Long-term use of thiazolidinediones and fractures in type 2 diabetes: a meta-analysis

Assessing the Effects of Thiazole-Carboxamide Derivatives on the Biophysical Properties of AMPA Receptor Complexes as a Potential Neuroprotective Agent

An optimal balance between excitatory and inhibitory transmission in the central nervous system provides essential neurotransmission for good functioning of the neurons. In the neurology field, a disturbed balance can lead to neurological diseases like epilepsy, Alzheimer's, and Autism. One of the critical agents mediating excitatory neurotransmission is α-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptors, which are concerned with synaptic plasticity, memory, and learning. An imbalance in neurotransmission finally results in excitotoxicity and neurological pathologies that should be corrected through specific compounds. Hence, the current study will prove to be an evaluation of new thiazole-carboxamide derivatives concerning AMPAR-modulating activity and extended medicinal potential. In the current project, five previously synthesized thiazole-carboxamide derivatives, i.e., TC-1 to TC-5, were used to interact with the AMPARs expressed in HEK293T cells, which overexpress different subunits of the AMPAR. Patch-clamp analysis was carried out while the effect of the drugs on AMPAR-mediated currents was followed with a particular emphasis on the kinetics of inhibition, desensitization, and deactivation. All tested TC compounds, at all subunits, showed potent inhibition of AMPAR-mediated currents, with TC-2 being the most powerful for all subunits. These compounds shifted the receptor kinetics efficiently, mainly enhancing the deactivation rates, and hence acted as a surrogate for their neuroprotective potentials. Additionally, recently published structure-activity relationship studies identified particular substituent groups as necessary for improving the pharmacologic profiles of these compounds. In this regard, thiazole-carboxamide derivatives, particularly those classified as TC-2, have become essential negative allosteric modulators of AMPAR function and potential therapeutics in neurological disturbances underlain by the dysregulation of excitatory neurotransmission. Given their therapeutic effectiveness and safety profiles, these in vivo studies need to be further validated, although computational modeling can be further developed for drug design and selectivity. This will open possibilities for new drug-like AMPAR negative allosteric modulators with applications at the clinical level toward neurology.

Potential Metabolic Pathways Involved in Osteoporosis and Evaluation of Fracture Risk in Individuals with Diabetes

Diabetes has a significant global prevalence. Chronic hyperglycemia affects multiple organs and tissues, including bones. A large number of diabetic patients develop osteoporosis; however, the precise relationship between diabetes and osteoporosis remains incompletely elucidated. The activation of the AGE-RAGE signaling pathway hinders the differentiation of osteoblasts and weakens the process of bone formation due to the presence of advanced glycation end products. High glucose environment can induce ferroptosis of osteoblasts and then develop osteoporosis. Hyperglycemia also suppresses the secretion of sex hormones, and the reduction of testosterone is difficult to effectively maintain bone mineral density. As diabetes therapy, thiazolidinediones control blood glucose by activating PPAR-γ. Activated PPAR-γ can promote osteoclast differentiation and regulate osteoblast function, triggering osteoporosis. The effects of metformin and insulin on bone are currently controversial. Currently, there are no appropriate tools available for assessing the risk of fractures in diabetic patients, despite the fact that the occurrence of osteoporotic fractures is considerably greater in diabetic individuals compared to those without diabetes. Further improving the inclusion criteria of FRAX risk factors and clarifying the early occurrence of osteoporosis sites unique to diabetic patients may be an effective way to diagnose and treat diabetic osteoporosis and reduce the risk of fracture occurrence.

Bone Health in Patients With Type 2 Diabetes

The association between type 2 diabetes mellitus (T2DM) and skeletal fragility is complex, with effects on bone at the cellular, molecular, and biomechanical levels. As a result, people with T2DM, compared to those without, are at increased risk of fracture, despite often having preserved bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). Maladaptive skeletal loading and changes in bone architecture (particularly cortical porosity and low cortical volumes, the hallmark of diabetic osteopathy) are not apparent on routine DXA. Alternative imaging modalities, including quantitative computed tomography and trabecular bone score, allow for noninvasive visualization of cortical and trabecular compartments and may be useful in identifying those at risk for fractures. Current fracture risk calculators underestimate fracture risk in T2DM, partly due to their reliance on BMD. As a result, individuals with T2DM, who are at high risk of fracture, may be overlooked for commencement of osteoporosis therapy. Rather, management of skeletal health in T2DM should include consideration of treatment initiation at lower BMD thresholds, the use of adjusted fracture risk calculators, and consideration of metabolic and nonskeletal risk factors. Antidiabetic medications have differing effects on the skeleton and treatment choice should consider the bone impacts in those at risk for fracture. T2DM poses a unique challenge when it comes to assessing bone health and fracture risk. This article discusses the clinical burden and presentation of skeletal disease in T2DM. Two clinical cases are presented to illustrate a clinical approach in assessing and managing fracture risk in these patients.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diabetes and Osteoporosis

Bone fragility is an emerging complication of diabetes. People with diabetes are at a significantly higher risk of fractures compared to the general population. Bone fragility occurs in diabetes as a result of complex and poorly understood mechanisms occurring at the cellular level contributed by vascular, inflammatory and mechanical derangements. Bone mineral density (BMD) as assessed by DEXA is low in type 1 diabetes. Type 2 diabetes has a high risk of fracture despite a normal to raised BMD. DEXA thus underestimates the fracture risk in diabetes. Data are scare regarding the efficacy of the available therapies in this low bone turnover state.

Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad?

It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.

Bavachinin selectively modulates PPAR γ and maintains bone homeostasis in Type 2 Diabetes

Full peroxisome proliferator-activated receptor (PPAR) γ agonists, Thiazolidinediones (TZDs), effectively prevent the process of Type 2 Diabetes Mellitus (T2DM), but their side effects have curtailed use in the clinic, including weight gain and bone loss. Here, we identified that a selective PPAR γ modulator, Bavachinin (BVC), isolated from the seeds of Psoralea Corylifolia L., could potently regulate bone homeostasis. MC3T3-E1 pre-osteoblast cells and C3H10T1/2 mesenchymal stem cells were assessed for osteogenic differentiation activities, and receptor activator of NF-κB ligand (RANKL)-induced RAW 264.7 cells were assessed osteoclasts formation. Leptin receptor-deficient mice and diet-induced obesity mice were applied to evaluate the effect of BVC on bone homeostasis in vivo. Compared to full PPAR γ agonist rosiglitazone, BVC significantly increased the osteogenesis differentiation activities under normal and high glucose conditions in MC3T3-E1 cells. Moreover, BVC could alleviate osteoclast differentiation in RANKL-induced RAW 264.7 cells. In vivo, synthesized BVC prodrug (BN) has been applied to improve water solubility, increase the extent of oral absorption of BVC and prolong its residence time in blood circulation. BN could prevent weight gain, ameliorate lipid metabolism disorders, improve insulin sensitivity, and maintain bone mass and bone biomechanical properties. BVC, a unique PPAR γ selective modulator, could maintain bone homeostasis, and its prodrug (BN) exhibits insulin sensitizer activity while circumventing the side effects of the TZDs, including bone loss and undesirable weight gain.

