Gout: A clinical overview and its association with cardiovascular diseases

Gout is a common disease caused by the deposition of monosodium urate (MSU) crystals in patients with hyperuricemia, and characterized by very painful recurrent acute attacks of arthritis. The gold standard for diagnosing gout is the identification of MSU crystals in synovial fluid by polarization light microscopy. Arthritis attacks can be treated with anti-inflammatory medications, such as non-steroidal anti-inflammatory drugs, colchicine, oral prednisone, or intra-articular or intramuscular glucocorticoids. To prevent gout uric acid lowering therapy with for example allopurinol can be prescribed. When gout is adequately treated, the prognosis is good. Unfortunately, the management of gout patients is often insufficient. Gout is associated with dietary factors, the use of diuretics, and several genetic factors. Comorbidities as hypertension, chronic kidney disease, cardiovascular diseases, the metabolic syndrome, diabetes, obesity, hyperlipidemia, and early menopause are associated with a higher prevalence of gout. Xanthine oxidase and chronic systemic inflammation seem to play an important role in the pathophysiology of the association between gout and cardiovascular diseases. To prevent cardiovascular diseases gout patients must be early screened for cardiovascular risk factors.

Epigenetic targets of rheumatoid arthritis

Rheumatoid arthritis (RA) is a systemic, inflammatory and autoimmune disorder, characterized by chronic arthritis with progressive joint destruction. It has a multifactorial aetiology involving both genetic and environmental factors. Epigenetics can be defined as modifications of DNA that result in altered gene expression. The two main epigenetic mechanisms are post translational modifications to histone tails and DNA methylation. Recent evidence has suggested that epigenetic mechanisms may be an important contributor to RA susceptibility. The aim of this editorial is to present evidence for the role of epigenetic mechanisms in the pathogenesis of RA and the potential to therapeutic target. Several studies targeting histone modification and DNA methylation in animal models of inflammatory arthritis will be reviewed and alterations in the epigenetic signature of genes of key RA related pathways such as pro-inflammatory cytokines, proteases and regulators of cellular proliferation.

Role of Apo2L/TRAIL in immunity: Applications to rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common inflammatory disease of the musculoskeletal system primarily affecting the joints. It is characterized by massive synovial hyperplasia and subsequent destruction of articular cartilage and bone. Although various aspects in the pathogenesis of RA remain unclear, genetic, environmental and of course immunological factors have been involved. Defects in apoptosis seem to play a role in both initiation and perpetuation of RA. Apo2 ligand/ tumor necrosis factor (TNF) related apoptosis-inducing ligand (Apo2L/TRAIL) is a cytokine that belongs to the TNF superfamily capable of inducing apoptosis on tumor cells through activation of the extrinsic pathway. Besides this function, like other members of the TNF superfamily, Apo2L/TRAIL has been shown to exert important functions in the regulation of the immune system. Concerning pathological conditions, the Apo2L/TRAIL signaling pathway plays an important role in the response to infections, in immune surveillance against tumors and in autoimmune diseases such as RA. Furthermore, its implication in suppression of autoimmunity suggests that Apo2L/TRAIL has potential as therapeutic agent not only in cancer but also in autoimmune diseases. In fact, Apo2L/TRAIL-based therapies have been shown effective in various animal models of RA. This review summarizes the current knowledge on the biology of Apo2L/TRAIL and its role in RA.

Spinal accessory neuropathy in patients with chronic neck pain

AIM: To assess the presence of spinal accessory neuropathy in patients with chronic neck pain.

METHODS: Patients with pain either regional or focal in the neck or shoulders for at least 6 mo (chronic neck pain) were recruited randomly from the Rheumatology and Rehabilitation Outpatient Clinic at the Faculty of Medicine-Suez Canal University. Two groups were compared: 30 patients with chronic neck pain with mean age (36.97 ± 12.45 years) and 10 apparently healthy controls. Trapezius muscle examination including inspection and range of motion both active and passive was performed. A full clinical neurological examination was carried out to exclude peripheral neuropathy and motor neuron disease. According to the subject’s type of work, cases were categorized into labor-intensive and non-labor intensive tasks. A nerve conduction study (NCS) was performed on spinal accessory nerves at both sides for all patients and controls. Parameters including latencies and amplitudes of compound motor action potential (CMAP) were compared with the chronicity of neck pain using the neck disability score. This cross sectional study was carried in the Rheumatology and Rehabilitation Department, at Suez Canal University Hospital, Ismailia, Egypt.

