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


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.]



Further articles in this publication




[István Holló, MD, professor 1926-2007]



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


[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.]


[The influence of menopause-related obesity and related changes of body fat distribution on the severity of sleep apnea]


[INTRODUCTION - The menopause is associated with an enhanced risk of obesity. During the postmenopausal period changes in the distribution of body fat lead to a variety of disorders. Obesity is among the major risk factors for Obstructive Sleep Apnea Syndrome (OSAS). The prevalence of OSAS increases after the menopause. This study was intended to explore the relationship between the severity of sleep apnea and the quantity, as well as the distribution of body fat in postmenopausal women with this condition. PATIENTS AND METHODS - Sixty-two postmenopausal women (aged 58.6±7.4 years) were studied. Patients suffering from OSAS - established by cardiorespiratory polygraphy - were enrolled. None of the subjects received hormone replacement therapy during the trial. Total and regional quantity of body fat was determined by dualenergy X-ray absorptiometry (DXA). The distribution of body fat, the ratio of android-to-gynoid regional fat, as well as body mass index were automatically calculated by the software of the DXA machine. A specific region was defined to measure the fat content of the cervical region, extending from the mental protuberance to the clavicular plane. The reliability coefficient of the test method was calculated to check the accuracy of regional body fat measurement. The severity of obstructive sleep apnea was determined by cardiorespiratory polygraphy and expressed using the apnea/hypopnea index. RESULTS - Testing for independence in this population revealed the lack of independence between android-type obesity and severe OSAS. Specifically, 74% of patients with severe OSAS were obese (BMI>30 kg/m2). As with the android-type, the khi square test similarly refuted the independence between obesity and the severity of OSAS. Fat content of the cervical region was 25.2% in mild and moderate, and 30.2% in severe OSAS. Two-Sample t-test demonstrated the significant influence of cervical fat content on OSAS severity. CONCLUSION - Elevated BMI, android-type obesity, and higher relative fat content of the cervical region all aggravate obstructive sleep apnea in postmenopausal women.]


[The rehabilitation team and distinct representatives of medicine in the service of osteopenic patients]

All articles in the issue

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[Biosimilar insulins on the horizon]


[Nowadays human insulins and insulin analogues are exclusively used in the clinical practice, when insulin therapy is needed. The patents of human insulins are expired and will expire soon for glargine, the first long-acting, basal insulin analogue preparation. The reliable production of biosimilar insulins is a new challenge for the pharmaceutical industry. Independently developed insulins with appreciable clinical efficacy have already become available in some countries where the quality criteria of regulatory process in place are less strict than in the European Union. The first approval for true biosimilar insulin, i.e. for biosimilar glargine was given in Europe in 2014. In this article, the characteristics of biosimilar insulins, especially the difficulties in the manufacturing process are reviewed in comparison with generic drugs. It is of note that potential efficacy and safety differences may occur due to even minor changes in the production, formulation and storage of the biological drugs. Therefore, biosimilarity should be investigated by detailed comparative pharmacokinetic and pharmacodynamic studies. Moreover, similar clinical efficacy and safety should be documented by randomized, comparative clinical trials. The potential impact of altered immunologic profile of biosimilar insulins should also be carefully monitored. ]


[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.]


[The risk factors of osteoporosis and osteoporotic fractures in Hungarian women: the results of the NOKK study]

MEZŐ Tibor, TABÁK Ádám, BHATTOA Harjit Pál, LAKATOS Péter

[INTRODUCTION - It is widely accepted from Western European and the US studies that race and geography significantly affect the risk for osteoporosis. Less is known about similar associations in Eastern European subjects. Our aim was to describe the risk factors for osteoporotic fractures and osteoporosis in a selected female population in a cross-sectional, multi-center study performed under the guidance of the Hungarian Society for osteoporosis and Osteoarthrology. MATERIAL AND METHOD - From 10 randomly selected regional osteoporosis centers, altogether 2602 women >18 years of age, referred with any osteoarthrological reason, participated. During their visit data on risk factors, blood pressure, anthropometry, and bone mineral density were collected. RESULTS - Using multiple regression we found that older age, lower diastolic blood pressure, family history of bone fracture, fall in previous year and lower T-score were independently related to fractures. Independent risk factors for femoral osteoporosis included older age, lower weight, family history of fracture, less physical activity, fall in the previous year and glucocorticoid treatment. DISCUSSION - Our study is the first large-scale epidemiological survey describing risk factors of osteoporosis and fractures in a Hungarian female population. Our data may suggest that lower diastolic blood pressure might be related to osteoporotic fractures.]

Lege Artis Medicinae

[The diabetic foot syndrome: pathomechanism, clinical picture, current treatment and prevention]


[Diabetic foot syndrome is a characteristic late complication of diabetes mellitus. It can develop in patients with type 1 as well as type 2 diabetes mellitus, especially in case of a long duration of diabetes and sustained poor metabolic state. Diabetic neuropathy plays a pivotal role in the pathomechanism, but vascular symptoms might also contribute to the complex clinical picture. For making the diagnosis, evaluation of complaints, performing physical examination and using simple tests for identifying both distal, somatosensory neuropathy and potential angiopathy are of great importance. Therapeutic approaches aim to achieve proper glycaemic control, as well as to ameliorate symptoms of neuropathy, improve peripheral blood supply by medicines, angioplasty or intervention radiological methods, fight against infections and off-load the foot. Surgical intervention might also be necessary, and in severe cases, amputation might be needed. The diabetic foot syndrome increases mortality risk in patients with diabetes. Complaints related to diabetic foot syndrome are often resistant to treatment and tend to recur. Thus, prevention with long-term, good metabolic control and protection of the foot are of particular importance.]

Lege Artis Medicinae


POÓR Gyula

[Osteoporosis poses a major public health problem worldwide due to the extreme number of patients and to the deterioration of quality of life, disability, excess mortality and costs associated with consequent fractures. Representative studies of the author’s group have previously shown that the average bone mineral density values of the Hungarian population are among the lowest in Europe while the prevalence of vertebral fractures is among the highest in international comparison. This revelation has led to the development of a National Osteoporosis Programme, the key element of which being the setting up of a network of osteoporosis centres that are based on the collaboration of various medical specialists, the availability of advanced diagnostic tools and outstanding therapeutic opportunities. On describing the 10-year activity of the centres, the main diagnostic, prevention and management approaches of osteoporosis are discussed. According to the WHO classification the diagnosis of osteoporosis is based on a low bone mineral density finding supported by the laboratory and radiological exclusion of other metabolic bone diseases and secondary forms of osteoporosis. According to the up-to-date treatment guidelines of osteoporosis, when considering medical treatment, preference should be given to patients with high fracture risk in giving drugs with extensive antifracture efficacy that has been confirmed by studies of evidencebased medicine. Among these drugs the most important are the antiresorptive bisphosphonates that have widely been used in Hungary and the bone forming teriparatide that is expected to gain wider use in the near future with the introduction of public health insurance financing. The efficacy of these specific antiosteoporotics is increased by supplementation with calcium and vitamin D. The internationally acknowledged Hungarian osteoporosis management system offers to Hungarian patients outstanding standards for the prevention and management of osteoporosis.]