Posted Mar 16 , 2017 02:54 PM

Longer Duration of Diabetes Strongly Impacts Fracture Risk Assessment: The Manitoba BMD Cohort

Majumdar SR, et al. J Clin Endocrinol Metab, November 2016, 101(11):4489–4496

What were the findings (excerpted from the Abstract)?

Type 2 diabetes is associated with a higher risk for major osteoporotic fracture (MOF) and hip fracture than predicted by the World Health Organization fracture risk assessment (FRAX) tool. [] The purpose of this study was to examine the impact of diabetes duration on fracture risk. They used a clinical dual-energy x-ray absorptiometry registry linked with the Manitoba administrative databases, and identified all women age 40 years or older with 10 or more years of prior health care coverage undergoing hip dual-energy x-ray absorptiometry measurements (1996–2013). Incident MOF and incident hip fractures were each studied over 7 years. Cox proportional hazards models were adjusted for FRAX (FRAX adjusted) and then FRAX plus comorbidity, falls, osteoporosis therapy, or insulin (fully adjusted). FRAX calibration was assessed comparing observed vs predicted probabilities. There were 49,098 women without and 8,840 women with diabetes (31.4% >10 y duration; 20.1% 5–10 y; 23.7% <5 y; 24.8% new onset). In FRAX-adjusted analyses, only duration longer than 10 years was associated with a higher risk for MOF (hazard ratio [HR] 1.47). In contrast, a higher risk for hip fracture was seen for all durations in a time-dependent fashion. FRAX significantly underestimated the MOF risk and hip fracture risk in those with diabetes duration longer than 10 years.

Why is this important?

Worldwide, osteoporosis causes more than 8.9 million fractures annually, resulting in an osteoporotic fracture every 3 seconds, and 1 in 3 women over age 50 will experience osteoporotic fractures. Osteoporosis takes a huge personal and economic toll in disability. In women over 45 years of age, osteoporosis accounts for more days spent in hospital than many other diseases, including diabetes. In women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors, the USPSTF judged that the benefit of treating screening-detected osteoporosis is at least moderate. Diabetes is a FRAX-independent risk factor for MOF only in women with a long duration of diabetes, but diabetes increases hip fracture risk, regardless of duration. Those with diabetes longer than 10 years are at particularly high risk of fracture, and this elevated risk is currently underestimated by FRAX. In light of the USPTF recommendation and the increased risk associated with long duration diabetes, clinicians should consider screening for fracture risk and early treatment whenever indicated. The USPTF recommends:

… screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.

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