RESULTS: Physical examination revealed that 80% of cases had spinal trapezius muscle spasm. Restricted neck motion was present in 16.6% of cases. No one suffered from muscle wasting or weakness. Pain was bilateral in 18 patients (60%), localized to the right side in six patients (20%) and localized to the left side in six patients (20%). The causes of neck pain in the patients studied were nonspecific, due to physical stresses, cervical spondylosis and mild cervical disc herniation. Mean disease duration in patients with labor-intensive tasks was (3.9 ± 2.1 years), which was longer than that in patients with non-labor intensive tasks (3.1 ± 1.9 years); however, this difference was statistically insignificant. Spinal accessory NCSs were performed while subjects were in sitting positions and relaxed with naturally suspended arms to minimize muscular movement. The results of electrophysiological studies revealed that mean right and left latencies of the spinal accessory nerve were 2.96 ± 0.69 ms, 2.98 ± 0.61 ms in the patient group and 2.44 ± 0.38 ms, 2.33 ± 0.36 ms in control group respectively. These differences were statistically significant with P = 0.028 and 0.006 respectively. Spinal accessory NCS showed normal CMAP amplitude in both patients and controls. Comparing the results of the neck disability index (NDI) to different characteristics in patients with chronic neck pain, showed that patients with labor-intensive work had a higher NDI score mean (34.7 ± 9.5) compared to those with non-labor-intensive work, with significant statistical difference (P = 0.011). In addition, mean NDI scores were higher in males, and patients aged over 40 years and this difference was statistically significant (P = 0.007 and P = 0.009 respectively). Correlation studies between right and left spinal accessory nerve latencies and disability percent calculated using the NDI revealed a positive correlation. Moreover, there was a positive correlation between age and disability percent.

CONCLUSION: This study demonstrates electrophysiological evidence of demyelination in a significant proportion of patients with chronic cervical pain.

Adrenocorticotropic hormone: A powerful but underappreciated therapeutic tool for acute crystal induced arthritis?

Treatment of acute gout is not always an easy task since patients usually have multiple comorbidities that preclude the use of nonsteroidal anti-inflammatory drugs and colchicine, the most widely used therapeutic tools. Adrenocorticotropic hormone (ACTH) has long been used in the treatment of acute gout and several studies have shown that it is highly effective and exhibits an excellent safety profile. ACTH belongs to a family of proteins called melanocortins; these molecules have strong anti-inflammatory properties and serve as natural inhibitors of inflammatory responses. We have recently reported that treatment of acute gout with 100 IU of synthetic ACTH is highly effective and associates with negligible side effects. It is note worthy that ACTH did not associate with significant “steroid related” side effects such as hypertension, hyperglycemia and hypokalemia. ACTH appears as a powerful and easy to use therapeutic tool for patients with multiple comorbidities. We believe that the role of ACTH as a treatment for acute gout should be reappraised, especially in light of new experimental data indicating that ACTH has pleiotropic anti-inflammatory properties and is not just a hormone that stimulates the release of steroids.

Greater awareness of biosimilars and shared decision-making among patients attending rheumatology practices in Colorado, United States: Real-world data

BACKGROUND

There is a lack of studies and educational programs focused on biosimilars and shared decision-making among patients diagnosed with various rheumatic diseases.

AIM

To improve knowledge and awareness of biosimilars and shared decision-making among patients attending rheumatology practices in Colorado as well as to assess a rheumatology patient’s interest in discussing biosimilars as well as shared decision-making with others (e.g., medical professionals, family members, friends).

METHODS

Our goal was to work with 80 rheumatology teams in Colorado.  We developed and distributed 2000 multi-page brochures to each participating office and later conducted an online anonymous survey.

RESULTS

There were a total of 49 (2.5%) rheumatology patients who responded to our survey. After reading our educational booklet, many survey respondents identified the correct answer in most questions focused on biosimilars or shared decision-making. Our survey results suggest that patients attending rheumatology practices in Colorado are generally not involved in discussions with their providers regarding treatment plans or options. The improvement in scores after reading our educational materials was statistically significant for biosimilars and shared decision-making.

CONCLUSION

Overall, the level of knowledge and awareness of biosimilars and shared decision-making among patients attending rheumatology practices in Colorado was low. More educational programs as well as follow up trainings to measure changes in knowledge and awareness regarding biosimilars and shared decision-making among patients attending rheumatology practices are recommended.

