Primum non nocere!

My e-mail inbox this morning carried the welcome daily briefing from the Endocrine Society but one of the contents disturbs me. It was the report of a study published in Diabetes Care, confirming that young women with type 1 diabetes have lower bone mineral density than non-diabetic peers. They reasoned that this might be responsible for the observed higher rates of osteoporosis-related fragility fractures later in life in type 1 diabetes. The authors recommended counseling young women with type 1 diabetes about a skeletally healthy diet (calcium, Vitamin D) and exercise to promote bone health. An excellent recommendation appropriate for each and every one of us!

But the article went too far in my opinion by recommending bone density screening in young women with type 1 diabetes.

I have recently blogged about the need for careful interpretation of BMD studies in premenopausal women: Z-scores, not T-scores; no diagnostic labels such as osteoporosis; no comments about bone “loss” in baseline studies. But that’s not my issue with the recommendation!

What should the treating physician do with the result once the screening is complete? The advice about diet and exercise should be given independent of the BMD or underlying diabetes. The only additional option I can think of would be to prescribe pharmacologic therapy for skeletal protection. No way! Or perhaps, “which drug would you choose?”

Raloxifene – no;

Estrogen – no;

Teriparatide – no;

Bisphosphonate – not in my practice to a woman with child bearing potential, as I have also blogged about before.

The only drug I haven’t yet mentioned is calcitonin. I think this is a very safe drug, although I doubt there is much data on its use and safety in a pregnant woman, nor much data on the effects of calcitonin on a developing human fetus.

We do need to look after the skeletal (and overall) health of every patient with type 1 diabetes with the primary observable goal being control of the diabetes. We may also learn a lot about both diabetes and the skeleton by continuing research such as the one reported above.

But screening for something about which we can do very little and has no immediate impact on the patient?

(I did have the courtesy to e-mail my concerns to the Endocrine Society a few hours before I prepared this blog.)