Exploring the molecular mechanism of Ling-Gui-Zhu-Gan decoction for the treatment of type 2 diabetes mellitus based on network pharmacology and molecular docking: A review

To investigate the mechanism of action of the classical formula Ling-Gui-Zhu-Gan (LGZG) decoction in treating type 2 diabetes mellitus based on network pharmacology and molecular docking. The active ingredients and targets of LGZG decoction were collected by the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform database and mapped using Cytoscape software to show their interrelationships. GeneCards, Pharmacogenomics Knowledge Base, OMIM, Therapeutic Target Database, and Drugbank databases were used to obtain targets related to type 2 diabetes; protein-protein interaction networks were established with the help of the STRING platform. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses were performed on selected core targets with the help of the Metascape platform. Finally, the AutoDock platform was used to perform molecular docking and display the results by Pymol software. One hundred twenty-one active ingredients, 216 effective target genes, 11,277 type 2 diabetes mellitus-related genes, 210 crossover genes, and 18 core genes were obtained for LGZG decoction. The results obtained by Kyoto Encyclopedia of Genes and Genomes indicated that the advanced glycosylation end products-receptor of advanced glycosylation end products signaling pathway, the phosphatidylinositol 3 kinase-Akt signaling pathway, and HIF-1 signaling pathway might be the key signaling pathways. Molecular docking showed that the binding energy of quercetin, kaempferol, naringenin, and licorice chalcone A to the core target genes were all <5.0 kJ-mol-1, with good affinity. In this study, the potential active ingredients and mechanisms of action of LGZG decoction in the treatment of type 2 diabetes were initially investigated, which provided a basis for the in-depth study of its drug basis and mechanisms of action.

Sex differences in adverse drug reactions: Are women more impacted?

Pharmacovigilance and pharmacoepidemiology studies regarding the sex difference in adverse drug reactions are numerous, and it is now a challenge to take them into account in order to increase drug safety. Here, we present an overview of this topic through data on epidemiology, mechanisms, and methods used for assessing sex differences in drug safety. Because the literature is extensive, we choose to expose a few examples of studies for cardiovascular drugs, anti-infectious, psychotropics, antidiabetics, anticancer drugs and some specific drugs to illustrate our purpose. Many studies show a higher risk in women for most of drugs involving in sex differences. However, physiological, methodological and subjective points have to be taken into account to interpret these results. Clinical trials must also enroll more women to better evaluate sex differences both in efficacy and pharmacovigilance. Nevertheless, when there is a pharmacological rationale underlying the observed association between sex and drug safety profile, it is now unavoidable to think about its consideration for a personalized prescription.

Development of PPARγ Agonists for the Treatment of Neuroinflammatory and Neurodegenerative Diseases: Leriglitazone as a Promising Candidate

Increasing evidence suggests that the peroxisome proliferator-activated receptor γ (PPARγ), a member of the nuclear receptor superfamily, plays an important role in physiological processes in the central nervous system (CNS) and is involved in cellular metabolism and repair. Cellular damage caused by acute brain injury and long-term neurodegenerative disorders is associated with alterations of these metabolic processes leading to mitochondrial dysfunction, oxidative stress, and neuroinflammation. PPARγ agonists have demonstrated the potential to be effective treatments for CNS diseases in preclinical models, but to date, most drugs have failed to show efficacy in clinical trials of neurodegenerative diseases including amyotrophic lateral sclerosis, Parkinson's disease, and Alzheimer's disease. The most likely explanation for this lack of efficacy is the insufficient brain exposure of these PPARγ agonists. Leriglitazone is a novel, blood-brain barrier (BBB)-penetrant PPARγ agonist that is being developed to treat CNS diseases. Here, we review the main roles of PPARγ in physiology and pathophysiology in the CNS, describe the mechanism of action of PPARγ agonists, and discuss the evidence supporting the use of leriglitazone to treat CNS diseases.

Medical treatment of Cushing's disease with concurrent diabetes mellitus

Cushing's disease (CD) is a severe endocrine disorder characterized by chronic hypercortisolaemia secondary to an overproduction of adrenocorticotropic hormone (ACTH) by a pituitary adenoma. Cortisol excess impairs normal glucose homeostasis through many pathophysiological mechanisms. The varying degrees of glucose intolerance, including impaired fasting glucose, impaired glucose tolerance, and Diabetes Mellitus (DM) are commonly observed in patients with CD and contribute to significant morbidity and mortality. Although definitive surgical treatment of ACTH-secreting tumors remains the most effective therapy to control both cortisol levels and glucose metabolism, nearly one-third of patients present with persistent or recurrent disease and require additional treatments. In recent years, several medical therapies demonstrated prominent clinical efficacy in the management of patients with CD for whom surgery was non-curative or for those who are ineligible to undergo surgical treatment. Cortisol-lowering medications may have different effects on glucose metabolism, partially independent of their role in normalizing hypercortisolaemia. The expanding therapeutic landscape offers new opportunities for the tailored therapy of patients with CD who present with glucose intolerance or DM, however, additional clinical studies are needed to determine the optimal management strategies. In this article, we discuss the pathophysiology of impaired glucose metabolism caused by cortisol excess and review the clinical efficacy of medical therapies of CD, with particular emphasis on their effects on glucose homeostasis.

Contributors to impaired bone health in type 2 diabetes

Type 2 diabetes (T2D) is associated with numerous complications, including increased risk of fragility fractures, despite seemingly protective factors [e.g., normal bone mineral density and increased body mass index(BMI)]. However, fracture risk in T2D is underestimated by current fracture risk calculators. Importantly, post-fracture mortality is worse in T2D following any fracture, highlighting the importance of identifying high-risk patients that may benefit from targeted management. Several diabetes-related factors are associated with increased fracture risk, including exogenous insulin therapy, vascular complications, and poor glycaemic control, although detailed comprehensive studies to identify the independent contributions of these factors are lacking. The underlying pathophysiological mechanisms are complex and multifactorial, with different factors contributing during the course of T2D disease. These include obesity, hyperinsulinaemia, hyperglycaemia, accumulation of advanced glycation end products, and vascular supply affecting bone-cell function and survival and bone-matrix composition. This review summarises the current understanding of the contributors to impaired bone health in T2D, and proposes an updated approach to managing these patients.

A narrative review of diabetic bone disease: Characteristics, pathogenesis, and treatment

Recently, the increasing prevalence of diabetes mellitus has made it a major chronic illness which poses a substantial threat to human health. The prevalence of osteoporosis among patients with diabetes mellitus has grown considerably. Diabetic bone disease is a secondary osteoporosis induced by diabetes mellitus. Patients with diabetic bone disease exhibit variable degrees of bone loss, low bone mineral density, bone microarchitecture degradation, and increased bone fragility with continued diabetes mellitus, increasing their risk of fracture and impairing their ability to heal after fractures. At present, there is extensive research interest in diabetic bone disease and many significant outcomes have been reported. However, there are no comprehensive review is reported. This review elaborates on diabetic bone disease in the aspects of characteristics, pathogenesis, and treatment.

Effects of Linagliptin and Pioglitazone on Fracture Healing in an Experimental Type 2 Diabetes Rat Model

AIM

Our study aimed to examine the effects of Linagliptin, Pioglitazone, and their combination on fracture healing in a diabetes rat femur fracture model.

MATERIAL AND METHODS

Type 2 diabetes mellitus (T2DM) induced rats were randomly divided into four groups: non-treated diabetes group (TD), Pioglitazone group (P), Linagliptin group (L), and Pioglitazone and Linagliptin group (PL). Daily oral dosage of pioglitazone (10 mg/kg/day), linagliptin (10 mg/kg/day), and their combination were administered. Femur fractures were stabilized intramedullary. At weeks 2 and 6, rats were sacrificed for evaluation radiologically, biomechanically, histopathologically, histomorphometrically, and immunohistochemically.

