Majumdar Sumit R, Leslie William D, Lix Lisa M, Morin Suzanne N, Johansson Helena, Oden Anders, McCloskey Eugene V, Kanis John A
Department of Medicine (S.R.M.), University of Alberta, Edmonton, Alberta, Canada T6G 2H7; Departments of Medicine (W.D.L.) and Community Health Sciences (L.M.L.), University of Manitoba, Winnipeg, Manitoba, Canada R3T 2N2; Department of Medicine (S.N.M.), McGill University, Montréal, Québec, Canada H9X 3V9; Centre for Metabolic Bone Diseases (H.J., A.O., E.V.M., J.A.K.), University of Sheffield Medical School, Sheffield S10 2JF, United Kingdom; and Institute for Health and Ageing (J.A.K.), Catholic University of Australia, 3065 Melbourne, Australia.
J Clin Endocrinol Metab. 2016 Nov;101(11):4489-4496. doi: 10.1210/jc.2016-2569. Epub 2016 Sep 7.
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.
The objective of the study was to examine the impact of diabetes duration on fracture risk.
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.
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.
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.
2型糖尿病患者发生主要骨质疏松性骨折（MOF）和髋部骨折的风险高于世界卫生组织骨折风险评估（FRAX）工具所预测的风险。
本研究旨在探讨糖尿病病程对骨折风险的影响。
利用与曼尼托巴省行政数据库相关联的临床双能X线吸收测定登记系统，我们识别出所有年龄在40岁及以上、有10年或更长时间医保覆盖且接受过髋部双能X线吸收测定的女性（1996 - 2013年）。分别对MOF和髋部骨折的新发病例进行了7年的研究。Cox比例风险模型先根据FRAX进行调整（FRAX调整），然后再加上合并症、跌倒、骨质疏松治疗或胰岛素进行完全调整。通过比较观察到的概率与预测概率来评估FRAX校准情况。
共有49098名无糖尿病女性和8840名患有糖尿病的女性（病程>10年的占31.4%；5 - 10年的占20.1%；<5年的占23.7%；新发的占24.8%）。在FRAX调整分析中，只有病程超过10年与MOF风险较高相关（风险比[HR]为1.47，95%置信区间[CI]为1.30 - 1.66），在完全调整模型中情况类似（HR为1.34，95%CI为1.17 - 1.54）。相比之下，髋部骨折风险在所有病程中均呈剂量依赖性增加（例如，FRAX调整后病程>10年的HR为2.10，95%CI为1.71 - 2.59，新发糖尿病的HR为1.32，95%CI为1.03 - 1.69）。FRAX显著低估了病程超过10年的患者发生MOF的风险（校准比为1.24，95%CI为1.08 - 1.39）和髋部骨折的风险（1.93，95%CI为1.50 - 2.35）。
糖尿病仅在糖尿病病程长的女性中是独立于FRAX的MOF风险因素，但无论病程长短，糖尿病都会增加髋部骨折风险。糖尿病病程超过10年的患者骨折风险特别高，而目前FRAX低估了这种升高的风险。
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