Published online Aug 15, 2019. doi: 10.4239/wjd.v10.i8.421
Peer-review started: April 8, 2019
First decision: May 9, 2019
Revised: June 3, 2019
Accepted: July 20, 2019
Article in press: July 20, 2019
Published online: August 15, 2019
Bone fragility has been recognized as a complication of diabetes, both type 1 diabetes (T1D) and type 2 diabetes (T2D), whereas the relationship between prediabetes and fracture risk is less clear. Fractures can deeply impact a diabetic patient’s quality of life. However, the mechanisms underlying bone fragility in diabetes are complex and have not been fully elucidated. Patients with T1D generally exhibit low bone mineral density (BMD), although the relatively small reduction in BMD does not entirely explain the increase in fracture risk. On the contrary, patients with T2D or prediabetes have normal or even higher BMD as compared with healthy subjects. These observations suggest that factors other than bone mass may influence fracture risk. Some of these factors have been identified, including disease duration, poor glycemic control, presence of diabetes complications, and certain antidiabetic drugs. Nevertheless, currently available tools for the prediction of risk inadequately capture diabetic patients at increased risk of fracture. Aim of this review is to provide a comprehensive overview of bone health and the mechanisms responsible for increased susceptibility to fracture across the spectrum of glycemic status, spanning from insulin resistance to overt forms of diabetes. The management of bone fragility in diabetic patient is also discussed.
Core tip: Diabetes mellitus, either type 1 or type 2, is associated with increased fracture risk. Diabetic hyperglycemia and insulin resistance underlie functional alterations of bone cells and bone marrow fat that affect several determinants of bone strength, including bone matrix proteins and bone mass, geometry and microarchitecture. Diabetes-related microvascular 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.