RESULTS

Flexural strength of the L and PL groups were significantly higher compared to the P group. The highest healing score was in the L group and lowest in the P group, while the highest inflammation score was in the P group and lowest in the L group. A cluster of differentiation (CD) CD 34 reactivity was highest in the L group and lowest in the PL group.

CONCLUSION

Linagliptin treatment significantly increased histological healing scores, callus volume, biomechanical strength, and vascularity, however, minimized the inflammatory process, which was increased by pioglitazone. The combination of linagliptin and pioglitazone restored BMD and increased biomechanical strength. Linagliptin monotherapy is rarely indicated; hence, T2DM patients with a high risk of bone fractures can be considered for combined therapy of pioglitazone and linagliptin.

Musculoskeletal complications in patients with diabetes mellitus

Musculoskeletal conditions are common in patients with diabetes. Several musculoskeletal disorders are viewed as chronic complications of diabetes because epidemiological studies have revealed high correlations between such complications and diabetes, but the pathophysiological links with diabetes remains unclear. Genetic predispositions, shared risk factors, microvascular impairments, progressive accumulation of advanced glycation end-products, and diabetic neuropathy may underlie the development of musculoskeletal disorders. Musculoskeletal complications of diabetics have received less attention than life-threatening microvascular or macrovascular complications. Here, we review several diabetic musculoskeletal complications with a focus on the clinical importance of early recognition and management, which would improve quality of life and physical function.

Mulberry-Derived 1-Deoxynojirimycin Prevents Type 2 Diabetes Mellitus Progression via Modulation of Retinol-Binding Protein 4 and Haptoglobin

Pre-diabetic or early-stage type 2 diabetes patients may develop an adverse diabetic progression, leading to several complications and increasing hospitalization rates. Mulberry leaves, which contain 1-deoxynojirimycin (DNJ), have been used as a complementary medicine for diabetes prevention and treatment. Our recent study demonstrated that mulberry leaf powder with 12 mg of DNJ improves postprandial hyperglycemia, fasting plasma glucose, and glycated hemoglobin. However, the detailed mechanisms are still unknown. This study investigates the effect of long-term (12-week) supplementation of mulberry leaves in obese people with prediabetes and patients with early-stage type 2 diabetes. Participants’ blood was collected before and after supplementation. The protein profile of the plasma was examined by proteomics. In addition, the mitochondrial function was evaluated by energetic and homeostatic markers using immunoelectron microscopy. The proteomics results showed that, from a total of 1291 proteins, 32 proteins were related to diabetes pathogenesis. Retinol-binding protein 4 and haptoglobin protein were downregulated, which are associated with insulin resistance and inflammation, respectively. For mitochondrial function, the haloacid dehalogenase-like hydrolase domain-containing protein 3 (HDHD-3) and dynamin-related protein 1 (Drp-1) displayed a significant increment in the after treatment group. In summary, administration of mulberry leaf powder extract in prediabetes and the early stage of diabetes can alleviate insulin resistance and inflammation and promote mitochondrial function in terms of energy production and fission.

Relationship between body composition and bone mineral density in postmenopausal women with type 2 diabetes mellitus

BACKGROUND

The aim of the study were to analyze the lumbar volumetric bone mineral density (BMD), fat distribution and changes of skeletal muscle with quantitative computed tomography (QCT) in postmenopausal women with type 2 diabetes mellitus (T2DM), and to evaluate the relationship between body composition and BMD.

METHODS

One hundred seventy-seven postmenopausal women with T2DM and 136 postmenopausal women without diabetes were included in the study and were divided into two groups according to age, 50-65 years age group and over 65 years of age group. The lumbar BMD (L1-L3), visceral fat mass (VFM), visceral fat area (VFA), subcutaneous fat mass (SFM), subcutaneous fat area (SFA), psoas major mass (PMM) and psoas major area (PMA) of each group were compared. Univariable and multivariable linear regression analysis were used to analyze the contribution of each variable to BMD in postmenopausal women with T2DM.

RESULTS

In women aged 50-65, the patients in the T2DM group had higher body mass index (BMI), VFM, VFA, and SFM (p < 0.05), compared with non-T2DM group. Over 65 years old, the BMI, BMD, VFM, VFA, and SFM was found to be much higher in participants with T2DM than in non-T2DM group (p < 0.05). Compared with women aged in 50-65 years old, those over 65 years old had higher VFA and VFM and lower BMD (p < 0.05), whether in the T2DM group or the non-T2DM group. Age, VFA and VFM were negatively correlated with BMD (r = -0.590, p ≤ 0.001; r = -0.179, p = 0.017; r = -0.155, p = 0.040, respectively). After adjusting for age, VFM and VFA were no longer correlated with BMD. No correlations between fat distribution or psoas major muscle and BMD in postmenopausal women with T2DM were observed.

CONCLUSIONS

T2DM can affect abdominal fat deposition in postmenopausal women. Postmenopausal elderly women with diabetes have higher BMD than normal elderly women. There was no correlation between fat distribution or psoas major and BMD in postmenopausal women with diabetes mellitus.

Pharmacological Inhibition of Inositol Hexakisphosphate Kinase 1 Protects Mice against Obesity-Induced Bone Loss

Obesity and type II diabetes mellitus (T2DM) are prominent risk factors for secondary osteoporosis due to the negative impacts of hyperglycemia and excessive body fat on bone metabolism. While the armamentarium of anti-diabetic drugs is expanding, their negative or unknown impacts on bone metabolism limits effectiveness. The inactivation of inositol hexakisphosphate kinase 1 (IP6K1) protects mice from high-fat-diet (HFD)-induced obesity (DIO) and insulin resistance by enhancing thermogenic energy expenditure, but the role of this kinase and the consequences of its inhibition on bone metabolism are unknown. To determine if IP6K1 inhibition in obese mice affords protection against obesity-induced metabolic derangements and bone loss, we maintained 2-month-old mice on a normal chow control diet or HFD under thermal neutral conditions for 100 d. Beginning on day 40, HFD-fed mice were divided into two groups and administered daily injections of vehicle or the pan-IP6K inhibitor TNP [N2-(m-Trifluorobenzyl), N6-(p-nitrobenzyl) purine]. HFD-fed mice developed obesity, hyperglycemia, hyperlipidemia, and secondary osteoporosis, while TNP administration protected mice against HFD-induced metabolic and lipid derangements and preserved bone mass, mineral density, and trabecular microarchitecture, which correlated with reduced serum leptin levels, reduced marrow adiposity, and preservation of marrow resident skeletal stem/progenitor cells (SSPCs). TNP also exhibited hypotensive activity, an unrealized benefit of the drug, and its prolonged administration had no adverse impacts on spermatogenesis. Together, these data indicate that the inhibition of IP6K1 using selective inhibitors, such as TNP, may provide an effective strategy to manage obesity and T2DM due to its bone sparing effects.

Management of Type 2 Diabetes Mellitus in Elderly Patients with Frailty and/or Sarcopenia

The life expectancy of the population is increasing worldwide due to improvements in the prevention, diagnosis, and treatment of diseases. This favors a higher prevalence of type 2 diabetes mellitus (T2DM) in the elderly. Sarcopenia and frailty are also frequently present in aging. These three entities share common mechanisms such as insulin resistance, chronic inflammation, and mitochondrial dysfunction. The coexistence of these situations worsens the prognosis of elderly patients. In this paper, we review the main measures for the prevention and management of sarcopenia and/or frailty in elderly patients with T2DM.

