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Ribeiro SCCR, Sales LP, Fernandes AL, Perez MO, Takayama L, Caparbo VF, Assad APL, Aiwaka NE, Goldenstein-Schainberg C, Borba EF, Domiciano DS, Figueiredo CP, Pereira RM. Bone erosions associated with systemic bone loss on HR-pQCT in women with longstanding polyarticular juvenile idiopathic arthritis. Semin Arthritis Rheum 2023; 63:152247. [PMID: 37595510 DOI: 10.1016/j.semarthrit.2023.152247] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVES To analyze longstanding polyarticular juvenile idiopathic arthritis (pJIA) for possible associations between localized bone damage (erosions), and systemic bone loss. Besides, to compare the systemic bone mass of pJIA with healthy controls. METHODS Thirty-four pJIA women and 99 healthy controls (HC) were included. Radius and tibia of all subjects were scanned by HR-pQCT. Volumetric bone mineral density (vBMD), bone microarchitecture, and -finite element parameters were analyzed. Patients underwent HR-pQCT of 2nd and 3rd metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the dominant hand, for bone erosions quantification. RESULTS The mean age of patients was 31.5 ± 7.4yrs with a mean disease duration of 21.7 ± 9.2yrs. Bone erosions were detectable in 79% of patients. The number of bone erosions was positively correlated with cortical porosity (Ct.Po) at tibia (r = 0.575, p = 0.001), and radius (r = 0.423, p = 0.018); and negatively correlated with cortical vBMD at tibia (r=-0.420, p = 0.015). In a logistic regression analysis, adjusted for anti-CCP, the presence of bone erosions was independently associated with Ct.Po at radius (p = 0.018) and cortical vBMD at tibia (p = 0.020). Moreover, cortical and trabecular vBMD, trabecular number, and μ-finite element parameters were decreased in patients compared to HC (p < 0.05). CONCLUSION Bone erosions in longstanding pJIA women were associated with decreased cortical bone parameters, and these patients showed systemic bone impairment at peripheral sites compared with healthy controls.
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Affiliation(s)
- Surian Clarisse C R Ribeiro
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Lucas P Sales
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Alan L Fernandes
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Mariana O Perez
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Liliam Takayama
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Valeria F Caparbo
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ana Paula L Assad
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Nadia E Aiwaka
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Cláudia Goldenstein-Schainberg
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eduardo F Borba
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Diogo S Domiciano
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Camille P Figueiredo
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Rosa Mr Pereira
- Bone Metabolism Laboratory, Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Charuvanij S, Malakorn H, Densupsoontorn N, Nakavachara P. Bone Mineral Density and Serum 25OHD in Children and Adolescents With Juvenile Idiopathic Arthritis. Clin Pediatr (Phila) 2022; 62:456-465. [PMID: 36366793 DOI: 10.1177/00099228221136982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Low bone mass is one of the complications of juvenile idiopathic arthritis (JIA). However, a study focusing on the low bone mass in children and adolescents with JIA in Southeast Asian countries is limited. This study aimed to evaluate the bone mineral density (BMD) of Thai patients with JIA and identify factors correlated with BMD. A cross-sectional study was conducted at a tertiary-care center. The BMD of the lumbar spines (BMDLS) and the total body (BMDTB) were measured by dual-energy X-ray absorptiometry. Thirty-eight patients were enrolled between July 2015 and January 2016. No patient had low BMDLS, and only 2 (5.3%) had low BMDTB. Serum 25-hydroxyvitamin D (25OHD) levels were significantly positively correlated with the BMDTB Z-score (coefficient: 0.047; 95% confidence interval = 0.011-0.082; P = .012). Our study demonstrated a very low prevalence of low bone mass. Optimization of the serum 25OHD level should be encouraged.
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Affiliation(s)
- Sirirat Charuvanij
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Hathaikan Malakorn
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Narumon Densupsoontorn
- Division of Nutrition, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pairunyar Nakavachara
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Di Marcello F, Di Donato G, d’Angelo DM, Breda L, Chiarelli F. Bone Health in Children with Rheumatic Disorders: Focus on Molecular Mechanisms, Diagnosis, and Management. Int J Mol Sci 2022; 23:ijms23105725. [PMID: 35628529 PMCID: PMC9143357 DOI: 10.3390/ijms23105725] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/13/2022] [Accepted: 05/19/2022] [Indexed: 02/04/2023] Open
Abstract
Bone is an extremely dynamic and adaptive tissue, whose metabolism and homeostasis is influenced by many different hormonal, mechanical, nutritional, immunological and pharmacological stimuli. Genetic factors significantly affect bone health, through their influence on bone cells function, cartilage quality, calcium and vitamin D homeostasis, sex hormone metabolism and pubertal timing. In addition, optimal nutrition and physical activity contribute to bone mass acquisition in the growing age. All these factors influence the attainment of peak bone mass, a critical determinant of bone health and fracture risk in adulthood. Secondary osteoporosis is an important issue of clinical care in children with acute and chronic diseases. Systemic autoimmune disorders, like juvenile idiopathic arthritis, can affect the skeletal system, causing reduced bone mineral density and high risk of fragility fractures during childhood. In these patients, multiple factors contribute to reduce bone strength, including systemic inflammation with elevated cytokines, reduced physical activity, malabsorption and nutritional deficiency, inadequate daily calcium and vitamin D intake, use of glucocorticoids, poor growth and pubertal delay. In juvenile arthritis, osteoporosis is more prominent at the femoral neck and radius compared to the lumbar spine. Nevertheless, vertebral fractures are an important, often asymptomatic manifestation, especially in glucocorticoid-treated patients. A standardized diagnostic approach to the musculoskeletal system, including prophylaxis, therapy and follow up, is therefore mandatory in at risk children. Here we discuss the molecular mechanisms involved in skeletal homeostasis and the influence of inflammation and chronic disease on bone metabolism.
