Bone mineral density in people with type 2 diabetes is typically normal or even elevated; paradoxically, fracture risk is higher and post-fracture mortality in diabetes is further increased. The mechanisms and contributing factors to this are not well-defined but may include hyperglycaemia, increased risk of falls and certain diabetes medications. Antiosteoporotic medications are effective in managing fracture risk in those with type 2 diabetes and should be used to minimise the morbidity and mortality in this vulnerable group.
- People with diabetes are at increased risk of fracture despite normal or elevated bone mineral density (BMD).
- Contributing factors to increased fracture risk may include hyperglycaemia, increased risk of falls due to peripheral neuropathy or impaired vision and some diabetes medications.
- Mortality from fractures is higher for people with diabetes than those without diabetes.
- Although BMD scores may be normal or high on dual energy x-ray absorptiometry scanning, trabecular bone score (which measures bone microarchitecture) and cortical bone measurements on quantitative CT are lower.
- Use of fracture risk calculators may underestimate the true risk of fracture in people with diabetes.
- There should be a low threshold for measuring BMD in a patient with type 2 diabetes, and those with an osteopenic-range BMD (T-score between −2.5 and −1.0) may require active surveillance.
- Thiazolidinediones and possibly insulin and canagliflozin are associated with increased fractures, whereas metformin and liraglutide may be protective. The remaining current therapies appear to be neutral with respect to fracture risk.
- Despite lower bone turnover, antiresorptive agents remain effective in reducing fracture risk in those with diabetes.