Trends in drug prescriptions for type 2 diabetes, hypertension, and dyslipidemia among adults with non-alcoholic fatty liver disease

INTRODUCTION AND OBJECTIVES

Clinical guidelines recommend specific drugs for type 2 diabetes (T2D), hypertension, and dyslipidemia in patients with non-alcoholic fatty liver disease (NAFLD) and/or non-alcoholic steatohepatitis (NASH). We aimed to investigate the differences in prescription trends of antidiabetic, antihypertensive, and lipid-lowering drugs among adult patients according to the presence of comorbid NAFLD and/or NASH.

METHODS

We conducted a cross-sectional analysis using a large claims database from January 2013 to December 2020.

RESULTS

Among 7,716,908 people, 47,157 patients with T2D, 180,050 with hypertension, and 191,348 with dyslipidemia were identified. A total of 8,897, 16,451, and 24,762 patients with NAFLD, as well as 435, 523, and 1033 patients with NASH, had T2D, hypertension, and dyslipidemia, respectively. Among antidiabetic drugs, sodium-glucose cotransporter-2 inhibitors (SGLT2is) and thiazolidine were more frequently prescribed to patients with NAFLD than to those without NAFLD (non-NAFLD) (thiazolidine: 1.4% and 2.8% and SGLT2is: 17.8% and 25.9% for non-NAFLD and NAFLD, respectively [2019-2020]). Among antihypertensive drugs, angiotensin II receptor antagonists exhibited a slightly higher prescription ratio in patients with NAFLD (33.6% vs. 39.0%). Regarding lipid-lowering drugs, fibrates were more frequently prescribed to patients with NAFLD (10.3% vs. 18.4%).

CONCLUSIONS

Specific drugs tended to be prescribed to patients with NAFLD. However, the differences in prescription ratios were not considerable. Further investigation is required to confirm the effects of drugs on the prognosis of patients with NAFLD or NASH.

Risk of Fracture With Dipeptidyl Peptidase-4 Inhibitors, Glucagon-like Peptide-1 Receptor Agonists, or Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis Combining 177 Randomized Controlled Trials With a Median Follow-Up of 26 weeks

Aim: This study aims to investigate the association between the use of dipeptidyl peptidase-4 inhibitors (DPP-4i), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and the risk of fracture among patients with type 2 diabetes mellitus.

Methods: Medline, Embase, Cochrane Library, and Clinical-Trials.gov databases were searched for randomized controlled trials (RCTs). Network meta-analysis was performed for total fracture and a series of secondary outcomes.

Results: A total of 177 RCTs (n = 165,081) involving the risk of fracture were identified (a median follow-up of 26 weeks). DPP-4i, GLP-1 RAs, and SGLT-2i did not increase total fracture risk compared with insulin (odds ratio: 0.86, 95% confidence interval: 0.39–1.90; 1.05, 0.54–2.04; 0.88, and 0.39–1.97, respectively), metformin (1.41, 0.48–4.19; 1.72, 0.55–5.38; 1.44, 0.48–4.30), sulfonylureas (0.77, 0.50–1.20; 0.94, 0.55–1.62; 0.79, 0.48–1.31), thiazolidinediones (0.82, 0.27–2.44; 1.00, 0.32–3.10; 0.83, 0.27–2.57), α-glucosidase inhibitor (4.92, 0.23–103.83; 5.99, 0.28–130.37; 5.01, 0.23–107.48), and placebo (1.04, 0.84–1.29; 1.27, 0.88–1.83; 1.06, 0.81–1.39).

Conclusions: The use of DPP-4i, GLP-1 RAs, or SGLT-2i is unlikely to increase the risk of fracture among type 2 diabetes mellitus patients.

Mapping Knowledge Landscapes and Emerging Trends of the Links Between Bone Metabolism and Diabetes Mellitus: A Bibliometric Analysis From 2000 to 2021

Background

Diabetes mellitus (DM) have become seriously threatens to human health and life quality worldwide. As a systemic metabolic disease, multiple studies have revealed that DM is related to metabolic bone diseases and always induces higher risk of fracture. In view of this, the links between bone metabolism (BM) and DM (BMDM) have gained much attention and numerous related papers have been published. Nevertheless, no prior studies have yet been performed to analyze the field of BMDM research through bibliometric approach. To fill this knowledge gap, we performed a comprehensive bibliometric analysis of the global scientific publications in this field.

Methods

Articles and reviews regarding BMDM published between 2000 and 2021 were obtained from the Web of Science after manually screening. VOSviewer 1.6.16, CiteSpace V 5.8.R3, Bibliometrix, and two online analysis platforms were used to conduct the bibliometric and visualization analyses.

Results

A total of 2,525 documents including 2,255 articles and 270 reviews were retrieved. Our analysis demonstrated a steady increasing trend in the number of publications over the past 22 years (R2 = 0.989). The United States has occupied the leading position with the largest outputs and highest H-index. University of California San Francisco contributed the most publications, and Schwartz AV was the most influential author. Collaboration among institutions from different countries was relatively few. The journals that published the most BMDM-related papers were Bone and Osteoporosis International. Osteoporosis and related fractures are the main bone metabolic diseases of greatest concern in this field. According to co-cited references result, “high glucose environment,” “glycation end-product” and “sodium-glucose co-transporter” have been recognized as the current research focus in this domain. The keywords co-occurrence analysis indicated that “diabetic osteoporosis,” “osteoarthritis,” “fracture risk,” “meta-analysis,” “osteogenic differentiation,” “bone regeneration,” “osteogenesis,” and “trabecular bone score” might remain the research hotspots and frontiers in the near future.

Conclusion

As a cross-discipline research field, the links between bone metabolism and diabetes mellitus are attracting increased attention. Osteoporosis and related fractures are the main bone metabolic diseases of greatest concern in this field. These insights may be helpful for clinicians to recognize diabetic osteopenia and provide more attention and support to such patients.

Assessment and treatment of osteoporosis and fractures in type 2 diabetes

There is substantial, and growing, evidence that type 2 diabetes (T2D) is associated with skeletal fragility, despite often preserved bone mineral density. As post-fracture outcomes, including mortality, are worse in people with T2D, bone management should be carefully considered in this highly vulnerable group. However, current fracture risk calculators inadequately predict fracture risk in T2D, and dedicated randomised controlled trials identifying optimal management in patients with T2D are lacking, raising questions about the ideal assessment and treatment of bone health in these people. We synthesise the current literature on evaluating bone measurements in T2D and summarise the evidence for safety and efficacy of both T2D and anti-osteoporosis medications in relation to bone health in these patients.

Metformin treatment is associated with an increase in bone mineral density in type 2 diabetes mellitus patients in China: a retrospective single center study

AIMS

- To investigate the association between metformin and bone mineral density (BMD) in a large cohort of Chinese patients with type 2 diabetes mellitus (T2DM).

METHODS

- A total of 11,458 T2DM patients aged ≥ 40 years were included. Information on demographic, anthropometric and clinical characteristics was collected from medical records. BMD at lumbar spine (LS), femoral neck (FN), and total hip(TH) was assessed by dual-energy X-ray absorptiometry.