What is the purpose of launching World Journal of Rheumatology?

The first issue of World Journal of Rheumatology (WJR), whose preparatory work was initiated on December 16, 2010, will be published on December 31, 2011. The WJR Editorial Board has now been established and consists of 116 distinguished experts from 29 countries. Our purpose of launching WJR is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.

Maligned non-steroidal anti-inflammatory drugs: Misunderstanding of their safety profile in patients with renal insufficiency

Non-steroidal anti-inflammatory drugs have a fundamental and pivotal position in management of many of the disorders managed by rheumatologists. Promulgation of a false perspective of their toxicity has compromised our ability to advise our patients and participate in the management of their disorders. The literature sources, from which the false perspective derives, do not accurately reflect safety and fail to address the value of appropriate drug use monitoring. We, as rheumatologists, must stand up and proactively address engrained misconceptions-if we are to be able to continue to provide safe, effective care for our patients.

Scleroderma: Not an orphan disease any more

Scleroderma (or systemic sclerosis) is a rare disease associated with significant morbidity and mortality. Although previously thought to have a uniformly poor prognosis, the outlook has changed in recent years. We review recent insights into the pathogenesis, clinical features, assessment and management of scleroderma.

Current review of trapeziometacarpal osteoarthritis (rhizarthrosis)

Trapeziometacarpal (TMC) joint is the secondly affected joint for osteoarthritis in the hand. TMC joint arthritis affects most commonly postmenopausal women after the fifth decade of life, due to hormonal and structural factors. Rhizarthrosis may lead to a clinical spectrum from subtle symptoms to advanced symptoms such as; severe pain, limitation of range of motion, muscular weakness, bony deformities, and end up ultimately with disability. Regardless of the etiopathogenesis; a variety of non-surgical and surgical methods have been used for the treatment of rhizarthrosis, depending on the age of the patient, symptomatology and the stage of the disease. The main goals of the treatments are as follows; relief of pain, conservation or restoration the stability and mobility of the TMC joint with the optimal preservation of the strength of surrounding musculature. In this article, the current methods, which have been used for the treatment of TMC joint osteoarthritis, will be mainly reviewed, together with concise up-to-date information on both its diagnosis and the anatomy of the TMC joint.

Use of biologic agents for rheumatic diseases in pregnancy

Biologic agents have ushered a new era in the treatment of inflammatory rheumatic diseases. In recent years, several biologic agents have been approved by food and drug administration and have significantly improved outcomes for patients with immune mediated inflammatory disorders including rheumatic and inflammatory bowel diseases. The most common used biologic therapeutic agents are tumor necrosis factor inhibitors (etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab), an interleukin (IL)-6 inhibitor (tocilizumab), an IL-1 receptor antagonist (anakinra), an anti-CD-20 antibody (rituximab), and a T cell co-stimulation modulator (abatacept). Their use during pregnancy has been controversial because of absence of controlled studies which have enrolled pregnant women. This brief overview provides published data on use of biologic agents for the treatment of rheumatic diseases in pregnancy.

Transcranial direct current electrical stimulation in combination with aerobic exercise: A pilot study in post-COVID-19 systemic autoimmune rheumatic patients

BACKGROUND

Systemic autoimmune rheumatic diseases (SARDs) are a group of diseases with multiorgan involvement and a high prevalence of chronic pain and fatigue. Patients with SARDs and post-coronavirus disease 2019 (COVID-19) syndrome experience aggravation of symptoms. In this context, it is essential to establish strategies to reduce chronic pain and fatigue and improve quality of life.

AIM

To assess the efficacy of transcranial direct current stimulation (tDCS) for the treatment of fatigue and pain-associated post-COVID-19 syndrome in patients with SARDs.

METHODS

This study included nine patients with different types of SARDs. All patients had reverse transcription-polymerase chain reaction (RT-PCR) test confirmed COVID-19 as well as significant, persistent fatigue and pain that began to worsen after infection. Anodal tDCS was administered in five daily sessions (2mA, 20 min). Concomitantly, patients were involved in aerobic exercise program. All participants were evaluated using specific questionnaires and strength assessment by handgrip and physical function by timed-up-and-go test and sit-to-stand test at baseline (within one week before tDCS protocol), and one week after tDCS protocol. During all procedures, the patients’ treatments remained unchanged.

