Letter to the Editor: “Association Between Cortical Bone Microstructure and Statin Use in Older Women”

We read with interest the recent report by Larsson et al. (1) wherein they illustrated that the use of statins was associated with higher cortical bone mineral density (BMD) and lower cortical porosity in the distal tibia and radius. The differences, though minor, were sustained after adjustment for group differences in the complete and unmatched cohorts. The authors reported that the prevalence of diabetes was higher in the statin-treated group, even after attempted matching of the cohorts. Because the study population was elderly women between the ages of 75 and 80 years, we presume that most, if not all, patients with diabetes had type 2 diabetes (rather than type 1). This assumption is relevant in the interpretation of results because studies show that despite higher trabecular volumetric BMD, patients with type 2 diabetes have lower cortical BMD and more cortical porosity in peripheral bones than patients without diabetes (2, 3). This raises the possibility that the effects of statins on cortical BMD and porosity might differ in patients with diabetes. We propose that the authors conduct subgroup analyses of the effect of statins on cortical bone microarchitecture separately in subjects with and without diabetes. It is possible that the beneficial effect of statins on cortical bone is enhanced, or alternately, nullified, in the presence of type 2 diabetes. Either way, the information would be useful because statin use is recommended for most patients with diabetes.

The authors conclude with a call for randomized controlled studies to evaluate the effect of statins on cortical bone. Although this pursuit has scientific merit, it should also be recognized that the benefits in cortical bone that are attributed to statins in the study were small. The clinical relevance of this effect of statins is not clear. In the presence of an ever-increasing armamentarium of treatments for osteoporosis and clear clinical indication of statins for cardiovascular prevention, it is unlikely that statins will be used solely for fracture prevention. A randomized controlled trial to evaluate the effect of statins on cortical bone would probably be expensive and is difficult to justify.

Acknowledgments

Disclosure Summary: The authors have nothing to disclose.

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