Type 2 Diabetes and Osteoporosis: A Guide to Optimal Management

Stavroula A. Paschou; Anastasia D. Dede; Panagiotis G. Anagnostis; Andromachi Vryonidou; Daniel Morganstein; Dimitrios G. Goulis


J Clin Endocrinol Metab. 2017;102(10):3621-3634. 

In This Article

Abstract and Introduction


Context: Both type 2 diabetes (T2D) and osteoporosis are affected by aging and quite often coexist. Furthermore, the fracture risk in patients with T2D is increased. The aim of this article is to review updated information on osteoporosis and fracture risk in patients with T2D, to discuss the effects of diabetes treatment on bone metabolism, as well as the effect of antiosteoporotic medications on the incidence and control of T2D, and to provide a personalized guide to the optimal management.

Evidence Acquisition: A systematic literature search for human studies was conducted in three electronic databases (PubMed, Cochrane, and EMBASE) until March 2017. Regarding recommendations, we adopted the grading system introduced by the American College of Physicians.

Evidence Synthesis: The results are presented in systematic tables. Healthy diet and physical exercise are very important for the prevention and treatment of both entities. Metformin, sulfonylureas, dipeptidyl peptidase-4 inhibitors, and glucagon-like peptide-1 receptor agonists should be preferred for the treatment of T2D in these patients, whereas strict targets should be avoided for the fear of hypoglycemia, falls, and fractures. Insulin should be used with caution and with careful measures to avoid hypoglycemia. Thiazolidinediones and canagliflozin should be avoided, whereas other sodium-dependent glucose transporter 2 inhibitors are less well-validated options. Insulin therapy is the preferred method for achieving glycemic control in hospitalized patients with T2D and fractures. The treatment and monitoring of osteoporosis should be continued without important amendments because of the presence of T2D.

Conclusions: Patients with coexisting T2D and osteoporosis should be managed in an optimal way according to scientific evidence.


The burden of diabetes is increasing as, according to the World Health Organization,~422 million people are affected globally.[1] Type 2 diabetes (T2D) accounts for most people affected and its prevalence increases with age. Osteoporosis affects ~125 million people in Europe, India, Japan, and the United States; it is estimated that one in three women and one in five men over the age of 50 will experience an osteoporotic fracture at some point in life.[2] As the prevalence of osteoporosis rises with age, the increasing life expectancy will result in further increases in the global burden of osteoporosis. Both diseases are affected by aging and by changes in lifestyle and they can coexist, especially in the elderly. The true prevalence of their coexistence would be hard to determine, as the fracture risk in patients with T2D is increased and is underestimated by conventional diagnostic criteria for osteoporosis. Interestingly, there is a complex pathophysiological interaction between them: T2D affects bone metabolism and strength in a direct way, certain antidiabetic medications affect bone metabolism, and there is an association between diabetic complications and risk for falls and subsequent fractures.[3]

Although many original papers, clinical statements, and guidelines focus on the management of patients with T2D and osteoporosis as separate diseases, their coexistence poses important pathophysiologic, diagnostic, and therapeutic issues that have not been fully elucidated. The aim of this article is to present updated information regarding the prevalence of osteoporosis and fracture risk in patients with T2D, to systematically review effects of medications on both entities, and to provide an individualized guide for the optimal management of patients with T2D and concomitant osteoporosis.