Anne L. Peters, MD, CDE


July 07, 2010

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Hi. I'm Dr. Anne Peters, Director of the Clinical Diabetes Programs at the University of Southern California. Today, I'm going to talk about how to deal with the increased risk of fracture that we found associated with thiazolidinedione (TZD) therapy.

I'm currently at the American Diabetes Association meetings in Orlando, Florida. One of the abstracts that I found interesting is an abstract from Scotland,[1] where they looked at 212,000 patients that they had in a database. They basically wanted to assess the relationship between TZD exposure and fracture.

They found an increase in distal fracture risk in women, which has been reported before, and not a significant increase in distal fracture risk in men. But in both men and women, they found an increased risk for hip fracture associated with use of TZDs.

This concerns me. I personally like TZDs and use them commonly. I think they have great effects on beta-cell function and preservation and they lower glucose levels. They are drugs that I have used often in my practice, but then I'm faced with the issue of how to deal with assessing for this increased risk for fracture.

We don't fully know the mechanisms for this increased risk and there is a lot of research going on, but I tend to be practical when it comes to treating my patients. If I have a patient who is currently having significant trouble with bone issues -- for instance, frequent fractures or really refractory osteoporosis -- that is a patient in whom I wouldn't use a TZD, or if I did, I would use the very lowest dose.

For patients in-between, patients who have some osteoporosis or some osteopenia, what do I do? I may screen earlier in both men and women than the currently recommended 65 years of age for women and 70 years of age for men. I'll screen at 50 or 55, because I'll consider patients who are on TZDs to be at increased risk for fracture. Obviously, if I find osteopenia or osteoporosis, I will treat it. I will treat all of my patients who are vitamin D deficient with vitamin D, as well as with calcium. Then I encourage appropriate follow-up based on their baseline findings.

I have found more cases of osteoporosis in men than I ever would have thought by screening them at a younger age before I put them on a TZD. I have found it useful to consider this as a risk, not wanting to worsen the risk or use TZDs in patients who have significant osteoporosis or who are having bone fractures.

I think it's important that we remember this risk, assess for it, treat the risk factors that are present, and then use TZDs appropriately. This has been Dr. Anne Peters for Medscape. Thank you.


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