RESULTS

The sample comprised eight women and one man with a mean age of 48.7 ± 9.6 years. After the tDCS protocol, pain and fatigue significantly improved on the visual analog scale (P < 0.05). The physical function also improved 9.5 ± 2.7 vs 6.8 ± 0.8 (P = 0.001) for timed-up-go-test and 10.3 ± 3.7 vs 15.1 ± 4.0 (P = 0.037) for sit-to-stand test. None of the patients experienced any adverse events.

CONCLUSION

The present study showed that tDCS in combination with aerobic exercise was effective in improving physical function, and reducing fatigue/pain in SARDs patients with post-COVID-19 syndrome.

Cautionary note: Electronic medical records, a potential disaster in the making?

Concern is expressed that electronic medical records may actually compromise care. Reports are electronically collated with patient charts, but when are they examined? Current electronic transmission of results to patients’ electronic medical records do not seem to notify of new information. The unknown time from prescription to patient action and the variable time required for individual test performance seem to mandate that a physician attempting to be conscientious would have to examine all sections of every patient medical record in their practice, every day. That is quite inefficient and error-prone. Electronic medical record still contains what appear to be dangerous “bugs” which compromise our ability to provide the care we believe our patients deserve? I remain unsure that outpatient electronic medical records are “ready for prime time.”

Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome as a cause of pneumothorax: A case report

BACKGROUND

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome, a rare inflammatory disease, was described in 1987 by Chamot et al, who identified its common characteristics and transitional forms through case reports. The incidence rate is now 1 in 10000 among Caucasians and 0.00144 in 10000 among Japanese. Pneumothorax occurs when gas enters the pleural cavity, typically due to lung disease or chest trauma, and is characterized as either spontaneous or traumatic. Spontaneous pneumothorax is commonly linked to congenital lung tissue abnormalities or lung conditions, such as ruptured pulmonary bullae, emphysema, and bronchial asthma. Respiratory involvement in SAPHO syndrome has historically been noted.

CASE SUMMARY

We present the case of a 44-year-old male patient who had previously been diagnosed with SAPHO syndrome. Following a two-year cessation of methotrexate therapy, he experienced recurrent anterior chest wall and joint pain accompanied by dyspnea. We conducted a comprehensive examination for the patient, which included physical examination, laboratory tests, and imaging studies. The clinical presentation and treatment outcomes suggest that his pneumothorax was related to an episode of SAPHO syndrome. We performed closed thoracic drainage surgery for the patient and treated his symptoms with etoricoxib (60 mg daily). Upon discharge, methotrexate was prescribed again. In subsequent follow-ups, there was no recurrence of joint and respiratory symptoms observed in the patient.

CONCLUSION

SAPHO syndrome has been proposed as a transitional stage between ankylosing spondylitis and psoriatic arthritis. One study reported a 0.29% incidence of spontaneous pneumothorax in patients with ankylosing spondylitis, higher than in the general population. Additionally, 30% of patients with SAPHO syndrome test positive for HLA-B27, an antigen linked to ankylosing spondylitis. Symptomatically, some patients with SAPHO syndrome meet diagnostic criteria for ankylosing spondylitis, with sternoclavicular joint involvement and paravertebral ossifications resembling syndesmophytes in ankylosing spondylitis. These features suggest a possible linked between SAPHO syndrome and ankylosing spondylitis.

Antiphospholipid syndrome in pregnancy: A comprehensive review

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by the presence of antiphospholipid antibodies and is associated with thrombotic events and pregnancy complications. The classification and management of APS has evolved over time. The classification criteria for APS include laboratory, macrovascular, microvascular, obstetric, cardiac, and hematologic domains. Management focuses on prevention of thrombotic events and/or anticoagulation as the primary treatment for thrombosis. Postpartum and long-term thromboprophylaxis after delivery are recommended to reduce the risk of thrombotic events. Despite these recommendations, optimal anticoagulation agents and intensity of treatment are still topics of debate. Further research is needed to understand the pathophysiology of APS and improve its management during pregnancy. In this review, we discuss the classification and pathophysiology of APS. Current treatment options and clinical trials are also discussed.

Physicians’ knowledge and attitude regarding bisphosphonates-related adverse events: An observational study

AIM

To assess the knowledge and attitude of Lebanese physicians regarding bisphosphonates (BPs)-related complications.

