Based on a review of how therapies for type 2 diabetes affect bone health and how, in turn, treatments for osteoporosis may affect glycemic control, researchers have developed a treatment algorithm for patients who have both.
Noting that type 2 diabetes and osteoporosis often coexist, particularly as people age, and that fracture risk is increased in patients with type 2 diabetes, Stavroula Α Paschou, MD, from the National Kapodistrian University of Athens, Greece, and colleagues observe that a “healthy diet and physical exercise are very important for…prevention and treatment” of type 2 diabetes and osteoporosis.
To treat type 2 diabetes in patients who also have osteoporosis, metformin should be used first and, if needed, a sulfonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitor, or glucagonlike peptide-1 (GLP-1) receptor agonist could be added, they note in their paper published online June 21 in the Journal of Clinical Endocrinology & Metabolism.
“Strict [HbA1c] targets should be avoided [to help prevent] hypoglycemia, falls, and fractures,” Dr Paschou and colleagues warn.
Moreover, insulin should be used very carefully, to avoid hypoglycemia.
Clinicians should avoid prescribing thiazolidinediones (TZDs) or the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin, both of which are associated with increased fracture risk.
On the other hand, “treatment and monitoring of osteoporosis should not be modified because of the presence of [type 2 diabetes],” according to the researchers, since they did not find any evidence of any detrimental effect of any osteoporosis medications on glucose metabolism.
Different Diabetes Medications, Different Fracture Risk
Until now, there has been no systematic review of studies and guidelines to better manage patients with coexisting type 2 diabetes and osteoporosis, Dr Paschou and colleagues write.
But evidence suggests that metformin protects bone health, they report.
Sulfonylureas have a neutral effect on bone metabolism and bone-mineral density, but patients need to watch out for hypoglycemia and falls.
TZDs should be avoided in women with increased risk of fractures.
DPP-4 inhibitors appear to have a neutral effect on fracture risk, as seen with saxagliptin (Onglyza, AstraZeneca) in SAVOR-TIMI and sitagliptin (Januvia, Merck) in TECOS.
A meta-analysis of GLP-1 receptor agonists suggests that liraglutide (Victoza, Novo Nordisk) may protect against fractures, whereas exenatide (Bydureon , Byetta, AstraZeneca) may have the opposite effect, but the individual studies were not powered for this outcome, they observe.
Among the SGLT2 inhibitors, canagliflozin (Invokana, Invokamet, Johnson & Johnson/Janssen) might harm bone health, which has led to a warning label for this drug. Empagliflozin (Jardiance, Lilly/Boehringer Ingelheim) and dapagliflozin (Farxiga, AstraZeneca) seem to have a neutral effect on bone health.
Patients treated with insulin generally have more fractures, and those who undergo bariatric surgery also seem to have an increased risk of fracture 1 to 2 years later.
Osteoporosisis Medications Seem to Have Minimal Effect on Glucose
Bisphosphonates, denosumab, teriparatide, strontium ranelate, and selective estrogen-receptor modulators (SERMs) (raloxifene and bazedoxifene) “are currently the only agents approved for the treatment of osteoporosis,” and so far, the data indicate that “antiosteoporotic medications have minimal, if any, effects on glucose metabolism,” according to the researchers.
Thus, osteoporosis treatment and monitoring are the same in patients with or without type 2 diabetes.
However, reports of a reduced risk of developing diabetes with bisphosphonates “warrants further investigation in well-designed studies,” they write.
In patients with both type 2 diabetes and osteoporosis, those who have had diabetes for a long time and also have cardiovascular disease and recurrent severe hypoglycemic episodes should have a higher HbA1c target of <7.5% to 8% (as opposed to <7%) to reduce their risk of hypoglycemia, falls, and fractures.
Most patients with type 2 diabetes also have hypertension, and treatment should aim to control blood pressure while avoiding hypotension and falls.
Similarly, these patients need regular eye exams and neuropathy assessment to prevent falls.
Insulin is recommended to achieve glycemic control in patients with type 2 diabetes who are hospitalized for fracture.
“Patients with coexisting [type 2 diabetes] and osteoporosis should be managed in an optimal way according to scientific evidence,” Dr Paschou and colleagues summarize.
The authors have no relevant financial relationships.
For more diabetes and endocrinology news, follow us on Twitter and on Facebook.
J Clin Endocrinol Metab. Published online June 21, 2017. Abstract
Tidak ada komentar:
Posting Komentar