RESULTS

- Overall prevalence of osteopenia and osteoporosis was 37.4% and 10.3%, and was lower in patients on metformin (34.6% vs 38.3% and 7.1% vs 11.3%, both P < 0.001). Patients who had a lower BMI, older age, and lower estimated glomerular filtration rate (eGFR), had more osteoporosis, lower BMD (osteoporosis or osteopenia), and a lower T-score at LS, FN and TH. Metformin use and male sex was associated with a higher BMD. Metformin treatment was also independently associated with higher T-score at LS, FN and TH (β values of 0.120, 0.082 and 0.108; all P < 0.001), and lower odds ratio of osteoporosis (OR = 0.779, 95%CI: 0.648-0.937, P = 0.008) or low BMD (OR = 0.834, 95%CI: 0.752 - 0.925, P = 0.001). However, when analyzed by sex, this association of a lower odds ratio for osteoporosis with metformin was only significant in women (OR= 0.775, 95% CI: 0.633-0.948; P = 0.013).

CONCLUSIONS

- Metformin treatment was associated with a higher T-score and a lower odds ratio of osteopenia and osteoporosis, especially in the female population, independent of age, BMI, and eGFR.

Associations of variability in body weight and glucose levels with the risk of hip fracture in people with diabetes

BACKGROUND

Diabetes is associated with a high risk of fragility fracture. However, there are controversies regarding the effect of fluctuations in metabolic parameters on the risk of fracture. We aimed to investigate the associations of body weight or glucose variability or their combination with the risk of hip fracture in people with diabetes.

METHODS

A population-based cohort study with 480,539 subjects over 40 years who had undergone three or more health examinations was performed. The degree of variability was evaluated using variability independent of the mean (VIM, 100 × standard deviation / mean^beta), coefficient of variation (CV), and average real variability (ARV, average of the absolute differences between consecutive values). High variability was defined as having values in the highest quartile. Cox proportional hazards models were used to estimate the risk of hip fracture.

RESULTS

There were 2834 hip fracture events (0.59%) during the mean follow-up of 8.1 years. After multivariable adjustment for age, sex, alcohol consumption, smoking, regular exercise, income, glucose, body mass index, hemoglobin, estimated glomerular filtration rate, diabetes duration, diabetes treatment with multiple agents, and osteoporosis, the HRs (95% CI) of hip fracture were 1.36 (1.24-1.50) and 1.29 (1.16-1.43) for high body weight VIM and high glucose VIM, respectively. The HR (95% CI) of both high VIM group was 1.63 (1.44-1.83), suggesting an additive effect of variabilities in body weight and glucose. The results were consistent when using CV and ARV and in various sensitivity analyses.

CONCLUSIONS

High variability in body weight and glucose levels is associated with an increased incidence rate and risk of hip fracture in people with diabetes.

Osteoporosis or fracture risk associated with thiazolidinedione and proton pump inhibitor co-administration in patients with type 2 diabetes mellitus

WHAT IS KNOWN AND OBJECTIVE

Thiazolidinedione (TZD) and proton pump inhibitor (PPI) belong to classes of drugs that affect bone metabolism; however, few studies have investigated the effects of these drugs on bone metabolism. The aim of this study was to assess the risk of osteoporosis or fracture in patients with type 2 diabetes mellitus (T2DM) co-administered TZD and PPIs.

METHODS

This retrospective cohort study was conducted using the National Sample Cohort database from 2003 to 2013. We included adult patients with T2DM who were prescribed TZD and PPIs together for the first time. The Cox proportional hazard model was used to determine the risk ratio of fracture or osteoporosis in the co-administration cohort (TZD + PPI) compared with the TZD-only group (TZD). We adjusted for age, sex, use of other medications and other diseases that affect the bone.

RESULTS AND DISCUSSION

Of 9073 patients administered TZD, the number of eligible patients was 7240 (545 TZD + PPI, 6695 TZD-only). After 1:3 propensity score matching, 545 patients remained in the TZD + PPI group and 1635 in the TZD-only group. The risk of osteoporosis or fracture was significantly higher in the TZD + PPI cohort than in the TZD-only cohort. The adjusted hazard ratio (HR) for fracture or osteoporosis was 1.47 (95% CI 1.05-2.07). TZD and PPI use in women were associated with an increased risk of skeletal outcomes.

WHAT IS NEW AND CONCLUSION

TZD and PPI use were associated with an increased risk of osteoporosis or fracture in patients with T2DM.

Bone fragility in diabetes: novel concepts and clinical implications

Increased fracture risk represents an emerging and severe complication of diabetes. The resulting prolonged immobility and hospitalisations can lead to substantial morbidity and mortality. In type 1 diabetes, bone mass and bone strength are reduced, resulting in up to a five-times greater risk of fractures throughout life. In type 2 diabetes, fracture risk is increased despite a normal bone mass. Conventional dual-energy x-ray absorptiometry might underestimate fracture risk, but can be improved by applying specific adjustments. Bone fragility in diabetes can result from cellular abnormalities, matrix interactions, immune and vascular changes, and musculoskeletal maladaptation to chronic hyperglycaemia. This Review summarises how the bone microenvironment responds to type 1 and type 2 diabetes, and the mechanisms underlying fragility fractures. We describe the value of novel imaging technologies and the clinical utility of biomarkers, and discuss current and future therapeutic approaches that protect bone health in people with diabetes.

Clinical implications of diabetes in chronic liver disease: Diagnosis, outcomes and management, current and future perspectives

Diabetes mellitus (DM) is common in liver cirrhosis (LC). The pathophysiological association is bidirectional. DM is a risk factor of LC and LC is a diabetogenic condition. In the recent years, research on different aspects of the association DM and LC has been intensified. Nevertheless, it has been insufficient and still exist many gaps. The aims of this review are: (1) To discuss the latest understandings of the association of DM and LC in order to identify the strategies of early diagnosis; (2) To evaluate the impact of DM on outcomes of LC patients; and (3) To select the most adequate management benefiting the two conditions. Literature searches were conducted using PubMed, Ovid and Scopus engines for DM and LC, diagnosis, outcomes and management. The authors also provided insight from their own published experience. Based on the published studies, two types of DM associated with LC have emerged: Type 2 DM (T2DM) and hepatogenous diabetes (HD). High-quality evidences have determined that T2DM or HD significantly increase complications and death pre and post-liver transplantation. HD has been poorly studied and has not been recognized as a complication of LC. The management of DM in LC patients continues to be difficult and should be based on drug pharmacokinetics and the degree of liver failure. In conclusion, the clinical impact of DM in outcomes of LC patients has been the most studied item recently. Nevertheless many gaps still exist particularly in the management. These most important gaps were highlighted in order to propose future lines for research.

Mechanisms and Active Compounds Polysaccharides and Bibenzyls of Medicinal Dendrobiums for Diabetes Management

BACKGROUND

Medicinal dendrobiums are used popularly in traditional Chinese medicine for the treatment of diabetes, while their active compounds and mechanism remain unclear. This review aimed to evaluate the mechanism and active compounds of medicinal dendrobiums in diabetes management through a systematic approach.

METHODS

A systematic approach was conducted to search for the mechanism and active phytochemicals in Dendrobium responsible for anti-diabetic actions using databases PubMed, Embase, and SciFinder.

RESULTS

Current literature indicates polysaccharides, bibenzyls, phenanthrene, and alkaloids are commonly isolated in Dendrobium genusin which polysaccharides and bibenzyls are most aboundant. Many animal studies have shown that polysaccharides from the species of Dendrobium provide with antidiabetic effects by lowering glucose level and reversing chronic inflammation of T2DM taken orally at 200 mg/kg. Dendrobium polysaccharides protect pancreatic β-cell dysfunction and insulin resistance in liver. Dendrobium polysaccharides up-regulate the abundance of short-chain fatty acid to stimulate GLP-1 secretion through gut microbiota. Bibenzyls also have great potency to inhibit the progression of the chronic inflammation in cellular studies.

