Longer Duration of Diabetes Strongly Impacts Fracture Risk Assessment: The Manitoba BMD Cohort

• Published in: The journal of clinical endocrinology and metabolism Vol. 101; no. 11; pp. 4489 - 4496
• Main Authors: Majumdar, Sumit R, Leslie, William D, Lix, Lisa M, Morin, Suzanne N, Johansson, Helena, Oden, Anders, McCloskey, Eugene V, Kanis, John A
• Format: Journal Article
• Language: English
• Published: United States Endocrine Society 01.11.2016; Copyright by The Endocrine Society
• Subjects: Absorptiometry, Photon; Adult; Aged; Bone Density; Diabetes Mellitus, Type 2 - complications; Female; Follow-Up Studies; Hip Fractures - epidemiology; Hip Fractures - etiology; Humans; Manitoba - epidemiology; Middle Aged; Original; Osteoporotic Fractures - epidemiology; Osteoporotic Fractures - etiology; Registries; Risk Assessment; Time Factors
• ISSN: 0021-972X; 1945-7197
• DOI: 10.1210/jc.2016-2569

Context: Type 2 diabetes is associated with a higher risk for major osteoporotic fracture (MOF) and hip fracture than predicted by the World Health Organization fracture risk assessment (FRAX) tool. Objective: The objective of the study was to examine the impact of diabetes duration on fracture risk. Methods: Using a clinical dual-energy x-ray absorptiometry registry linked with the Manitoba administrative databases, we identified all women age 40 years or older with 10 or more years of prior health care coverage undergoing hip dual-energy x-ray absorptiometry measurements (1996–2013). Incident MOF and incident hip fractures were each studied over 7 years. Cox proportional hazards models were adjusted for FRAX (FRAX adjusted) and then FRAX plus comorbidity, falls, osteoporosis therapy, or insulin (fully adjusted). FRAX calibration was assessed comparing observed vs predicted probabilities. Results: There were 49 098 women without and 8840 women with diabetes (31.4% >10 y duration; 20.1% 5–10 y; 23.7% <5 y; 24.8% new onset). In FRAX-adjusted analyses, only duration longer than 10 years was associated with a higher risk for MOF (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.30–1.66), and this was similar in the fully adjusted models (HR 1.34, 95% CI 1.17–1.54). In contrast, a higher risk for hip fracture was seen for all durations in a dose-dependent fashion (eg, FRAX adjusted HR 2.10, 95% CI 1.71–2.59 for duration >10 y vs HR 1.32, 95% CI 1.03–1.69 for new onset). FRAX significantly underestimated the MOF risk (calibration ratio 1.24, 95% CI 1.08–1.39) and hip fracture risk (1.93, 95% CI 1.50–2.35) in those with a diabetes duration longer than 10 years. Conclusion: Diabetes is a FRAX-independent risk factor for MOF only in women with a long duration of diabetes, but diabetes increases hip fracture risk, regardless of duration. Those with diabetes longer than 10 years are at particularly high risk of fracture, and this elevated risk is currently underestimated by FRAX. In a large study we found it was long duration of diabetes that was more important than the diagnosis itself in predicting fracture risk, and that FRAX under-estimates risk in women with diabetes.