METHODS

An observational cross-sectional study was conducted at a major tertiary teaching hospital in Beirut city, and its affiliated primary health care center. Data were collected through a new self-administered questionnaire distributed via a delegated secretary to physicians expected to regularly prescribe BPs (n = 215). It assessed participants’ knowledge, fear and experience regarding BPs-reported complications.

RESULTS

One hundred and fifty-seven physicians fulfilled the questionnaire (response rate: 73.0%): 77.7% and 75.2% considered that gastrointestinal intolerance and osteonecrosis of the jaw are linked to BPs, respectively. Conversely, the least recognised complications are ocular inflammation (7.6%) and severe musculoskeletal pain (37.6%). The association of BPs with oesophageal cancer, atrial fibrillation and hepatotoxicity was reported by 11.5%, 13.4% and 24.8% of respondents, respectively. The multivariate analysis showed a significant association between level of knowledge and physicians’ department affiliation (P-value = 0.043), their gender (P-value = 0.044), whether or not they prescribe a BP (P-value = 0.012), and the number of BP prescriptions delivered monthly (P-value = 0.012). Physicians are mainly concerned about osteonecrosis of the jaw and nephrotoxicity when prescribing a BP. Yet, the complications commonly met in their practice are gastrointestinal intolerance (44.6%) and acute phase reactions (26.7%).

CONCLUSION

This study revealed the presence of a deficient knowledge regarding BPs-related adverse events among our physicians. Professional training proposals are needed to increase their knowledge and improve their practices. Pharmaceutical industries should reconsider the instructions they provide to physicians regarding the complications of medications they promote. Moreover, they must actively collaborate with education providers and institutions in educational interventions.

Pulmonary arterial hypertension associated with systemic sclerosis: Current diagnostic approach and therapeutic strategies

Pulmonary arterial hypertension (PAH) represents a devastating vascular complication of systemic sclerosis (SSc) and is found in 10%-15% of cases carrying a severe prognosis. PAH has a dramatic impact on the clinical course and overall survival, being the single most common cause of death in patients with this entity. The clinical course and aggressive progression of PAH has led clinicians to perform annual screening for it, since early detection and diagnosis are the cornerstone of a prompt therapeutic intervention. The diagnosis of PAH can be challenging to clinicians, particularly in its early stages, since in the context of SSc, the multiple causes of dyspnea need to be assessed. Doppler echocardiography represents the best initial screening tool, however, right heart catheterization remains the gold standard and definitive diagnostic means. Remarkable advances have been achieved in elucidating the pathogenesis of PAH in the past two decades, leading to the development of disease-specific targeted therapies: prostacyclin analogues, endothelin receptor antagonists and inhibitors of five phosphodiesterase pathways. However, the clinical response to these therapies in SSc-associated PAH has not been as great as the one seen with idiopathic PAH. This review also focuses on the diagnosis and novel therapies that are currently available for PAH, as well as potential future therapeutic developments based on newly acquired knowledge of diverse pathogenic mechanisms.

Roles of plasmablasts in IgG4-related disease and various immune-based diseases

IgG4-related disease (IgG4-RD) is a systemic fibro-inflammatory disease with multiple organ disorders. Recently, in IgG4-RD, increased circulating plasmablasts have been found. The subsets of plasmablasts are negative for RP105 (CD180). A large population of B cells lacking RP105 (RP105-negative B cells) are found in patients with active with systemic lupus erythematosus and other systemic autoimmune diseases, including dermatomyositis, and Sjögren’s syndrome. In other conditions, such as neuromyelitis optica, Kawasaki’s disease, primary biliary cirrhosis and aging, RP105 expression on B cells and monocytes also alters. We review the basic science and clinical significance of RP105-negative B cells including plasmablasts in various immune-based diseases. RP105-negative B cells, especially plasmablasts, play crucial roles in both systemic and organ-specific autoimmune and inflammatory disorders.

B cell depletion in scleroderma lung disease: A promising new treatment?

Evidence suggests that B cells may participate in the fibrotic process Based on this experimental evidence, treatment with rituximab (RTX) has been tried in systemic sclerosis (SSc) with promising results. In a randomized controlled study from our research group it was shown that treatment with 2 courses of RTX leads to a significant improvement of lung function at 1 year compared to baseline. All relevant studies have so far reported clinical and/or histologic improvement of skin fibrosis something that adds further evidence in favor of a disease modifying role of RTX in SSc. It is more than obvious that novel therapies for SSc-associated lung disease are needed. A large scale, randomized, controlled study assessing the efficacy of RTX in SSc associated interstitial lung disease is warranted. If RTX turns out to be effective it would be a major therapeutic advance in SSc since it can be administered on a long term basis due to its acceptable safety profile.