CONCLUSION

Polysaccharides and bibenzyls are the major active compounds in medicinal dendrobiums for diabetic management through the mechanisms of lowering glucose level and reversing chronic inflammation of T2DM by modulating pancreatic β-cell dysfunction and insulin resistance in liver as a result from gut microbita regulation.

An Approach to the Management of Diabetes Mellitus in Cirrhosis: A Primer for the Hepatologist

The management of diabetes in cirrhosis and liver transplantation can be challenging. There is difficulty in diagnosis and monitoring of diabetes as fasting blood sugar values are low and glycosylated hemoglobin may not be a reliable marker. The challenges in the management of diabetes in cirrhosis include the likelihood of cognitive impairment, risk of hypoglycemia, altered drug metabolism, frequent renal dysfunction, risk of lactic acidosis, and associated malnutrition and sarcopenia. Moreover, calorie restriction and an attempt to lose weight in obese diabetics may be associated with a worsening of sarcopenia. Many commonly used antidiabetic drugs may be unsafe or be associated with a high risk of hypoglycemia in cirrhotics. Post-transplant diabetes is common and may be contributed by immunosuppressive medication. There is inadequate clinical data on the use of antidiabetic drugs in cirrhosis, and the management of diabetes in cirrhosis is hampered by the lack of guidelines focusing on this issue. The current review aims at addressing the practical management of diabetes by a hepatologist.

Fracture Patterns in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review of Recent Literature

PURPOSE OF REVIEW

In this narrative review, we have summarized the literature on fracture risk in T1DM and T2DM with a special focus on fracture site, time patterns, glucose-lowering drugs, and micro- and macrovascular complications.

RECENT FINDINGS

T1DM and T2DM were associated with an overall increased fracture risk, with preferent locations at the hip, vertebrae, humerus, and ankle in T1DM and at the hip, vertebrae, and likely humerus, distal forearm, and foot in T2DM. Fracture risk was higher with longer diabetes duration and the presence of micro- and macrovascular complications. In T2DM, fracture risk was higher with use of insulin, sulfonylurea, and thiazolidinediones and lower with metformin use. The increased fracture risk in T1DM and T2DM concerns specific fracture sites, and is higher in subjects with longer diabetes duration, vascular complications, and in T2DM with the use of specific glucose-lowering medication.

18:0 Lyso PC, a natural product with potential PPAR-γ agonistic activity, plays hypoglycemic effect with lower liver toxicity and cardiotoxicity in db/db mice

Rosiglitazone, a specific agonist of peroxisome proliferator-activated receptor-γ (PPAR-γ), displays a robust hypoglycemic action in patients with type 2 diabetes mellitus (T2DM) and elicits serious adverse reactions, especially hepatotoxicity and cardiotoxicity. Here, we aims to find a new natural PPAR-γ agonist with less adverse reactions than rosiglitazone in db/db mice. The method of virtual screening was used to identify a PPAR-γ agonist 18:0 Lyso PC from an in-house natural product library. We verified its pharmacological effects and adverse reactions comparing with rosiglitazone in vivo and in vitro. 18:0 Lyso PC exhibited pharmacological effects similar to those of rosiglitazone in db/db mice. Moreover, 18:0 Lyso PC showed a lower extent of liver injury and cardiotoxicity in db/db mice. The mechanism, by which this natural compound alleviates metabolic syndrome, involves a reduction in fatty acid synthesis mediated by activation of the phosphorylation of adenosine 5'-monophosphate (AMP)-activated protein kinase-alpha (AMPKα) and acetyl-CoA carboxylase (ACC) and an increase expression of uncoupled protein 1 (UCP1) and PPAR-γ coactivator-1 alpha (PGC1-α). 18:0 Lyso PC, a natural compound, can show a similar hypoglycemic effect to rosiglitazone by activating PPAR-γ, while eliciting markedly fewer adverse reactions than rosiglitazone.

Tibetan Medicine for Diabetes Mellitus: Overview of Pharmacological Perspectives

Diabetes mellitus (DM) and its complications pose a major public health threat which is approaching epidemic proportions globally. Current drug options may not provide good efficacy and even cause serious adverse effects. Seeking safe and effective agents for DM treatment has been an area of intensive interest. As a healing system originating in Tibet, Traditional Tibetan Medicine (TTM) has been widely used by Tibetan people for the prevention and treatment of DM and its complications for hundreds of years. Tibetan Materia Medica (TMM) including the flower of Edgeworthia gardneri (Wall.) Meisn., Phyllanthi Fructus, Chebulae Fructus, Huidouba, and Berberidis Cortex are most frequently used and studied. These TMMs possess hypoglycemic, anti-insulin resistant, anti-glycation, lipid lowering, anti-inflammatory, and anti-oxidative effects. The underlying mechanisms of these actions may be related to their α-glucosidase inhibitory, insulin signaling promoting, PPARs-activating, gut microbiota modulation, islet β cell-preserving, and TNF-α signaling suppressive properties. This review presents a comprehensive overview of the mode and mechanisms of action of various active constituents, extracts, preparations, and formulas from TMM. The dynamic beneficial effects of the products prepared from TMM for the management of DM and its complications are summarized. These TMMs are valuable materia medica which have the potential to be developed as safe and effective anti-DM agents.

Observational study methods used to assess pharmacotherapy effects of type 2 diabetes on fracture risk: a scoping review protocol

OBJECTIVE

The objective of this review is to summarize observational research methods employed to study fracture risk and the use of type 2 diabetes mellitus medications. The methods summary will be used as a case study to illustrate current practices in the study of medication effects on fracture risk.

INTRODUCTION

Observational studies examining drug effects on fracture risk fill knowledge gaps left by clinical trials but require specific design considerations. In recent years, several pharmacoepidemiologic studies have examined fracture risk as a possible adverse effect of type 2 diabetes mellitus medications using varying methodologies; these studies can illustrate design considerations for studies of fracture risk.

INCLUSION CRITERIA

This scoping review will consider peer-reviewed observational studies that examine the effects of type 2 diabetes mellitus medications on fracture risk. Primary literature comprising empirical pharmacoepidemiologic studies, such as cohort, case-control, case-crossover, self-controlled, case series, and case-cohort designs, that evaluate fracture risk associated with at least one type 2 diabetes mellitus medication will be eligible. Studies without use of an administrative database and those with an experimental, cross-sectional, or time-series design will be excluded.

METHODS

This scoping review will follow JBI methodology for scoping reviews. MEDLINE (Ovid), Embase (Ovid), and CINAHL Plus with Full Text (EBSCO) will be searched from January 1, 2000 (to capture recent methodologies) to the present to identify eligible articles. After de-duplication, titles and abstracts will be screened independently by two reviewers, then full texts will be reviewed. Data on study methods will be extracted from eligible texts using a piloted form developed by the authors, and study methods will be aggregated in tabular format.

