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TraumaCohort

Systemic glucocorticoid use increases fracture risk similarly in individuals with and without type 2 diabetes: a Danish nationwide cohort study

Osteoporosis International · 11 Sept 2026

Rigour50/100
Clinical45/100
Impact†49/100

† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.

Why it matters

Clinicians often assume diabetic patients face extra glucocorticoid-related fracture risk, but this large study suggests the relative risk increase is similar, meaning fracture prevention counselling should focus on glucocorticoid exposure itself rather than diabetes status as an added multiplier.

The evidence

This Danish nationwide cohort study used registry data on nearly 478,000 people who started systemic glucocorticoids (about 28,000 with type 2 diabetes) to see whether diabetes makes glucocorticoid-related fracture risk worse. Using a within-person before/after design with statistical weighting, glucocorticoids raised major osteoporotic fracture risk substantially (adjusted IRR 1.70, 95% CI 1.55-1.85), but this increase was essentially the same in people with and without type 2 diabetes (interaction/product term IRR 1.01, 95% CI 0.87-1.17), and this held across sex, age, fracture site, and multiple sensitivity analyses.

first major osteoporotic fracture (MOF): Hazard ratio 1.01 (95% CI 0.87 to 1.17; ratio). The interval includes no difference. This does not establish equivalence or rule out an important effect.

Why this rigour score?

Registry cohort (adjusted)Design starting point: 37.4

50/ 100

Raised the score

  • Post-adjustment balance demonstrated+4.3
  • New-user design+3.4

Lowered the score

    No negative adjustments recorded.

    Methods at a glance

    Recorded assessment
    • Confounding adjustmentInverse-probability weighting / doubly robust
    • Covariate balance confirmedMet
    • Outcome assessors blindedNot reported
    • Comparable start of follow-upMet
    • Adequate statistical powerNot reported
    • Prospective registrationNot met

    Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.

    See the full score breakdown
    Study design starting point
    37.4
    New-user design
    +3.4
    Post-adjustment balance demonstrated
    +4.3
    Aligned time zero
    +2.5
    Validated coding algorithm
    +2.5
    Final rigour score rounded
    50 / 100

    Study design sets the starting point and a ceiling of 80. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.

    Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.

    For journal club

    1.Should orthopaedic surgeons and endocrinologists treat glucocorticoid-associated fracture risk the same way in diabetic and non-diabetic patients, given that the relative risk increase appears similar despite diabetics' higher baseline risk?

    2.Given that fracture risk from glucocorticoids was highest early in treatment and with higher doses, how should this inform timing of DXA screening or bone-protective therapy initiation after starting steroids?

    Original publication title

    Systemic glucocorticoid use increases fracture risk similarly in individuals with and without type 2 diabetes: a Danish nationwide cohort study

    Read original paper