SUN-740 - Beyond Bone Mineral Density: Exploring the Diabetic Bone Paradox using Radiofrequency Echographic Multi Spectrometry (REMS)

Background and objective: Type 2 diabetes mellitus (T2DM) is a highly prevalent metabolic disease characterized by insulin resistance, progressive beta-cell dysfunction, and chronic hyperglycaemia. Beyond its well-known systemic complications, T2DM has emerged as a relevant risk factor for skeletal fragility. Paradoxically, T2DM patients often exhibit normal BMD when assessed by standard densitometric technologies such DXA, despite experiencing a markedly increased risk of fractures, particularly non-vertebral fractures. This discrepancy, known as the “diabetic bone paradox”, suggests that alterations in bone quality rather than bone quantity play a crucial role in skeletal fragility in T2DM. Consequently, technologies capable to provide quantitative insights into bone quality are needed to improve fracture risk stratification in this population. In the first structured review and meta-analysis assessing the effects of T2DM on hip fracture outcomes, diabetics have an increased mortality as compared to non-diabetics, with relative risk equal to 1.24.
In this context, this study aimed to evaluate BMD in patients with T2DM using Radiofrequency Echographic Multi Spectrometry (REMS) in comparison with DXA. In addition, bone quality was explored through the REMS Fragility Score (FS).

Methods: Inclusion criteria encompassed Caucasian individuals, both genders, with a diagnosis of T2DM. All patients underwent both DXA and REMS scans at the same axial reference sites (lumbar spine and femur). Bone quantity was assessed using both DXA- and REMS-BMD, whereas bone quality was evaluated using the REMS-FS, a non-dimensional parameter ranging from 0 to 100, where higher values indicate a higher compromised microarchitectural framework. Comparisons between DXA- and REMS-BMD were analysed using paired t-tests.

Results: A total of n = 95 patients (mean age = 72.6 ± 7.9 years) were included in the analysis. BMD evaluations of the lumbar spine were as follows: 0.805 ± 0.103 g/cm2 and 0.979 ± 0.198 g/cm2 for REMS and DXA scans, respectively with a statistically significant difference (p < 0.0001). REMS bone quality analysis revealed a mean FS of 51.8 ± 5.9, indicating a highly compromised bone microarchitecture. Similar trends were observed in the analysis of the femoral site.

Conclusions: This study demonstrated significant differences between REMS and DXA in the assessment of BMD in patients with T2DM, with REMS-BMD showing lower values, and thus identifying a higher prevalence of osteopenic/osteoporotic condition. Furthermore, the inclusion of bone quality analysis through REMS-FS enables the evaluation of skeletal microarchitectural and fragility, providing additional insights into the effects of T2DM on bone health. Overall, these findings support the potential role of REMS as a valuable tool to improve osteoporosis diagnosis and fracture risk assessment in patients with T2DM.

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