Abstract

Diabetes mellitus (DM) is associated with decreased bone strength as well as increased fracture risk. The link between diabetes and bone appears to be mediated by complex pathways, including the insulin-insulin growth factors system, accumulation of advanced glycation endproducts (AGEs) in bone collagen, microangiopathy,  and increased bone marrow fat content.Bone mineral density (BMD)is decreased in type 1 diabetes, but bone fragility in type 2 diabetes mellitus (T2DM), depends on bone quality deterioration rather than bone mass reduction. Thus, surrogate markers and examination methods are needed to replace the insensitivity of BMD in assessing fracture risks of T2DM patients. Also, at least in T2DM, the classical diagnosis of osteoporosis by dual-energy X-ray absorptiometry and the fracture risk estimation by FRAX (fracture risk assessment tool) are only partially useful in assessing fracture risk. Trabecular bone score (TBS) and trabecular bone score- adjusted FRAX offer an enhanced estimation of fracture risk in these patients. One reason for the occurrence of more fractures despite higher bone density in T2D could be an increasedrisk of trauma, which is possibly linked to hypoglycemia or an increased number of falls because of complications  from impaired eyesight, cerebral ischemia, and poor balance resulting from neuropathy. Adequate glycemic control is generally associated with decreased fracture risk, with the exception of specific antidiabetics (thiazolidinediones, canagliflozin) that have been shown to have a detrimental effect. Besides optimal glycemic control, general recommendations regarding adequate dietary calcium and Vit.D intake, regular exercise, adequate treatment for diabetes and avoidance of other potential risk factors should be given. Most currently used antiosteoporotic treatments seem equally effective in diabetic patients as compared with patients without diabetes, but clinical data regarding the reduction in fracture risk specifically in patients with diabetes mellitus are lacking.