Effects of diabetes drugs on the skeleton

Christian Meier; Ann V Schwartz; Andrea Egger; Beata Lecka-Czernik

doi:10.1016/j.bone.2015.04.026

Effects of diabetes drugs on the skeleton

Bone. 2016 Jan:82:93-100. doi: 10.1016/j.bone.2015.04.026. Epub 2015 Apr 23.

Authors

Christian Meier¹, Ann V Schwartz², Andrea Egger³, Beata Lecka-Czernik⁴

Affiliations

¹ Division of Endocrinology, Diabetes and Metabolism, University Hospital, Basel, Switzerland. Electronic address: christian.meier@unibas.ch.
² Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
³ Division of Endocrinology, Diabetes and Metabolism, University Hospital, Basel, Switzerland.
⁴ Department of Orthopedic Surgery, Center for Diabetes and Endocrine Research, University of Toledo College of Medicine, Toledo, OH, USA; Department of Physiology and Pharmacology, Center for Diabetes and Endocrine Research, University of Toledo College of Medicine, Toledo, OH, USA.

PMID: 25913633
DOI: 10.1016/j.bone.2015.04.026

Abstract

Type 2 diabetes is associated with increased fracture risk and the mechanisms underlying the detrimental effects of diabetes on skeletal health are only partially understood. Antidiabetic drugs are indispensable for glycemic control in most type 2 diabetics, however, they may, at least in part, modulate fracture risk in exposed patients. Preclinical and clinical data clearly demonstrate an unfavorable effect of thiazolidinediones on the skeleton with impaired osteoblast function and activated osteoclastogenesis. The negative effect of thiazolidinediones on osteoblastogenesis includes decreased activity of osteoblast-specific transcription factors (e.g. Runx2, Dlx5, osterix) and decreased activity of osteoblast-specific signaling pathways (e.g. Wnt, TGF-β/BMP, IGF-1). In contrast, metformin has a positive effect on osteoblast differentiation due to increased activity of Runx2 via the AMPK/USF-1/SHP regulatory cascade resulting in a neutral or potentially protective effect on bone. Recently marketed antidiabetic drugs include incretin-based therapies (GLP-1 receptor agonists, DPP-4 inhibitors) and sodium-glucose co-transporter 2 (SGLT2)-inhibitors. Preclinical studies indicate that incretins (GIP, GLP-1, and GLP-2) play an important role in the regulation of bone turnover. Clinical safety data are limited, however, meta-analyses of trials investigating the glycemic-lowering effect of both, GLP-1 receptor agonists and DPP4-inhibitors, suggest a neutral effect of incretin-based therapies on fracture risk. For SGLT2-inhibitors recent data indicate that due to their mode of action they may alter calcium and phosphate homeostasis (secondary hyperparathyroidism induced by increased phosphate reabsorption) and thereby potentially affect bone mass and fracture risk. Clinical studies are needed to elucidate the effect of SGLT2-inhibitors on bone metabolism. Meanwhile SGLT2-inhibitors should be used with caution in patients with high fracture risk, which is specifically true for the use of thiazolidinediones.

Keywords: DPP-4 inhibitors; Diabetes mellitus; Incretins; Metformin; SGLT2 inhibitors; TZDs.

Publication types

Review

MeSH terms

Animals
Blood Glucose / drug effects
Blood Glucose / metabolism
Diabetes Mellitus / drug therapy*
Diabetes Mellitus / epidemiology*
Diabetes Mellitus / metabolism
Dipeptidyl-Peptidase IV Inhibitors / adverse effects
Fractures, Bone / chemically induced*
Fractures, Bone / epidemiology*
Fractures, Bone / metabolism
Glucagon-Like Peptide 1 / antagonists & inhibitors
Glucagon-Like Peptide 1 / metabolism
Humans
Hypoglycemic Agents / adverse effects*
Insulin-Like Growth Factor I / antagonists & inhibitors
Insulin-Like Growth Factor I / metabolism
Metformin / adverse effects

Substances

Blood Glucose
Dipeptidyl-Peptidase IV Inhibitors
Hypoglycemic Agents
Insulin-Like Growth Factor I
Glucagon-Like Peptide 1
Metformin