[Diagnosis and management of diabetes and co-existing osteoporosis (Update 2026)]

Diabetes mellitus and osteoporosis are among the most frequent chronic diseases and therefore often occur in one and the same individual. As the prevalence of both diseases increases with age, in view of the age structure of our population their frequency will increase. Patients with diabetes have an elevated risk of fragility fractures. The pathophysiology is unclear and presumably multifactorial. Longitudinal studies have shown that the Fracture Risk Assessment Tool (FRAX) and the bone mineral density (BMD) measured by dual energy X‑ray absorptiometry (DXA, T‑score) and a possibly present trabecular bone score (TBS) can predict the individual risk of fractures; however, an adjustment must be made in order not to underestimate the risk. From an osteological perspective an optimal approach is not yet available as there are no studies with patients who have only diabetes and osteoporosis. Patients with diabetes mellitus and an elevated risk of fractures should be treated in exactly the same way as patients with an increased risk of fractures but without diabetes. The vitamin D level should in every case always be optimized and a sufficient calcium intake should be ensured (preferably via the nutrition). In the selection of the antihyperglycemic treatment, substances with a proven negative effect on bones should be omitted. In the case of a fragility fracture a long-term specific osteological treatment is indicated, independent of all available findings. Antiresorptive medications are the first choice for prevention of fragility fractures and also anabolic drugs according to national reimbursement criteria. Monitoring of treatment should be carried out in compliance with the national osteoporosis guidelines (revised version Autumn 2024).