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Kuniyil A, Pal S, Sachdev N, Yadav TP. Effect of 2-6 weeks of systemic steroids on bone mineral density in children. Clin Exp Pediatr 2022; 65:254-261. [PMID: 34793668 PMCID: PMC9082250 DOI: 10.3345/cep.2021.00045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 10/01/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The use of systemic steroids for 6+ weeks in children is associated with decreased bone mineral content (BMC) and density (BMD). However, the effects of a shorter duration of use on BMD are unknown. PURPOSE To determine the effect of the use of systemic steroids for 2-6 weeks on BMD and BMC in pediatric patients. METHODS Twenty-five pediatric patients (21 with tuberculosis, 2 with systemic juvenile idiopathic arthritis, 1 with inflammatory bowel disease, 1 with autoimmune hemolytic anemia) who received systemic steroids for 2-6 weeks and 25 age- and sexmatched controls were enrolled. BMC, BMD, and z scores of the whole body (WB), lumbar spine (LS), nondominant distal radius (DR), and total body less the head (TBLH) were determined by dual-energy x-ray absorptiometry at baseline, the end of steroid therapy or 6 weeks (whichever was earlier; first follow-up), and at the end of 3 months from baseline (second follow-up) in patients and at baseline in controls. The values were adjusted for confounding variables. Continuous and categorical variables were compared using Student t test and the chi-square test or Fisher exact test, respectively. Pairwise comparisons employed Bonferroni correction. RESULTS Statistically significant decreases in BMC, BMD, and all z scores were observed. BMC declined by 5.37%, 2.08%, 1.82%, and 2.27%, and 11.42%, 3.75%, 3.34%, and 4.17% for WB, LS, DR, and TBLH, respectively, at the first and second follow-ups, respectively. Similarly, BMD declined by 2.01%, 2.31%, 2.18%, and 1.70% and 4.59%, 3.76%, 3.14%, and 3.50% for the WB, LS, DR, and TBLH, respectively, at the first and second follow-ups, respectively. A significant negative correlation was found among bone densitometric parameters, duration, and cumulative dose. CONCLUSION The use of systemic steroids for 2-6 weeks in pediatric patients decreased the BMD and BMC of trabecular and cortical bones, an effect that persisted after discontinuation.
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Affiliation(s)
- Athira Kuniyil
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Somdipa Pal
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Namrita Sachdev
- Department of Radiodiagnosis, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Tribhuvan Pal Yadav
- Department of Pediatrics, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
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Abstract
Arthritis is a common condition affecting millions of people in the UK and worldwide. All members of the dental team will be seeing and treating patients with this condition, and it is important to understand the disease, its management and medications used. This article outlines the five most common types of arthritis: osteoarthritis (OA), rheumatoid arthritis (RA), axial spondyloarthritis (sPA), juvenile idiopathic arthritis (JIA), and gout. It further discusses the medications used to treat these conditions and any dental implications. Finally, advice is offered on considerations for the dental team when treating such patients.
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Affiliation(s)
| | - Matthew Chia
- Consultant Orthodontist, Clinical Lead Orthodontics & Restorative Dentistry, Croydon University Hospital, London, UK
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Diaz-Cordovés Rego G, Núñez-Cuadros E, Mena-Vázquez N, Aguado Henche S, Galindo-Zavala R, Manrique-Arija S, Martín-Pedraz L, Redondo-Rodríguez R, Godoy-Navarrete FJ, Fernández-Nebro A. Adiposity Is Related to Inflammatory Disease Activity in Juvenile Idiopathic Arthritis. J Clin Med 2021; 10:jcm10173949. [PMID: 34501396 PMCID: PMC8432058 DOI: 10.3390/jcm10173949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To identify factors associated with the higher proportion of fatty tissue and overweight/obesity observed in patients with juvenile idiopathic arthritis (JIA). PATIENTS AND METHODS We performed a cross-sectional study of 80 JIA patients aged 4-15 years with 80 age- and sex-matched healthy controls. Body composition was assessed using dual-energy x-ray absorptiometry. The 27-joint Juvenile Arthritis Disease Activity score (JADAS27) was calculated. Two multivariate models were constructed to identify factors associated with overweight/obesity and fat mass index (FMI). RESULTS No differences were found between cases and controls in body mass index (BMI) or body composition. However, compared with controls, patients with a high inflammatory activity (JADAS27 > 4.2 for oligoarticular JIA or >8.5 for polyarticular disease) had higher values for BMI (p = 0.006); total fat mass (p = 0.003); FMI (p = 0.001); and fat in the legs (p = 0.001), trunk (p = 0.001), and arms (p = 0.002). The factors associated with overweight/obesity in patients were the duration of therapy with biological drugs, measured in months (OR [95% CI] = 1.12 [1.02-1.04]; p = 0.037), and physical activity (OR [95% CI] = 0.214 [0.07-0.68]; p = 0.010), while the factors associated with FMI were age (β [95% CI] = 0.30 [0.17-1.41]; p = 0.014), JADAS27 (β [95% CI] = 0.45 [0.16-1.08]; p = 0.009), and physical activity (β [95% CI] = -0.22 [-5.76 to 0.29]; p = 0.031). CONCLUSION Our study revealed no differences between JIA patients with well-controlled disease and low disability and the healthy population in BMI or body composition. Furthermore, the association observed between inflammatory activity and adiposity could be responsible for poorer clinical course.
