With Diabetes negatively affecting bone health and creating other clinical problems doctors need to consider the use of anti-osteoporotic drugs to supplement standard anti-Diabetes medications in patients suffering with Diabetic bone loss

Patients are often surprised to realise that they are at increased risk of various bone disorders if they are Diabetic. Given the increasing prevalence of Diabetes Mellitus (Type 1 and Type 2) in India, patients should be better informed about the proper protocols to manage diabetes while ensuring that bone health is taken care of. It is a multi-pronged approach: Prevention of avoidable falls and fractures, lifestyle changes such as improved diet and weight-bearing exercises and caution in the use of certain medications.

Causes

Type 1 or Type 2, is associated with increased fracture risk. According to the World Journal of Diabetes: “Diabetes-related complications and certain antidiabetic drugs appear to further increase fracture risk, both directly and indirectly. The prevention and management of bone fragility in diabetes includes identification of patients at risk, correction of modifiable risk factors including appropriate choice of antidiabetic drugs and use of antifracture drugs with proven efficacy.”

Studies published by the US National Institutes of Health suggest that Type 1 Diabetes causes reduction in Bone Mineral Density (BMD) while Type 2 Diabetes may cause an increase in BMD. BMD is related to bone density and thus a reduction may lead to osteoporosis, a disorder that makes bones weak and more prone to fracture. On the other hand, increased BMD due to Type 2 Diabetes, while it may appear benign, is possibly due to lower rates of bone turnover (ie. creation and resorption) and increased porosity, and these could also lead to increased risk of breakage.

Skeletal fragility is now recognised as a complication of Type 1 and Type 2 Diabetes. Hence a focus on detecting Diabetic bone disease is important along with other Diabetic complications. With Diabetes negatively affecting bone health and creating other clinical problems, and treatment options potentially exacerbating these effects, doctors need to consider the use of anti-osteoporotic drugs to supplement standard anti-diabetes medications in patients suffering with Diabetic bone loss.

Prevention

Some of the complications of Diabetes like nerve damage, muscle weakness, episodes of low blood sugar, and vision problems, increase the risk of falls and may  cause fractures. Hence fall prophylaxis is essential and thus detecting hypoglycaemia, orthostatic hypotension and other factors that increase the risk of falls is important. Fracture history and risk factors should be assessed in older patients with Diabetes. Proper management of blood glucose is desirable.

Treatment

Unfortunately some treatment options that are useful in treating insulin resistance have negative side effects that compound the health issues seen with diabetic bone. Antidiabetic drugs like TZD (glitazones) which have negative effects on bone health should be avoided. All SGLT2 inhibitors should be avoided in diabetics with bone fragility.

Medications with a neutral or favourable effect on bone metabolism such as metformin and incretin based treatments should be the preferred treatment. Insulin is of course a major pillar in Diabetes management. For Type 1, there is little evidence of any impact on bone health. However, for Type 2, some studies suggest a non-trivial (40 to 100%) increase in the risk of bone fracture with insulin as compared to Metformin treatment.

The writer is Dr Lakshmi V Reddy MBBS, FEDM, FACE (US) Endocrinologist Sparsh Yeswanthpur