and poor glycaemic control, although detailed comprehensive studies to identify the independent contributions of these factors are lacking. The underlying pathophysiological mechanisms are complex and multifactorial, with different factors contributing during the course of T2D disease. These include obesity, hyperinsulinaemia, hyperglycaemia, accumulation of advanced glycation end products, and vascular supply affecting bone-cell function and survival and bone-matrix composition. This review summarises the current understanding of the contributors to impaired bone health in T2D, and proposes an updated approach to managing these patients.

A narrative review of diabetic bone disease: Characteristics, pathogenesis, and treatment

Recently, the increasing prevalence of diabetes mellitus has made it a major chronic illness which poses a substantial threat to human health. The prevalence of osteoporosis among patients with diabetes mellitus has grown considerably. Diabetic bone disease is a secondary osteoporosis induced by diabetes mellitus. Patients with diabetic bone disease exhibit variable degrees of bone loss, low bone mineral density, bone microarchitecture degradation, and increased bone fragility with continued diabetes mellitus, increasing their risk of fracture and impairing their ability to heal after fractures. At present, there is extensive research interest in diabetic bone disease and many significant outcomes have been reported. However, there are no comprehensive review is reported. This review elaborates on diabetic bone disease in the aspects of characteristics, pathogenesis, and treatment.

Fracture prediction tools in diabetes

PURPOSE OF REVIEW

Type 1 (T1D) and 2 diabetes (T2D) are associated with increased risk of fracture independent of bone mineral density (BMD). Fracture risk prediction tools can identify individuals at highest risk, and therefore, most likely to benefit from antifracture therapy. This review summarizes recent advances in fracture prediction tools as applied to individuals with diabetes.

RECENT FINDINGS

The Fracture Risk Assessment (FRAX) tool, Garvan Fracture Risk Calculator (FRC), and QFracture tool are validated tools for fracture risk prediction. FRAX is most widely used internationally, and considers T1D (but not T2D) under secondary osteoporosis disorders. FRAX underestimates fracture risk in both T1D and T2D. Trabecular bone score and other adjustments for T2D-associated risk improve FRAX-based estimations. Similar adjustments for T1D are not identified. Garvan FRC does not incorporate diabetes as an input but does includes falls. Garvan FRC slightly underestimates osteoporotic fracture risk in women with diabetes. QFracture incorporates both T1D and T2D and falls as input variables, but has not been directly validated in individuals with diabetes.

SUMMARY

Further research is needed to validate and compare available fracture prediction tools and their performance in individuals with diabetes.