Diabetes Does Not Alter Anti-Osteoporotic Treatment Response

spine lumbar vertebra MRI lower back
spine lumbar vertebra MRI lower back
Anti-osteoporotic medications (mainly bisphosphonates) seem to equally prevent bone loss, especially in the lumbar spine, in patients with diabetes compared with patients without diabetes.

The anti-osteoporotic response of increasing bone mineral density (BMD) and risk reduction of vertebral fractures may not be altered in individuals diagnosed with diabetes, according to a study published in Endocrine

Researchers conducted a systematic review of the literature and identified 9 retrospective, observational, prospective, and randomized controlled trials studying the efficacy of anti-osteoporotic medications in individuals with type 1 diabetes (T1D) (n=1) and type 2 diabetes (T2D) (n = 8), compared with individuals without diabetes.

In addition, researchers investigated their effect on BMD and bone turnover markers (BTM). The studies, published between 2004 and 2016, were conducted in Japan, the United States, the United Kingdom, Romania, Denmark, and two of the studies were multicenter. 

When markers of bone formation (bone resorption or bone alkaline phosphatase) were observed in both groups, there was no difference in the magnitude of reduction. BMD increases were found to be similar in the lumbar spine (LS) of postmenopausal women with or without T2D (n=35 and 35, respectively) with no difference in the femoral neck (FN) after 12 months of treatment. Alendronate also demonstrated similar results, with increases in BMD observed in individuals with and without T2D.  

In the one study of risedronate, the LS BMD increased 5.52% from baseline after 12 months of treatment in both individuals with (n=53) and without (n=832) T2D. Individuals with and without diabetes treated with teriparatide also demonstrated similar increases in LS and total hip (TH) BMD; however, a greater increase in FN BMD was observed in individuals with T2D compared with individuals without T2D.

The vertebral (P =.85), hip (P =.77), and forearm (P =.11) fracture risk in individuals exposed to alendronate with T1D and T2D (n=2054) was the same as in individuals not diagnosed with diabetes (n=53,036), with no differences observed between the two different types of diabetes. 

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Raloxifene was found to be more effective in reducing vertebral fracture risk after 36 months of treatment in individuals with T2D (n=124) compared with individuals without diabetes (n=4412) when both treatment groups were compared with placebo (P =.04). Individuals with T2D in the placebo group were at a higher risk for vertebral fractures compared with individuals in the raloxifiene treatment group (odds ratio [OR] 2.17; 95% CI, 0.93-5.06; P =.07). The two other studies found no differences in the anti-fracture potential of raloxifene in individuals with or without diabetes.

There were no differences in non-vertebral fracture rate reduction at 0 to 6 months vs 6 to 24 months in individuals with T2D and individuals without diabetes treated with teriparatide.

Researchers concluded that the presence of diabetes in an individual does not affect the fracture prevention potential of raloxifene, teriparatide, or bisphosphonates (alendronate and risedronate), and therefore equally prevents bone loss in these individuals.

There is similar vertebral fracture risk in individuals with osteoporosis with and without diabetes, but current research evidence is not able to preclude equal anti-fracture efficacy. There are limited and conflicting results regarding non-vertebral fracture risk, but diabetes does not appear to affect the fracture-preventative potential of the researched anti-osteoporotic drugs. Clinicians should therefore treat all individuals with anti-osteoporotic drugs without making amendments in the therapeutic algorithm when treating individuals diagnosed with diabetes.


Anagnostis P, Paschou SA, Gkekas NN, et al. Efficacy of anti-osteoporotic medications in patients with type 1 and 2 diabetes mellitus: a systematic review [published online February 6, 2018]. Endocrine. doi:10.1007/s12020-018-1548-x