A Literature Review of the Potential Impact of Medication on Vitamin D Status

In recent years, there has been a significant increase in media coverage of the putative actions of vitamin D as well as the possible health benefits that supplementation might deliver. However, the potential effect that medications may have on the vitamin D status is rarely taken into consideration. This literature review was undertaken to assess the degree to which vitamin D status may be affected by medication. Electronic databases were searched to identify literature relating to this subject, and study characteristics and conclusions were scrutinized for evidence of potential associations. The following groups of drugs were identified in one or more studies to affect vitamin D status in some way: anti-epileptics, laxatives, metformin, loop diuretics, angiotensin-converting enzyme inhibitors, thiazide diuretics, statins, calcium channel blockers, antagonists of vitamin K, platelet aggregation inhibitors, digoxin, potassium-sparing diuretics, benzodiazepines, antidepressants, proton pump inhibitors, histamine H2-receptor antagonists, bile acid sequestrants, corticosteroids, antimicrobials, sulphonamides and urea derivatives, lipase inhibitors, hydroxychloroquine, highly active antiretroviral agents, and certain chemotherapeutic agents. Given that the quality of the data is heterogeneous, newer, more robustly designed studies are required to better define likely interactions between vitamin D and medications. This is especially so for cytochrome P450 3A4 enzyme (CYP3A4)-metabolized medications. Nevertheless, this review suggests that providers of health care ought to be alert to the potential of vitamin D depletions induced by medications, especially in elderly people exposed to multiple-drug therapy, and to provide supplementation if required.

Let's talk about sex: Differences in drug therapy in males and females

Professor Henry Higgins in My Fair Lady said, 'Why can't a woman be more like a man?' Perhaps unintended, such narration extends to the reality of current drug development. A clear sex-gap exists in pharmaceutical research spanning from preclinical studies, clinical trials to post-marketing surveillance with a bias towards males. Consequently, women experience adverse drug reactions from approved drug products more often than men. Distinct differences in pharmaceutical response across drug classes and the lack of understanding of disease pathophysiology also exists between the sexes, often leading to suboptimal drug therapy in women. This review explores the influence of sex as a biological variable in drug delivery, pharmacokinetic response and overall efficacy in the context of pharmaceutical research and practice in the clinic. Prospective recommendations are provided to guide researchers towards the consideration of sex differences in methodologies and analyses. The promotion of disaggregating data according to sex to strengthen scientific rigour, encouraging innovation through the personalisation of medicines and adopting machine learning algorithms is vital for optimised drug development in the sexes and population health equity.

Bone fragility in patients with diabetes mellitus: A consensus statement from the working group of the Italian Diabetes Society (SID), Italian Society of Endocrinology (SIE), Italian Society of Gerontology and Geriatrics (SIGG), Italian Society of Orthopaedics and Traumatology (SIOT)

Bone fragility is one of the possible complications of diabetes, either type 1 (T1D) or type 2 (T2D). Bone fragility can affect patients of different age and with different disease severity depending on type of diabetes, disease duration and the presence of other complications. Fracture risk assessment should be started at different stages in the natural history of the disease depending on the type of diabetes and other risk factors. The risk of fracture in T1D is higher than in T2D, imposing a much earlier screening and therapeutic intervention that should also take into account a patient's life expectancy, diabetes complications etc. The therapeutic armamentarium for T2D has been enriched with drugs that may influence bone metabolism, and clinicians should be aware of these effects. Considering the complexity of diabetes and osteoporosis and the range of variables that influence treatment choices in a given individual, the Working Group on bone fragility in patients with diabetes mellitus has identified and issued recommendations based on the variables that should guide screening of bone fragility and management of diabetes and bone fragility: (A)ge, (B)MD, (C)omplications, (D)uration of disease, & (F)ractures (ABCD&F). Consideration of these parameters may help clinicians identify the best time for screening, the appropriate glycaemic target and anti-osteoporosis drug for patients with diabetes at risk of or with bone fragility.

Type 2 diabetes and bone fragility- An under-recognized association

BACKGROUND AND AIMS

Diabetes and osteoporosis are common chronic disorders with growing prevalence in the aging population. Skeletal fragility secondary to diabetes increases the risk of fractures and is underestimated by currently available diagnostic tools like fracture risk assessment (FRAX) and dual-energy X-ray absorptiometry (DXA). In this narrative review we describe the relationship and pathophysiology of skeletal fragility and fractures in Type 2 diabetes (T2DM), effect of glucose lowering medications on bone metabolism and the approach to diagnosing and managing osteoporosis and bone fragility in people with diabetes (PWD).

METHODS

A literature search was conducted on PubMed for articles in English that focused on T2DM and osteoporosis or bone/skeletal fragility. Articles considered to be of direct clinical relevance to physicians practicing diabetes were included.

RESULTS

T2DM is associated with skeletal fragility secondary to compromised bone remodeling and bone turnover. Long duration, poor glycemic control, presence of chronic complications, impaired muscle function, and anti-diabetic medications like thiazolidinediones (TZD) are risk factors for fractures among PWD. Conventional diagnostic tools like DXA and FRAX tool underestimate fracture risk in diabetes. Presence of diabetes does not alter response to anti-osteoporotic treatment in post-menopausal women.

CONCLUSION

Estimation of fragility fracture risk should be included in standard of care for T2DM along with screening for traditional complications. Physicians should proactively screen for and manage osteoporosis in people with diabetes. It is important to consider effects on bone health when selecting glucose lowering agents in people at risk for fragility fractures.

Risk of non-vertebral fractures in men with type 2 diabetes: A systematic review and meta-analysis of cohort studies

PURPOSE

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder. Research regarding the risk of non-vertebral fractures in men, especially in elderly men with T2DM, has not been a priority. T2DM is not a known independent risk factor for low-energy fractures in patients. We aimed to explore the relationship between men (especially older men) with T2DM and the risk of non-vertebral fractures and the reasons for the sex differences.

METHODS

The PubMed, MEDLINE, and Cochrane Library databases were searched for articles on T2DM and fracture risk. A meta-analysis, including heterogeneity testing, publication bias analysis, and subgroup analysis of the included studies, was performed using STATA software.

RESULTS

Sixteen studies involving 1,758,225 participants, 59,909 non-vertebral fracture events, and 6430 vertebral fracture events were included in this research. The adjusted relative risk of T2DM and non-vertebral fracture in men was 1.20 (95% confidence interval [CI] 1.09-1.31), implying that men with T2DM have a slightly increased risk of non-vertebral fracture.

CONCLUSION

Male patients with T2DM have a slightly increased risk of non-vertebral fractures. Due to the differences in bone strength, sex steroid hormone levels, bone quality and muscle strength and balance, men with type 2 diabetes have a lower risk of non-vertebral fractures than women.

Current treatment paradigms and emerging therapies for NAFLD/NASH

Non-alcoholic fatty liver disease (NAFLD) is one the fastest emerging manifestations of the metabolic syndrome worldwide. Non-alcoholic steatohepatitis (NASH), the progressive form of NAFLD, may culminate into cirrhosis and hepatocellular cancer (HCC) and is presently a leading cause of liver transplant. Although a steady progress is seen in understanding of the disease epidemiology, pathogenesis and identifying therapeutic targets, the slowest advancement is seen in the therapeutic field. Currently, there is no FDA approved therapy for this disease and appropriate therapeutic targets are urgently warranted. In this review we discuss the role of lifestyle intervention, pharmacological agents, surgical approaches, and gut microbiome, with regard to therapy for NASH. In particular, we focus the role of insulin sensitizers, thyroid hormone mimetics, antioxidants, cholesterol lowering drugs, incretins and cytokines as therapeutic targets for NASH. We highlight these targets aiming to optimize the future for NASH therapy.

