The association between insulin use and volumetric bone mineral density, bone micro-architecture and bone strength of the distal radius in patients with type 2 diabetes - The Maastricht study

Type 2 diabetes mellitus (T2DM) has been associated with an increased risk of fractures, despite normal to increased bone mineral density (BMD). Insulin use is one of the factors linked to this increased fracture risk. However, direct negative effects of insulin on bone quality are not expected since insulin is thought to be anabolic to bone. In this cross-sectional study the association between insulin use and volumetric BMD (vBMD), bone micro-architecture and bone strength of the distal radius, as measured with HR-pQCT, was examined. Data from 50 participants with T2DM of The Maastricht Study (mean age 62 ± 7.5 years, 44% women) was used. Participants were classified as insulin user (n = 13) or non-insulin user (n = 37) based on prescription data. Linear regression analysis was used to estimate the association between current insulin use and HR-pQCT derived parameters. After adjustment for age, sex, body mass index, glycated hemoglobin A1c and T2DM duration, insulin use was associated with lower total vBMD (standardized beta (β):− 0.56 (95% CI:− 0.89 to − 0.24)), trabecular vBMD (β:− 0.58 (95% CI:− 0.87 to − 0.30)), trabecular thickness (β:− 0.55 (95% CI:− 0.87 to − 0.23)), cortical thickness (β:− 0.41 (95% CI:− 0.74 to − 0.08)), log cortical pore volume (β:− 0.43 (95% CI:− 0.73 to − 0.13)), bone stiffness (β:− 0.39 (95% CI:− 0.62 to − 0.17)) and failure load (β:− 0.39 (95% CI:− 0.60 to − 0.17)) when compared to the non-insulin users. Insulin use was not associated with cortical vBMD, trabecular number, trabecular separation, cortical porosity and cortical pore diameter. This study indicates that insulin use is negatively associated with bone density, bone micro-architectural and bone strength parameters. These findings may partly explain the previously observed increased fracture risk in insulin users, although there may be residual confounding by other factors related to disease severity in insulin users.