Pathogenetic mechanisms of antiphospholipid antibody production in antiphospholipid syndrome

Antiphospholiipid syndrome (APS) is an autoimmune disease characterized by the pathological action of antiphospholipid antibodies (aPL), that leads to recurrent pregnancy loss and thrombosis. Despite limited evidence, it is clear that there are both inherited and acquired components of the ontogeny of these antibodies. Animal genetic studies and human familial and population studies highlight the influence of genetic factors in APS, particularly human leukocyte antigen associations. Similarly, both animal and human studies have reported the importance of acquired factors in APS development and infectious agents in particular have a great impact on aPL production. Bacterial and viral agents have been implicated in the induction of autoimmune responses by various mechanisms including molecular mimicry, cryptic autoantigens exposure and apoptosis. In this review we highlight the latest updates with regards to inherited and acquired factors leading to the manufacturing of pathogenic antibodies and APS.

Return to clinical in contrast to serologically-based diagnoses

The future of rheumatology is predicated upon a return to basics. The advent and facile availability of laboratory testing led to reduction of emphasis on clinical skills. Recognition that immunologic abnormalities are not limited to individuals who clearly have related pathology provides new motivation for reorientation of training programs to assure that graduates have appropriate information gathering, diagnostic and procedural skills. Inadequate accessibility to rheumatologic care requires innovative approaches and especially training and educating those individuals who provide primary care. While the rheumatologist can elicit the patient’s history remotely, telerheumatology will be feasible only when the individual interacting physically with the patient has confidence in their examination skills and when those skills have been validated. Named syndromes or diseases will be modified to avoid impugning the individual or compromising their future access to health, disability and life insurance. Interventions will be pursued in a more cost-effective, evidence-based manner. The future of rheumatology is dependent upon the rheumatologist’s ability to amortize the inadequate reimbursement for direct patient interaction, depending on skills of interpretation of standard X-rays, ultrasound performance and results.

Osteoporosis in rheumatic diseases

Rheumatic diseases, characterized by chronic inflammation and damage to various organs and systems, include systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis and other connective tissue diseases. Bone is a target in many inflammatory rheumatic diseases. In recent years, the survival of patients with rheumatic diseases has increased markedly and the relationship between rheumatic diseases and osteoporosis (OP) has become more prominent. OP and related fragility fractures increase the morbidity and mortality of rheumatic disease. The cause of OP in rheumatic diseases is complex. The pathogenesis of OP in rheumatic diseases is multifactorial, including disease and treatment-related factors. Osteoimmunology, a crosstalk between inflammatory and bone cells, provides some insight into the pathogenesis of bone loss in systematic inflammatory diseases. The aim of this article is to review different risk factors in rheumatic diseases. Several factors play a role, such as chronic inflammation, immunological factors, traditional factors, metabolism and drug factors. Chronic inflammation is the most important risk factor and drug treatment is complex in patients with OP and rheumatic disease. Attention should be paid to bone loss in rheumatic disease. Optimal treatment of the underlying rheumatic disease is the first step towards prevention of OP and fractures. Apart from that, a healthy lifestyle is important as well as calcium and vitamin D supplementation. Bisphosphonates or denosumab might be necessary for patients with a low T score.

Hot topics in lupus pregnancy

Systemic lupus erythematosus (SLE) typically affects women in their childbearing age, who have the same fertility rates as the healthy population. The effect of pregnancy on the disease and the effect of SLE on pregnancy and the fetus are highly important issues for the attending physician. Whether lupus flares are more frequent during pregnancy remains controversial. Among the possible effects of SLE on pregnancy are a greater number of abortions, fetal loss, pre-term deliveries and perinatal mortality. The newborn may be affected by the onset of neonatal lupus erythematosus (neonatal LE), either as a skin or blood disease, or by the presence of congenital heart block. The frequent association between SLE and antiphospholipid syndrome represents another risk situation for the mother and the product of conception. Multiples drugs used in SLE patients should be evaluated. Those with teratogenic potential should be withdrawn before pregnancy, and when necessary, appropriate medications should be indicated to treat the mother without compromising the safety of the baby. In conclusion, pregnancies in lupus patients represent a challenge for the physician and must be closely followed up and treated if necessary, during all trimesters and in the puerperium period, to improve outcome.