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livered by nasal spray, is an option for\npeople who are 2 –49 years of age and\nwho are not pregnant, but people withchronic conditions such as diabetes are\ncautioned against taking the liveattenuated in fluenza vaccine and are in-\nstead recommended to receive the inac-tive or recombinant in fluenza vaccination. | [
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For individuals $65 years of age, there\nmay be additional bene fit from the high-\ndose quadrivalent inactivated in fluenza\nvaccine (21).\nPneumococcal Pneumonia\nLike in fluenza, pneumococcal pneumonia\nis a common, preventable disease. Peoplewith diabetes are at increased risk for\npneumococcal infection and have been... | [
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pneumococcal infection and have been re-\nported to have a high risk of hospitaliza-tion and death, with a mortality rate ashigh as 50% (22). There are two types ofvaccines available in the U.S., pneumococ-cal conjugate vaccines (PCV13, PCV15, andPCV20) and pneumococcal polysaccharidevaccine (PPSV23), with distinct sch... | [
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for children and adults.\nIt is recommended that all children re-\nceive a four-dose series of PCV13 orP C V 1 5b y1 5m o n t h so fa g e .F o rc h i l d r e n\nwith diabetes who have incomplete se-\nries by ages 2 –5 years, the CDC recom-\nmends a catch-up schedule to ensurethat these children have four doses. Chil- | [
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dren with diabetes between 6 and 18 years\nof age are also advised to receive one\ndose of PPSV23, preferably after receipt\nof PCV13.\nAdults aged $65 years whose vac-\ncine status is unknown or who have notreceived pneumococcal vaccine should\nreceive one dose of PCV15 or PCV20. If\nPCV15 is used, it should be follow... | [
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PCV15 is used, it should be followed by\nPPSV23.\nAdults aged 19 –64 years with certain\nunderlying risk factors or other medicalconditions whose vaccine status is un-\nknown or who have not received pneu-\nmococcal vaccine should receive one\ndose of PCV15 or PCV20. As for adults\naged$65 years, if PCV15 is used, it\n... | [
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aged$65 years, if PCV15 is used, it\nshould be followed by PPSV23.\nThe recommended interval between\nPCV15 and PPSV23 is $1y e a r .I fP P S V 2 3i s\nthe only dose received, PCV15 or PCV20may be given $1 year later.\nFor adults with immunocompromising\nconditions, cochlear implant, or cerebro-spinal fluid leak, a mini... | [
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8 weeks can be considered for dosing ofPCV15 and PPSV23 when PCV15 has been\nused.\nAdults who received PCV13 should fol-\nlow the previously recommended PPSV23series (23 –26). Adults who received only\nPPSV23 may receive PCV15 or PCV20$1 year after their last dose.\nRespiratory Syncytial Virus\nRespiratory syncytial v... | [
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Respiratory syncytial virus (RSV) is a cause\nof respiratory illness in older adults. Peo-\nple with chronic conditions such as diabe-\ntes have a higher risk of severe illness. The\nFood and Drug Administration (FDA) ap-\nproved the first vaccines for prevention of\nRSV-associated lower respiratory tract dis-ease in ad... | [
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2023, ACIP voted to recommend thatadults aged $60 years may receive a sin-\ng l ed o s eo fa nR S Vv a c c i n e ,u s i n gs h a r e dclinical decision-making. The ACIP Respira-\ntory Syncytial Virus Vaccines Adult Work\nGroup continues to monitor the effi cacyTable 4.2 —Assessment and treatment plan\nAssessing risk of ... | [
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Assessing risk of diabetes complications\n/C15ASCVD and heart failure history\n/C15ASCVD risk factors and 10-year ASCVD risk assessment\n/C15Staging of chronic kidney disease (see Table 11.1 )\n/C15Hypoglycemia risk (see Section 6, “Glycemic Goals and Hypoglycemia ”)\n/C15Assessment for retinopathy\n/C15Assessment for ... | [
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/C15Assessment for retinopathy\n/C15Assessment for neuropathy\n/C15Assessment for NAFLD/NASH\nGoal setting\n/C15Set A1C/blood glucose/time in range\n/C15If hypertension is present, establish blood pressure goal\n/C15Weight management and physical activity goals\n/C15Diabetes self-management goals\nTherapeutic treatment... | [
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Therapeutic treatment plans\n/C15Lifestyle management\n/C15Pharmacologic therapy: glucose lowering\n/C15Pharmacologic therapy: cardiovascular and kidney disease risk factors\n/C15Weight management with pharmacotherapy or metabolic surgery, as appropriate\n/C15Use of glucose monitoring and insulin delivery devices | [
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/C15Use of glucose monitoring and insulin delivery devices\n/C15Referral to diabetes education, behavioral health, and medical specialists\nAssessment and treatment planning are essential components of initial and all follow-up vis- | [
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its. ASCVD, atherosclerotic cardiovascular disease; NAFLD, nonalcoholic fatty liver disease;NASH, nonalcoholic steatohepatitis.\nTable 4.3 —Referrals for initial care management\n/C15Eye care professional for annual dilated eye exam\n/C15Family planning for individuals of childbearing potential | [
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/C15Family planning for individuals of childbearing potential\n/C15Registered dietitian nutritionist for medical nutrition therapy\n/C15Diabetes self-management education and support\n/C15Dentist for comprehensive dental and periodontal examination\n/C15Behavioral health professional, if indicated\n/C15Audiology, if in... | [
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/C15Audiology, if indicated\n/C15Social worker/community resources, if indicated\n/C15Rehabilitation medicine or another relevant health care professional for physical and\ncognitive disability evaluation, if indicated | [
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cognitive disability evaluation, if indicated\n/C15Other appropriate health care professionalsdiabetesjournals.org/care Comprehensive Medical Evaluation and Assessment of Comorbidities S57\n©AmericanDiabetesAssociation | [
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Table 4.4 —Highly recommended immunizations for adults with diabetes (Advisory Committee on Immunization Practices\nand Centers for Disease Control and Prevention)\nVaccine Recommended ages Schedule GRADE evidence type* References\nCOVID-19 Recommended for all\n6 months of age\nand olderCurrent initial vaccination | [
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6 months of age\nand olderCurrent initial vaccination\nand boostersCenters for Disease Control and\nPrevention, Interim ClinicalConsiderations for Use of COVID-19\nVaccines, 2023 (295)\nHepatitis B Recommended for adults with\ndiabetes aged <60 years; for\nadults aged $60 years, | [
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diabetes aged <60 years; for\nadults aged $60 years,\nhepatitis B vaccine may beadministered at the discretionof the treating clinician based\non the person ’s likelihood of\nacquiring hepatitis B infectionWeng et al., Universal Hepatitis B\nVaccination in Adults Aged 19 –59\nYears: Updated Recommendations | [
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Vaccination in Adults Aged 19 –59\nYears: Updated Recommendations\nof the Advisory Committee onImmunization Practices —United\nStates, 2022 (18)\nInfluenza All people with diabetes advised\nnot to receive live attenuatedinfluenza vaccineAnnual Centers for Disease Control and\nPrevention, Prevention and Controlof Seasonal... | [
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Recommendations of the AdvisoryCommittee on Immunization\nPractices —United States, 2023– 24\nInfluenza Season (296)\nPneumonia (PPSV23\n[Pneumovax])19–64 years of age, vaccinate\nwith PneumovaxOne dose is recommended for those who\npreviously received PCV13; if PCV15\nwas used, follow with PPSV23 $1y e a r | [
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was used, follow with PPSV23 $1y e a r\nlater; PPSV23 is not indicated afterPCV20; adults who received only\nPPSV23 may receive PCV15 or PCV20\n$1 year after their last dose2 Centers for Disease Control and\nPrevention, UpdatedRecommendations for Prevention ofInvasive Pneumococcal DiseaseAmong Adults Using the 23-Valen... | [
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Pneumococcal Polysaccharide\nVaccine (PPSV23) (23)\n$65 years of age One dose is recommended for those\nwho previously received PCV13; ifPCV15 was used, follow with PPSV23$1 year later; PPSV23 is not\nindicated after PCV20; adults whoreceived only PPSV23 may receivePCV15 or PCV20 $1 year after their\nlast dose2 Falkenh... | [
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last dose2 Falkenhorst et al., Effectiveness of the\n23-Valent PneumococcalPolysaccharide Vaccine (PPV23)Against Pneumococcal Disease in\nthe Elderly: Systematic Review and\nMeta-analysis (24)\nPCV20 or PCV15 Adults 19 –64 years of age, with\nan immunocompromisingcondition (e.g., chronic renalfailure), cochlear implant... | [
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cerebrospinal fluid leakOne dose of PCV15 or PCV20 is\nrecommended by the Centers for\nDisease Control and Prevention3 Kobayashi et al., Use of 15-Valent\nPneumococcal Conjugate Vaccineand 20-Valent PneumococcalConjugate Vaccine Among U.S.\nAdults: Updated Recommendations\nof the Advisory Committee on\nImmunization Prac... | [
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of the Advisory Committee on\nImmunization Practices —United\nStates, 2022 (25)19–64 years of age,\nimmunocompetentFor those who have never received any\npneumococcal vaccine, the CDCrecommends one dose of PCV15 orPCV20\n$65 years of age, | [
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$65 years of age,\nimmunocompetent, haveshared decision-makingdiscussion with health careprofessionalsOne dose of PCV15 or PCV20; PCSV23\nmay be given $8 weeks after PCV15;\nPPSV23 is not indicated after PCV20\nRSV Older adults $60 years of age\nwith diabetes appear to be arisk groupAdults aged $60 years may receive a | [
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single dose of an RSV vaccineCenters for Disease Control and\nPrevention, CDC Recommends RSVVaccine for Older Adults (29)\nTetanus, diphtheria,\npertussis (Tdap)All adults; pregnant individuals\nshould have an extra doseBooster every 10 years 2 for effectiveness,\n3 for safetyHavers et al., Use of Tetanus Toxoid, | [
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3 for safetyHavers et al., Use of Tetanus Toxoid,\nReduced Diphtheria Toxoid, andAcellular Pertussis Vaccines:\nUpdated Recommendations of the\nAdvisory Committee on\nImmunization Practices —United\nStates, 2019 (297) | [
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Immunization Practices —United\nStates, 2019 (297)\nContinued on p. S59S58 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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-0.058358997106552124,
0.045491646975278854,
-0.06894698739051819,
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0.07917739450931549,
0.06676296889781952,
-0.07815482467412949,
-0.016900403425097466,
-0.014923465438187122,
0.0637921392917633,
-0.03299105167388916,
0.01695... |
of these vaccines among adults aged\n$60 years (27 –29).\nASSESSMENT OF COMORBIDITIES\nBesides assessing diabetes-related com-plications, clinicians and people withdiabetes need to be aware of commoncomorbidities that affect people with dia-betes and that may complicate manage-ment (30 –32). Diabetes comorbidities are | [
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conditions that affect people with diabe-tes more often than age-matched peoplewithout diabetes. This section discusses\nmany of the common comorbidities ob-\nserved in people with diabetes but is notnecessarily inclusive of all the conditionsthat have been reported.\nAutoimmune Diseases\nRecommendations\n4.7People wit... | [
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Recommendations\n4.7People with type 1 diabetes should\nbe screened for autoimmune thyroiddisease soon after diagnosis and peri-odically thereafter. B\n4.8Adults with type 1 diabetes should\nbe screened for celiac disease in thepresence of gastrointestinal symptoms,\nsigns, laboratory manifestations, or clin- | [
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0.022... |
signs, laboratory manifestations, or clin-\nical suspicion suggestive of celiac dis-ease. B\nPeople with type 1 diabetes are at in-\ncreased risk for other autoimmune dis-\neases, with thyroid disease, celiac disease,\nand pernicious anemia (vitamin B12\ndeficiency) being among the most com-\nmon (33). Other associated ... | [
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mon (33). Other associated conditions\ninclude autoimmune liver disease, pri-\nmary adrenal insuf ficiency (Addison dis-\nease), collagen vascular diseases, andmyasthenia gravis (34 –37). Type 1 diabe-\ntes may also occur with other autoim-\nmune diseases in the context of speci fic | [
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mune diseases in the context of speci fic\ngenetic disorders or polyglandular auto-immune syndromes (38). Given the highprevalence, nonspeci fics y m p t o m s ,a n di n -\nsidious onset of primary hypothyroidism,\nroutine screening for thyroid dysfunction is\nrecommended for all people with type 1diabetes. Screening for... | [
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-... |
should be considered in adults with dia-\nbetes with suggestive symptoms (e.g.,diarrhea, malabsorption, and abdominal\npain) or signs (e.g., osteoporosis, vitamin\ndeficiencies, and iron defi ciency anemia)\n(39,40). Measurement of vitamin B12\nlevels should be considered for people\nwith type 1 diabetes and peripheral n... | [
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Bone Health\nRecommendations\n4.9Fracture risk should be assessed\nin older adults with diabetes as a\npart of routine care in diabetes clin-\nical practice, according to risk fac-\ntors and comorbidities. A\n4.10 Monitor bone mineral density\nusing dual-energy X-ray absorptiome-\ntry of high-risk older adults with dia... | [
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0... |
betes (aged >65 years) and younger\nindividuals with diabetes and multiplerisk factors every 2 –3 years. A\n4.11 Clinicians should consider the po-\ntential adverse impact on bone healthwhen selecting pharmacological op-tions to lower glucose levels in people\nwith diabetes. Prioritizing medications\nwith a proven safe... | [
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0.0177... |
with a proven safety pro file for bones\nis recommended, particularly for thoseat elevated risk for fractures. A\n4.12 To reduce the risk of falls and\nfractures, glycemic management goalsshould be individualized for people\nwith diabetes at a higher risk of frac-\nture. CPrioritize use of glucose-lowering\nmedications ... | [
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0.0... |
medications that are associated with\nlow risk for hypoglycemia to avoid\nfalls. ETable 4.4 —Continued\nVaccine Recommended ages Schedule GRADE evidence type* References\nZoster $50 years of age Two-dose Shingrix, even if\npreviously vaccinated1 Dooling et al., Recommendations of\nthe Advisory Committee on | [
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0.025210656225681305,
0.13443328440189362,
-0.07097838819026947,
-0.004427608102560043,
-0.03617377579212189,
0.02128402329981327,
0.057496897876262665,
0.0615... |
the Advisory Committee on\nImmunization Practices for Use ofHerpes Zoster Vaccines (298)\nFor a comprehensive list of vaccines, refer to the Centers for Disease Control and Prevention web site at cdc.gov/vaccines/. Advisory Commit- | [
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0.0647... |
tee on Immunization Practices recommendations can be found at cdc.gov/vaccines/acip/recommendations. GRADE, Grading of Recommendations\nAssessment, Development, and Evaluation; PCV13, 13-valent pneumococcal conjugate vaccine; PCV15, 15-valent pneumococcal conjugate vaccine; | [
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PCV 20, 20-valent pneumococcal conjugate vaccine; PPSV23, 23-valent pneumococcal polysaccharide vaccine. *Evidence type: 1, randomized con-trolled trials (RCTs) or overwhelming evidence from observational studies; 2, RCTs with important limitations or exceptionally strong evidence | [
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0.07041227072477341,
0.032720278948545456,
0.10184092819690704,
0.08328329026699066,
0.0608440600335598,
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0.06521197408437729,
0.075173... |
from observational studies; 3, observational studies or RCTs with notable limitations; 4, clinical experience and observations, observational\nstudies with important limitations, or RCTs with several major limitations.\nTable 4.5 —General and diabetes-specifi c risk factors for fracture\nGeneral risk factors\n/C15Prior ... | [
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0.046495646238327026,
0.06740449368953705,
0.015443024225533009,
-0.07232064753770828,
0.16816984117031097,
-0.02680227719247341,
0.008220842108130455,
-0.05260586738586426,
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-0.04943867027759552,
0.026... |
General risk factors\n/C15Prior osteoporotic fracture\n/C15Age>65 years\n/C15Low BMI\n/C15Sex\n/C15Malabsorption\n/C15Recurrent falls\n/C15Glucocorticoid use\n/C15Family history\n/C15Alcohol/tobacco abuse\n/C15Rheumatoid arthritis\nDiabetes-speci fic risk factors\n/C15Lumbar spine or hip T-score #/C02.0\n/C15Frequent hy... | [
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0.020998137071728706,
0.011441695503890514,
0.04195393994450569,
-0.016176000237464905,
0.013043774291872978,
-0.06806814670562744,
0.14410555362701416,
-0.05219510942697525,
-0.006626105401664972,
-0.05147051811218262,
-0.038038019090890884,
-0.055198948830366135,
-... |
/C15Frequent hypoglycemic events\n/C15Diabetes duration >10 years\n/C15Diabetes medications: insulin, thiazolidinediones, sulfonylurea\n/C15A1C>8%\n/C15Peripheral and autonomic neuropathy\n/C15Retinopathy and nephropathydiabetesjournals.org/care Comprehensive Medical Evaluation and Assessment of Comorbidities S59\n©Ame... | [
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0.08428356796503067,
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0.10210508108139038,
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-0.07145936787128448,
-0.00037068809615448117,
0.003766237525269389,
-0.053201254457235336,
... |
4.13 Advise people with diabetes on\ntheir intake of calcium and vitamin D\nto ensure it meets the recommended\ndaily allowance for those at risk forfracture, either through their diet orsupplemental means. B\n4.14 Antiresorptive medications and\nosteoanabolic agents should be con-sidered for people with diabetes whoha... | [
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0.04866962507367134,
0.031293198466300964,
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0.01948048174381256,
0.07389464229345322,
0.08414679020643234,
-0.060710083693265915,
0.011022069491446018,
0.020116051658988,
0.012270970270037651,
-0.07060007750988007,
0.0236660... |
T-score #/C02.0 or have experienced\nfragility fractures. B\nFracture risk has traditionally relied on\nmeasurements of bone mineral density(BMD) and the World Health Organization–defined T-score of #/C02.5 SD. However, it is | [
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0.008440664038062096,
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0.041563235223293304,
0.0029308253433555365,
0.15639203786849976,
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0.02917676977813244,
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0.008681005798280239,
0.0... |
now established that the consideration ofother risk factors improves the categoriza-tion of fracture risk ( Table 4.5 ). There are\nfactors beyond BMD testing that contribute\nto bone strength in people with diabetes.\nHip or vertebral fracture with low trauma\nin people aged $65 years is diagnostic\nfor osteoporosis i... | [
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for osteoporosis independent of BMD\nand is one of the strongest risk factorsfor subsequent fractures, especially in the\nfirst 1–2 years after a fracture (41,42). Os-\nteoporotic hip fractures are associated\nwith signifi cant morbidity, mortality, and\nsocietal costs (43). It is estimated that 20%of individuals do not ... | [
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0.043085742741823196,
0.012062867172062397,
... |
hip fracture, while 60% do not regain their\nprior functionality, living with permanentdisability (44).\nHip fractures in people with diabetes\nare associated with higher risk of mor-tality (28% in women and 57% in men),\nlonger recovery, and delayed healing\n(45) compared with individuals withoutdiabetes.\nEpidemiolog... | [
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0.08100125193595886,
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... |
Epidemiology and Risk Factors\nAge-speci fic fracture risk is signi ficantly\nincreased in people with type 1 or type 2diabetes in both sexes, with a 34% in-c r e a s ei nf r a c t u r er i s kc o m p a r e dw i t h\nthose without diabetes (46).\nType 1 Diabetes. Fracture risk in people | [
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0.0031878931913524866,
0.04066145792603493,
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0.046165306121110916,
0.09883363544940948,
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0.04903031885623932,
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-0... |
those without diabetes (46).\nType 1 Diabetes. Fracture risk in people\nwith type 1 diabetes is increased by4.35 times for hip fractures, 1.83 times\nfor upper limb fractures, and 1.97 timesfor ankle fractures (47). Fractures occureven at young ages, 10 –15 years earlier | [
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0.09905218333005905,
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than they do in people without diabetes,and are less frequent at the vertebrallevel. Type 1 diabetes is often associatedwith low bone mass, although BMDunderestimates the high risk of fracture\nobserved even in young individuals (47).\nType 2 Diabetes. In people with type 2\ndiabetes, hip fracture risk is increased | [
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diabetes, hip fracture risk is increased\nby 1.79 times, and risk throughout life\nis 40 –70% higher than in it is in individ-\nuals without diabetes (46,48). Fracturerisk is increased also in the upper limbsand ankle. Hip fracture risk is increased\neven at early stages of the disease de- | [
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-0.... |
even at early stages of the disease de-\ns p i t en o r m a lo rh i g h e rB M D( 4 9 , 5 0 ) .However, bone loss is accelerated, andlow BMD remains an independent riskfactor for fractures (51).\nGlucose control signi ficantly impacts | [
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Glucose control signi ficantly impacts\nfracture risk in people with diabetes. Ameta-analysis revealed an 8% increasedfracture risk per 1% rise in A1C level(risk ratio [RR] 1.08 [95% CI 1.03 –1.14])\n(52). Poor glycemic control (A1C >9%) | [
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(52). Poor glycemic control (A1C >9%)\nover 2 years in individuals with type 2diabetes correlated with a 29% height-ened fracture risk (53). Notably, this riskwas higher in the White demographicthan in other racial groups. Hypoglyce-\nmia also escalated the risk of fractures | [
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mia also escalated the risk of fractures\nat the hip and other skeletal sites (RR1.52 [95% CI 1.23 –1.88]) (52). A Japa-\nnese study echoed these findings, show-\ning a fracture risk increase (hazard ratio\n[HR] 2.24 [95% CI 1.56 –3.21]) with se-\nvere hypoglycemia episodes (54).\nLonger disease duration further ele- | [
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0.02943645976483822,
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0.1255212277173996,
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0.033004917204380035,
0.00180570... |
vere hypoglycemia episodes (54).\nLonger disease duration further ele-\nvates fracture risk (55); data indicate indi-\nviduals with T2D for >10 years and those\nwith type 1 diabetes for >26 years face\nsignifi cantly higher fracture risks, which | [
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0.03885595127940178,
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0.12521065771579742,
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-0.0105... |
signifi cantly higher fracture risks, which\nare largely attributed to ensuing micro-vascular and macrovascular damage af-fecting the skeleton. Additionally, highfracture risk is seen in people with car-\ndiovascular issues, nephropathy, retinop-\nathy, neuropathy, and frequent falls (45,56–59).\nCertain glucose-lowerin... | [
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Certain glucose-lowering medications\nalso factor into fracture risk. Studies have\nreported increased fracture incidences in\nwomen using thiazolidinediones (TZD),with the risk doubling with 1 –2 years of\nTZD use (HR 2.23 [95% CI 1.65 –3.01])\n(60,61). According to the Action to Control\nCardiovascular Risk in Diabet... | [
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0.03154... |
Cardiovascular Risk in Diabetes (ACCORD)\nstudy, reduced risk is noted in women whohad discontinued TZD use for 1 –2 years\n(HR 0.57 [95% CI 0.35 –0.92]) or >2 years\n(HR 0.42 [95% CI 0.24 –0.74]) compared | [
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-0... |
(HR 0.42 [95% CI 0.24 –0.74]) compared\nwith current users (62). Furthermore, indi-viduals with type 2 diabetes on insulin (RR1.49 [95% CI 1.29– 1.73]) or sulfonylurea(RR 1.30 [95% CI 1.18 –1.43]) treatment ex-\nhibit a heightened fracture risk (63).\nScreening | [
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0.0... |
hibit a heightened fracture risk (63).\nScreening\nMost evidence on screening in individu-als at risk for fracture is available frompeople with type 2 diabetes, while frac-\nture risk prediction in type 1 diabetes | [
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ture risk prediction in type 1 diabetes\nhas not been explored. Health care pro-fessionals should assess fracture historyand risk factors in older people with di-abetes and recommend measurement\nof BMD if appropriate according to the\nindividual ’s age and sex.\nType 2 Diabetes. People with type 2 diabe-\ntes have 5 –... | [
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0.009309744462370872,
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-... |
tes have 5 –10% higher BMD than people\nwithout diabetes. A T-score adjustment of/C00.5 has been proposed to improve frac-\nture prediction by dual-energy X-ray ab-sorptiometry (DXA). For example, a T-score#/C02.0 should be interpreted as equiva-\nlent to /C02.5 in a person without diabetes | [
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0.... |
lent to /C02.5 in a person without diabetes\n(51). Notably, the Fracture Risk AssessmentTool (FRAX), although useful, does not fac-tor in type 2 diabetes; an inclusion of thecondition is estimated to mirror the effect\nof either a 10-year age increase or a | [
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0.0008810524013824761,
0.1148855909705162,
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... |
of either a 10-year age increase or a\n0.5 SD reduction in BMD T-score (64).Fracture risk was higher in large obser-vational studies in participants with dia-betes compared with those without\ndiabetes for a given T-score and age or | [
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0.0203... |
diabetes for a given T-score and age or\nfor a given FRAX score (51). Additionally,integrating the diagnosis of rheumatoidarthritis in FRAX can potentially improvefracture risk prediction for people with\ntype 2 diabetes. Growing evidence sug- | [
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0.03323328495025635,
0.02604... |
type 2 diabetes. Growing evidence sug-\ngests that fracture risk prediction is en-hanced by use of trabecular bone score(64), although such studies are not availablefor individuals with type 1 diabetes and are\nbased on data from the U.S. or Canada.\nIn people with type 2 diabetes, in the\nabsence of other comorbiditie... | [
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0.022042306140065193,
0.08701328933238983,
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0.0698077455163002,
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0.0049... |
absence of other comorbidities, DXA scan\nshould be performed at least 5 years afterthe diagnosis of diabetes, and reassess-ment is recommended every 2 –3 years\n(64) depending on the screening evalua-tion and the presence of additional riskfactors ( Table 4.5 ). According to the Euro- | [
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0.013116828165948391,
0.08457116782665253,
-0.059750642627477646,
... |
pean Association for the Study of Obesity(EASO), DXA should be performed every\ntwo years in subjects undergoing bariatric-\nmetabolic surgery.\nBone turnover markers are commonly\nused in clinical practice, although theyare suppressed in people with diabetes\nand have not been shown to predict frac- | [
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0.010024484246969223,
0.021522212773561478,
-0.05391101539134979,
... |
and have not been shown to predict frac-\nture risk (65).S60 Comprehensive Medical Evaluation and Assessment of Comorbidities Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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0.00703115900978446,
-0.027375470846891403,
-0.00... |
Type 1 Diabetes. Because hip fracture\nrisk in type 1 diabetes starts to increase\nafter the age of 50, clinicians may con-\nsider assessing BMD after the 5th de-cade of life (47). In people with type 1diabetes, BMD underestimates fracturerisk, but studies do not address the ex-tent of underestimation of fracture risk. | [
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0.042281437665224075,
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0.07977212965488434,
-0.052841994911432266,
-0.00... |
According to the International Society\nfor Pediatric and Adolescent Diabetes(ISPAD), regular assessment of bone healthusing bone densitometry in youth withtype 1 diabetes is still controversial andnot recommended, but it may be con-sidered in association with celiac dis-ease because of the involvement ofinflammatory pa... | [
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0.06598655879497528,
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0.0450280... |
Management\nMaintaining glucose control and minimiz-ing hypoglycemic episodes are crucial forbone health in people with diabetes. Indi-viduals with prolonged disease, microvas-cular and macrovascular complications,or frequent hypoglycemic episodes facehigher fracture risks and fall risks due to\nfactors like sarcopenia... | [
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0.015997178852558136,
0.003203649539500475,
0.06062210723757744,
-0.030327174812555313,
... |
factors like sarcopenia and impaired gait.\nHealth care professionals should advo-cate moderate physical activity to en-hance muscle health, gait coordination,and balance as part of fracture preventivestrategies (58,59,67).\nAerobic and weight-bearing exercise | [
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0.09109801054000854,
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0.028516951948404312,
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0.0... |
Aerobic and weight-bearing exercise\nshould be recommended to counteractthe potential negative effect of weightloss on bone; speci fic guidelines have\nbeen published for older adults withtype 2 diabetes (68).\nOsteoporosis and fracture prevention\narefirst based on measures applied to the | [
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0.007618078030645847,
0.058405790477991104,
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0.003... |
arefirst based on measures applied to the\ngeneral population. All people with diabe-tes should receive an adequate daily in-take of proteins, calcium, and vitamin D,stop smoking, and have regular physicalactivity (69 –71).\nIntake of calcium should re flect the age-\nspecific recommendations of the general | [
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specific recommendations of the general\npopulation and should be obtained throughdiet and/or oral supplements (72).\nThe optimal level of 25-hydroxyvitamin D\nis a matter of controversy (73), althoughserum levels $20 ng/mL are generally\nthought to be suf ficient (74). Because di- | [
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0.03202195465564728,
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0.01... |
thought to be suf ficient (74). Because di-\nabetes is a risk factor for fractures, otherguidelines suggest a goal >30 ng/mL\n(75).\nThe safe upper limit is also a matter of\ndebate, and there is substantial disagree-ment over whether to treat to a speci fied\nserum level. In the U.S., the recommendeddaily allowance of v... | [
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... |
people aged 51 –70 years and 800 IU for\npeople aged >70 years (74). In clinical prac-\ntice, this dose of supplement is often notenough to reach recommended goals, andhigher doses of D2 or D3 may be needed.\nFractures are main determinants of | [
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Fractures are main determinants of\nfrailty, a predisability condition that shouldbe mitigated with individualized interven-tions to prevent falls, maintain mobility,\nand delay disability (68). In many circum- | [
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0.01454... |
stances, conservative management (cal-cium, vitamin D, and lifestyle measures) arenot enough to reduce fracture risk. Whenpharmacological treatment is needed,medication decision-making strategiesare the same as those used for the generalpopulation. Antiosteoporosis medicationsreduce bone resorption (bisphosphonates, | [
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0.05371720716357231,
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selective estrogen receptor modulators, | [
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and denosumab), stimulate bone forma-tion (teriparatide and abaloparatide), orhave dual actions by stimulating bone for-mation and reducing bone resorption (ro-mosozumab). These agents improve bonedensity and reduce the risk of vertebraland nonvertebral fractures. Althoughthere are no studies speci fically designed | [
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for people with diabetes, data on antire-\nsorptives and osteoanabolic agents sug-\ngest similar ef ficacy in type 2 diabetes\ncompared with individuals without diabe-tes (76 –78). Using individual patient data | [
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from randomized trials, antiresorptivetherapies show similar effects in peoplewith and without type 2 diabetes for ver-tebral, hip, and nonvertebral fractures(76). No similar studies of ef ficacy of anti-\nosteoporosis treatment in people withtype 1 diabetes have been published.\nPrimary Prevention of Fragility Fracture... | [
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Primary Prevention of Fragility Fractures\nin People With Diabetes. In the general\npopulation, a T-score #/C02.5 is the thresh-\nold to consider pharmacological treatment\nfor osteoporosis. In type 2 diabetes, sinceT-score underestimates fracture risk (asdiscussed above), a T-score #/C02.0 may | [
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be more appropriate for considering initi-ation of a first-line drug, including bi-\nsphosphonates (alendronate, risedronate,and zoledronate) or denosumab.\nDenosumab is preferred in individu-\nals with estimated glomerular filtration\nrate<30–35 mL/min/1.73 m\n2.S e l f - | [
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0.022633608430624008,
0.016551176086068153,
0.03... |
rate<30–35 mL/min/1.73 m\n2.S e l f -\nmanagement abilities of the person with di-abetes should be considered in medicationselection, as there can be rebound boneloss with missed doses of denosumab ordelays in care. Zoledronic acid may be\nmore appropriate in these cases.\nSecondary Prevention of Fragility Fractures. | [
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0.01130653079599142,
0.020411109551787376,
0.0... |
Secondary Prevention of Fragility Fractures.\nThe risk of subsequent fracture in indi-viduals with hip or vertebral fracture issignificantly high, especially in the first\n1–2 years after a fracture. Antiosteopo-\nrosis treatment reduces the risk of frac-\nture in older individuals with prior hip\nor vertebral fracture. | [
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ture in older individuals with prior hip\nor vertebral fracture.\nAs in the general population, people\nwith diabetes who experience fragility\nfracture should 1) be given the diagnosis\nof osteoporosis regardless of DXA data\nand 2) receive therapy to prevent future\nfractures (79). Individuals at particularlyhigh ris... | [
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bidities) should be referred to a bone\nmetabolic specialist. In these cases, aspecialist may choose to initiate an os-\nteoanabolic agent to opt imize bone for-\nmation and reduce immediate fracture\nrisk (80). It is strongly recommended that\nall individuals with a fragility fracture be\nstarted on antiosteoporosis t... | [
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started on antiosteoporosis therapy and\nadequate calcium and vitamin D supple-\nmentation, if needed, as early as possi-ble, even during hospitalization (79).\nThere are some additional considera-\ntions related to medication selection inpeople with diabetes. Data from a phase 3trial and population studies have indica... | [
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positive effects of denosumab on fasting\nglucose and on diabetes prevention. The\nFracture Reduction Evaluation of Denosu-\nmab in Osteoporosis Every 6 Months(FREEDOM) trial and its 10-year extension\nhave shown that people with diabetes\ntreated with denosumab experience sig-nificant improvements in BMD and lower | [
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0.08931957185268402,
-0.042527321726083755,
-... |
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