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Affiliation(s)
- Gisela Diaz-Cordovés Rego
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (G.D.-C.R.); (S.M.-A.); (R.R.-R.); (F.J.G.-N.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Esmeralda Núñez-Cuadros
- UGC de Pediatría, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain; (E.N.-C.); (R.G.-Z.); (L.M.-P.)
| | - Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (G.D.-C.R.); (S.M.-A.); (R.R.-R.); (F.J.G.-N.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Correspondence: ; Tel.: +34-952-290-360
| | - Soledad Aguado Henche
- Departamento de Anatomía y Embriología Humana, Facultad de Medicina, Universidad de Alcalá de Henares, 29009 Madrid, Spain;
| | - Rocío Galindo-Zavala
- UGC de Pediatría, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain; (E.N.-C.); (R.G.-Z.); (L.M.-P.)
| | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (G.D.-C.R.); (S.M.-A.); (R.R.-R.); (F.J.G.-N.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Laura Martín-Pedraz
- UGC de Pediatría, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain; (E.N.-C.); (R.G.-Z.); (L.M.-P.)
| | - Rocio Redondo-Rodríguez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (G.D.-C.R.); (S.M.-A.); (R.R.-R.); (F.J.G.-N.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Francisco Javier Godoy-Navarrete
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (G.D.-C.R.); (S.M.-A.); (R.R.-R.); (F.J.G.-N.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (G.D.-C.R.); (S.M.-A.); (R.R.-R.); (F.J.G.-N.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, 29010 Málaga, Spain
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Marstein HS, Godang K, Flatø B, Sjaastad I, Bollerslev J, Sanner H. Bone mineral density and explanatory factors in children and adults with juvenile dermatomyositis at long term follow-up; a cross sectional study. Pediatr Rheumatol Online J 2021; 19:56. [PMID: 33902632 PMCID: PMC8077908 DOI: 10.1186/s12969-021-00543-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/14/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is the most common idiopathic inflammatory myopathy in children and adolescents. Both the disease and its treatment with glucocorticoids may negatively impact bone formation. In this study we compare BMD in patients (children/adolescence and adults) with long-standing JDM with matched controls; and in patients, explore how general/disease characteristics and bone turnover markers are associated with BMD. METHODS JDM patients (n = 59) were examined median 16.8y (range 6.6-27.0y) after disease onset and compared with 59 age/sex-matched controls. Dual-energy X-ray absorptiometry (DXA) was used to measure BMD of the whole body and lumbar spine (spine) in all participants, and of ultra-distal radius, forearm and total hip in participants ≥20y only. Markers of bone turnover were analysed, and associations with outcomes explored. RESULTS Reduced BMD Z-scores (<-1SD) were found in 19 and 29% of patients and 7 and 9% of controls in whole body and spine, respectively (p-values < 0.05). BMD and BMD Z-scores for whole body and spine were lower in all patients and for < 20y compared with their respective controls. In participants ≥20y, only BMD and BMD Z-score of forearm were lower in the patients versus controls. In patients, BMD Z-scores for whole body and/or spine were found to correlate negatively with prednisolone use at follow-up (yes/no) (age < 20y), inflammatory markers (age ≥ 20y) and levels of interferon gamma-induced protein 10 (IP-10) (both age groups). In all patients, prednisolone use at follow-up (yes/no) and age ≥ 20y were independent correlates of lower BMD Z-scores for whole body and spine, respectively. CONCLUSION In long-term JDM, children have more impairment of BMD than adults in spine and whole-body. Associations with BMD were found for both prednisolone and inflammatory markers, and a novel association was discovered with the biomarker of JDM activity, IP-10.
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Affiliation(s)
- Henriette Schermacher Marstein
- Institute for Experimental Medical Research and KG Jebsen Center for Cardiac Research, University of Oslo and Oslo University Hospital, Ullevål, 0027, Oslo, Norway. .,Bjørknes University College, Oslo, Norway.
| | - