Ca&Bone

[The increase of fracture risk in type 1 and type 2 diabetes mellitus]

HULLÓ DANIELLA1

FEBRUARY 14, 2007

Ca&Bone - 2007;10(01)

[Studies in the last couple of years found more and more convincing evidence about the fact that impaired glucose metabolism leads to structural changes in the skeletal system leading toward osteoporosis. While patients with type 1 diabetes mellitus have decreased bone density, measurement showed increased bone mineral density in patients with type 2 diabetes mellitus. Despite these differences, risk of vertebral and nonvertebral fractures is increased in both groups of diabetic patients. Decreased pancreatic beta cell function is accompanied by several hormonal disturbances leading to decreased bone formation even in the early stage of diabetes. Peak bone mass of diabetic children is lower than found in nondiabetic children. Late complications of diabetes, vascular and neuronal impairments, impaired renal function, and secondary hormonal disturbances are added to this process. IGF-1 may have a crucial role in the pathogenesis of osteoporosis in diabetes. The structure of the molecule is similar to insulin. IGF-1 has effect on normal bone formation, inhibits the apoptosis and interferes with several other metabolic pathways. IGF-1 mediates the effect of growth hormone to the muscular and skeletal system. IGF-1 level decreases with age, and lower level of IGF-1 is found in diabetic patients. Long term complications of diabetes can also occur, which may enhance the process of bone resorption. Although the evidence is growing that fracture risk is higher in diabetic patiens, there are still scientists who question the association between the two disorders.]

AFFILIATIONS

  1. Szegedi Tudományegyetem, Szent-Györgyi Albert Orvos- és Gyógyszerésztudományi Centrum, Általános Orvostudományi Kar, Szak- és Továbbképzési Központ, Szeged

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[István Holló, MD, professor 1926-2007]

SZŰCS János

[In memoriam - István Holló]

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[Osteology Congress]

[Osteology Congress, 2007;10(01)]

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[Dear Readers and Colleagues!]

HORVÁTH CSABA

Ca&Bone

[Disturbances of the bone metabolism in type 1 diabetic patients]

KERÉNYI ZSUZSA, TAMÁS GYULA, TABÁK Gy. Ádám, SPEIZER SZABINA, SPEER Gábor, MÉSZÁROS SZILVIA, LAKATOS Péter, HORVÁTH CSABA

[AIMS - Because of contradictory data in literature our aim was to study bone metabolic disturbances and their correlates with anthropometric and metabolic parameters in type 1 diabetic patients (T1DM). Since quantitative bone ultrasound (QUS) measures bone qualities different from BMD, and it has only been scarcely investigated in T1DM, our aim was to describe covariates of QUS parameters. PATIENTS AND METHODS - Osteodensitometry was performed (lumbal spine, femur neck - DEXA; calcaneal ultrasound) on 115 T1DM patients (34 male, 81 female; mean age: 41.4±11 [± SD] yrs; BMI: 23.9±3.0 kg/m2; diabetes duration: 21.6±11.7 yrs; HbA1c: 8.1±1.3%). In addition anthropometric, blood pressure and laboratory parameters (HbA1c, lipids, renal function, fibrinogen, homocystein, PTH, TSH, β-CrossLaps, vitamine D3, osteocalcin, osteoprotegerin) were measured, data using a questionnaire were collected. RESULTS - The prevalence of osteoporosis was 9/112 (8%). A further 21/62 patients with osteopenia were found. Disturbances of bone metabolism have been more frequently proven on lumbal spine (p<0.001). Using multiple linear regression modelling, the independent covariates of osteopathy were systolic blood pressure, body weight, β-CrossLaps and cystatin C. The average broadband ultrasound attenuation (BUA) was 114.2±14.9 in males vs. 108.4±16.3 dB/MHz in females (p=0.07), the mean speed of sound (SOS) 1552±26 in males vs. 1559±32 m/s in females (p=0.32). SOS values in addition to bone density were associated with fracture risk. The independent covariates of BUA were body weight and height (R=0.473, p<0.001), and of SOS only fibrinogen (R=0.305, p=0.032). CONCLUSIONS - According to our results the prevalence of osteoporosis in acceptable controlled T1DM patients is relatively low. The more common metabolic calcipenic osteopathy show a correlation with body weight, markers of bone resorption and diabetic complications/co-morbidities (nephropathy, hypertension) being therefore not only an a priori consequence but also a complication of diabetes mellitus. Our data provide baseline data of QUS in type 1 diabetic patients. Because of the frequency of lower bone mineral content and their known high fracture risk bone metabolism screening of T1DM patients has to be considered.]

Ca&Bone

[Higher bone fracture prevalence in postmenopausal pollen allergic women]

FERENCZ VIKTÓRIA, MÉSZÁROS SZILVIA, CSUPOR EMŐKE, TÓTH EDIT, BORS Katalin, FALUS ANDRÁS, HORVÁTH CSABA

[Our aim was to investigate whether pollen allergy can affect bone mass and fractures in postmenopausal women. A total of 125 postmenopausal pollen allergic women (mean age 61.26 years) were split into four groups: treated neither with H1 histamine receptor (H1R) antagonist nor with inhaled corticosteroid (n=43), treated only with H1R antagonist (n=53), treated both with H1R antagonist and inhaled corticosteroid (n=17), treated only with inhaled corticosteroid (n=12) for at least five years, seasonally. One-hundred non-allergic postmenopausal subjects matched for age, body mass index (BMI) and age at menopause served as controls. Overweight and obesity (25 kg/m2 ≤ BMI) were common among allergic women (76%). Allergic patients without treatment had a slightly lower bone density than their non-allergic mates. Untreated allergic had almost triple the rate of prevalent low-energy fractures (distal forearm, hip and clinical vertebral fractures: 34.9%) compared to non-allergic women (13%, χ2 p=0.003). Bone fracture occurred more often in H1R-only treated patients (30.19%) than in controls (χ2 p=0.01), however, clinical vertebral or hip fractures developed neither in those treated only with H1R antagonist nor in those who received both H1R antagonist and inhaled corticosteroid. Bone fractures were more frequent among patients with inhaled steroid treatment than among patients with a combined treatment of inhaled steroid and antihistamine (50% vs. 29.4%). BMI predicted prevalent fractures at 1.278 (95% CI, 1.047 to 1.559, p=0.016) for 1 kg/m2 increase among untreated allergic patients. In conclusion we found a high prevalence of low-energy fractures among pollen-allergic postmenopausal women, which was associated with obesity. It is possible that the H1R antagonists compensate for the negative effect of pollen-allergy and the adverse effect of inhaled corticosteroid treatment on bone fracture risk.]

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Clinical Neuroscience

Management of bone metabolism in epilepsy

UÇAN TOKUÇ Ezgi Firdevs , FATMA Genç, ABIDIN Erdal, YASEMIN Biçer Gömceli

Many systemic problems arise due to the side effects of antiepileptic drugs (AEDs) used in epilepsy patients. Among these adverse effects are low bone mineral density and increased fracture risk due to long-term AED use. Although various studies have supported this association with increased risk in recent years, the length of this process has not been precisely defined and there is no clear consensus on bone density scanning, intervals of screening, and the subject of calcium and vitamin D supplementation. In this study, in accordance with the most current recommendations, our applications and data, including the detection of possible bone mineralization disorders, treatment methods, and recommendations to prevent bone mineralization disorders, were evaluated in epilepsy patients who were followed up at our outpatient clinic. It was aimed to draw attention to the significance of management of bone metabolism carried out with appropriate protocols. Epilepsy patients were followed up at the Antalya Training and Research Hospital Department of Neurology, Epilepsy Outpatient Clinic who were at high risk for osteoporosis (use of valproic acid [VPA] and enzyme-inducing drugs, using any AED for over 5 years, and postmenopausal women) and were evaluated using a screening protocol. According to this protocol, a total of 190 patients suspected of osteoporosis risk were retrospectively evaluated. Four patients were excluded from the study due to secondary osteoporosis. Of the 186 patients who were included in the study, 97 (52.2%) were women and 89 (47.8%) were men. Prevalence of low bone mineral density (BMD) was 42%, in which osteoporosis was detected in 11.8% and osteopenia in 30.6% of the patients. Osteoporosis rate was higher at the young age group (18-45) and this difference was statistically significant (p=0.018). There was no significant difference between male and female sexes according to osteoporosis and osteopenia rates. Patients receiving polytherapy had higher osteoporosis rate and lower BMD compared to patients receiving monotherapy. Comparison of separate drug groups according to osteoporosis rate revealed that osteoporosis rate was highest in patient groups using VPA+ carbamazepine (CBZ) (29.4%) and VPA polytherapy (19.4%). Total of osteopenia and osteoporosis, or low BMD, was highest in VPA polytherapy (VPA+ non-enzyme-inducing AED [NEID]) and CBZ polytherapy (CBZ+NEID) groups, with rates of 58.3% and 55.1%, respectively. In addition, there was no significant difference between drug groups according to bone metabolism markers, vitamin D levels, and osteopenia-osteoporosis rates. Assuming bone health will be affected at an early age in epilepsy patients, providing lifestyle and diet recommendations, avoiding polytherapy including VPA and CBZ when possible, and evaluating bone metabolism at regular intervals are actions that should be applied in routine practice.

LAM KID

[New findings in the cortical bone biology and its role in bone fractures]

BALOGH Ádám, BHATTOA Harjit Pál

[The authors surveyed the already known factors responsible for the osteoporotic bone fragility. Then the results of using modern imaging techniques (micro-CT, high-resolution peripheral computed quantitative tomograph - HR-pQCT) and advanced computer analytic methods (finite element analysis, FEA) are presented. These data - beyond the already known fracture risk factors (age, risk of falling, bone mineral density - BMD, and fine structure damage of trabecular bone) are stressing the importance of the (micro)damage of cortical bone as a fracture risk factor, which has been still underrated. The cortical thickening and increased porosity - verified on various population samples - are increasing the risk of fractures in certain subgroups of subjects having identical BMD values, even among those, who are considered only osteopenic by the earlier classification based on BMD values. Backed with modern software batteries, the new imaging techniques are expected to enter clinical application in the near future. Pharmacologic agents with stronger cortical effect are already available and research is continuing to find new drugs to use in the management of osteoporotic patients of high fracture risk.]

Ca&Bone

[Evaluation of quality of life following treatment with calcitonin nasal spray in patients with osteoporosis: preliminary results of the MERLIN study]

BORS Katalin, KÓSA József, BORBÉLY Judit, TABÁK Ádám, HORVÁTH CSABA

[INTRODUCTION - MERLIN (Management of Osteoporosis in Elderly with Calcitonin) is an open-label, multicenter, prospective, follow-up study conducted in Hungary, part of which is to assess the impact of treatment with Miacalcic, - an intranasal salmon calcitonin, on the quality of life (QoL) among patients with osteoporosis. In this paper we report the preliminary results of the MERLIN study. PATIENTS - The study initially involved 1949 senior patients (aged >65 years) to whom calcitonin was prescribed for osteoporosis according to the application instructions. Patients presented at outpatient clinics and consisted of two groups; they were either newly diagnosed or they had been receiving a therapy for osteoporosis other than calcitonin. METHODS - This latter group discontinued their previous treatment and all patients received 200 IU intranasal salmon calcitonin (SCT) once daily for three months. Patient and physician questionnaires were used to collect information on the patients' QoL (EQ-5D VAS) and their general well-being at baseline and at follow-up visits at week 4 and week 12. RESULTS - Calcitonin use was associated with improvements in all EQ-5D domains and component scores as well as in VAS. Patients with previously known osteoporosis who, switched to calcitonin therapy achieved better results (0,046 QALY), than the newly diagnosed patients (0,0405 QALY). CONCLUSIONS - We conclude that intranasal SCT 200 IU daily is safe and effective in improving QoL of both, male and female patients with low bone mineral density.The conclusions that can be drawn from this study are limited due to the lack of a control group and to the unblinded design. Further placebo-controlled studies are needed to confirm these results. Nevertheless, our study was the first in Hungary to evaluate the quality of life impact of an osteoporosis treatment, and hopefully it will be followed by more such studies directed to other osteoporosis treatments.]

Ca&Bone

[Bone metabolism and body mass index in postmenopausal women]

TÁRCZY Csaba, TOLDY Erzsébet, SZERB János, VARGA László

[INTRODUCTION - In addition to several other causes constitutional factors play an important role in the development of osteoporosis.Various aspects of bone metabolism were examined to explain the differences in bone density between women with low and high body mass index (BMI). PATIENTS AND METHOD - One hundred and ninetytwo postmenopausal women were included in the study. Bone density was measured by forearm densitometry.To assess bone formation, serum osteocalcin levels were measured, while the rate of bone absorption was estimated from C-terminal telopeptide levels of collagen type I measured in urine and blood. RESULTS - The prevalence of osteoporosis was higher in women with low BMI than in those with normal or higher BMI. Bone metabolism - both formation and absorption - was increased in both groups, however, in women with low BMI this increase was more pronounced and bone metabolism tended to be shifted to absorption compared to patients with normal or higher BMI. CONCLUSION - Postmenopausal lean women have accelerated bone metabolism compared to obese women. This fact and the shift to absorption may be the main reasons for the higher frequency of osteoporosis found by densitometry in women with low BMI than in those with higher BMI.]

Ca&Bone

[Bone mineral density and diabetes mellitus - First results]

TÕKE Judit, TAMÁS GYULA, STELLA Péter, NAGY Erzsébet, NÁDASDI Ágnes, VARGA Piroska, KERÉNYI ZSUZSA

[INTRODUCTION - Data on bone mineral density (BMD) in diabetes mellitus are contradictory in the literature. Early studies described a decreased bone mineral density in type 1 diabetes mellitus (T1DM), but recent studies report no osteopenia in T1DM.The BMD may depend on the quality of treatment for diabetes mellitus and on the presence of chronic complications. In type 2 diabetes mellitus (T2DM) the BMD is not decreased, occasionally it can even be increased. PATIENTS AND METHODS - Bone mineral density was measured in 122 regularly controlled diabetic patients (T1DM: n=73, mean age: 43.6±11.1 years,T2DM: n=49, mean age: 61.8±9.8 years) by dual energy X-ray absorptiometry at the lumbar spine and at the femur. Results were compared to those of 40 metabolically healthy control persons with a mean age of 47.5±11.9 years.The patients’ carbohydrate metabolism was assessed by the average HbA1c level of the last three years.These values were 7.9±1.4 % in T1DM, and 7.5±1.7 % in T2DM. BMDs were classified based on the T-score and Z-score using the WHO criteria. RESULTS - There was no significant difference in T1DM or in T2DM compared to the reference group in the prevalence of either osteoporosis or of osteoporosis and osteopenia combined. CONCLUSION - BMD was not found to be decreased in patients with well-controlled metabolism compared to healthy controls.]