Thyroid Hormones, Glucocorticoids, Insulin, and Bone

Several endocrine systems have important effects on bone tissue. Thyroid hormones are essential for normal growth and development. Excess of these hormones will result in clinically significant changes that may require intervention. Glucocorticoids also have a marked effect on bone metabolism by several pathways. Their endogenous or exogenous excess will induce pathological processes that might elevate the risk of fractures. Insulin and the carbohydrate metabolism elicit a physiological effect on bone; however, the lack of insulin (type 1 diabetes) or insulin resistance (type 2 diabetes) have deleterious influence on bone tissue.

Glucose-Lowering Drugs and Fracture Risk-a Systematic Review

PURPOSE OF REVIEW

Diabetes mellitus (DM) is associated with increased fracture risk. The aim of this systematic review was to examine the effects of different classes of glucose-lowering drugs on fracture risk in patients with type 2 DM. The heterogeneity of the included studies did not allow formal statistical analyses.

RECENT FINDINGS

Sixty studies were included in the review. Metformin, dipeptidylpeptidase-IV inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter 2-inhibitors do not appear to increase fracture risk. Results for insulin and sulphonylureas were more disparate, although there may be an increased fracture risk related to hypoglycemia and falls with these treatments. Glitazones were consistently associated with increased fracture risk in women, although the evidence was sparser in men. New glucose-lowering drugs are continuously being developed and better understanding of these is leading to changes in prescription patterns. Our findings warrant continued research on the effects of glucose-lowering drugs on fracture risk, elucidating the class-specific effects of these drugs.

Impact of Type 2 Diabetes Mellitus and Antidiabetic Medications on Bone Metabolism

PURPOSE OF REVIEW

This review focuses on the complex interactions between hyperglycemia and bone fragility and the effects of antidiabetic medications on bone metabolism.

RECENT FINDINGS

Type 2 diabetes (T2D) is associated with increased risk of bone fracture even in those with increased or normal bone mineral density (BMD). The pathophysiology of diabetic bone disease is not completely understood, but it is thought to be multifactorial and associated with complex cross talk among factors such as AGEs, IGF-1, enteric hormones, and pro-inflammatory cytokines. Treatment for T2D may have an impact on bone metabolism. Diabetic bone disease should be considered a serious complication of long-standing T2D.

Executive summary of clinical practice guide on fracture risk in lifestyle diseases

Accumulating evidence has shown that patients with lifestyle diseases such as type 2 diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease are at increased risk of osteoporotic fracture. Fractures deteriorate quality of life, activities of daily living, and mortality as well as a lifestyle disease. Therefore, preventing fracture is an important issue for those patients. Although the mechanism of the lifestyle diseases-induced bone fragility is still unclear, not only bone mineral density (BMD) reduction but also bone quality deterioration are involved in it. Because fracture predictive ability of BMD and FRAX^® is limited, especially for patients with lifestyle diseases, the optimal management strategy should be established. Thus, when the intervention of the lifestyle diseases-induced bone fragility is initiated, the deterioration of bone quality should be taken into account. We here review the association between lifestyle diseases and fracture risk and proposed an algorism of starting anti-osteoporosis drugs for patients with lifestyle diseases.

The mother relationship between insulin resistance and non-alcoholic steatohepatitis: Glucosinolates hydrolysis products as a promising insulin resistance-modulator and fatty liver-preventer

Non-alcoholic fatty liver disease (NFLD) is one of the present public health problems which have no specific and effective treatment. The speed of the disease progression depends on the patient's lifestyle. Due to life stresses and lack of time, a high number of people depend on fast food containing a high amount of fats which one of the main causes of insulin resistance (IR). IR is one of the metabolic disorders which strongly intersected with molecular NAFLD and leading to its progression into non-alcoholic steatohepatitis (NASH). In this review, we introduced the updated statistics of NAFLD and NASH progression all over the world shows its importance, etiologies, and pathogenesis. Also, IR and its role in NASH initiation and progression explored, and current treatments with its limitations have been explained. Glucosinolates (GLS) is a group of phytochemicals which known by its potent hydrolysis products with promising anti-cancer effect. In this review, we have collected the recent experimental studies of different GLS hydrolysis products against IR and chronic liver diseases supported by our lab finding. Finally, we recommend this group of phytochemicals as promising molecules to be studied experimentally and clinically against a wide range of chronic liver diseases with an acceptable safety margin.

Sodium-glucose cotransporter 2 inhibitors and fracture risk in patients with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials

Background:

Patients with type 2 diabetes mellitus (T2DM) have an increased risk of fracture compared with those without T2DM. Some oral glucose-lowering agents may increase the incidence of fracture. Whether sodium-glucose co-transporter 2 inhibitors (SGLT2is) are associated with increased risk of fracture remains unclear.

Methods:

We retrieved articles from PubMed, Embase, Cochrane Library database, and other sources up to 24 October 2019. We included randomized controlled trials (RCTs) that reported fractures and analyzed the fracture incidence of SGLT2i, canagliflozin, dapagliflozin, and empagliflozin. Subgroup analysis was also performed based on baseline characteristics.

Results:

A total of 78 RCTs with 85,122 patients were included in our analysis. The overall SGLT2i fracture incidence was 2.56% versus 2.77% in the control group [odds ratio (OR), 1.03; 95% confidence interval (CI) (0.95, 1.12); p = 0.49]. Compared with the control treatment, treatment with canagliflozin led to a higher rate of fractures [OR, 1.17; 95% CI (1.00, 1.37); p = 0.05], but no significant difference was observed when compared with dapagliflozin [OR, 1.02; 95% CI (0.90, 1.15); p = 0.79] or empagliflozin [OR, 0.89; 95% CI (0.73, 1.10); p = 0.30]. Subgroup analysis showed that, in a follow-up of less than 52 weeks, SGLT2i decreased the incidence of fracture by 29% [OR, 0.71; 95% CI (0.55, 0.93); p = 0.01], but this benefit was lost when the follow-up extended to more than 52 weeks [OR, 1.08; 95% CI (0.98, 1.18); p = 0.12].

Conclusion:

Canagliflozin seems to increase the risk of fracture, while other SGLT2is do not result in a higher incidence of fracture.

Type 2 diabetes management in people aged over seventy-five years: targets and treatment strategies

Older people (those aged 65 years or more) with diabetes comprise a heterogenous group of patients with special needs and features; this is particularly true for those aged 75 years or more. It is important that individualized glycemic targets be adopted in this population, after considering life expectancy, presence of diabetic complications and other comorbidities. In general, less rigorous targets and avoidance of overtreatment seems to be a reasonable strategy in daily clinical settings. There is a paucity of data regarding the efficacy and safety of various hypoglycemic agents, especially for those aged over 75. The evidence suggests that sulfonylureas and insulin regimens should be used with caution due to a high risk of hypoglycemia. Dipeptidyl peptidase-4 inhibitors are a good choice for the management of diabetes in older age groups, although a warning against the use of specific agents in people with heart failure is valid. There are insufficient data to decide whether the cardiorenal protective properties of sodium-glucose co-transporter 2 inhibitors outweigh the risks associated with these drugs. The use of glucagon-like peptide-1 receptor agonists by older patients is supported not only by their good safety and efficacy profiles, but also by their potential to improve glucose-independent outcomes, through their pleiotropic actions. The aim of this narrative review is to summarize the evidence on glycemic targets and optimal therapeutic approaches for older patients with type 2 diabetes and discuss the risk-benefit balance of various therapeutic approaches in this group.