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Unmasking Fracture Risk in Type 2 Diabetes: The Association of Longitudinal Glycemic Hemoglobin Level and Medications.

CONTEXT
Fracture risk is underestimated in people with type 2 diabetes (T2D).


OBJECTIVE
To investigate the longitudinal relationship of glycated hemoglobin (HbA1c) and common medications on fracture risk in people with T2D.


DESIGN
Retrospective cohort study was conducted using de-identified claims and EHR data obtained from the OptumLabs ® Data Warehouse during 01/01/2007 to 09/30/2015. For each individual, the study was conducted within a two-year HbA1c observation period and a two-year fracture follow-up period.


SETTING
Population-based study.


PARTICIPANTS
157,439 individuals with T2D [age ≥ 55 years with mean HbA1c value ≥ 6%] were selected from 4,018,250 US Medicare Advantage/Commercial enrollee with T2D diagnosis. Main Outcome Measures. All fractures and fragility fractures were measured.


RESULTS
With covariates adjusted, poor glycemic control in T2D individuals was associated with an 29% increase of all fracture risk, compared to T2D individuals with adequate glycemic control (HR: 1.29, 95% CI 1.22-1.36). Treatment with metformin (HR: 0.88, 95% CI 0.85-0.92) and DPP4 inhibitors (HR: 0.93, 95% CI 0.88-0.98) were associated with a reduced all fracture risk, while insulin (HR: 1.26, 95% CI 1.21-1.32), thiazolidinediones (HR: 1.23, 95% CI 1.18-1.29), meglitinides (HR: 1.12, 95% CI 1.00-1.26) were associated with an increased all fracture risk (All p-value < 0.05). Bisphosphonates were associated similarly with increased fracture risk in T2D group and in non-diabetic group.


CONCLUSIONS
Longitudinal two-year HbA1c is independently associated with an elevated all fracture risk in T2D individuals during a two-year follow-up period. Metformin and DPP4 inhibitors can be used for management of T2D fracture risk.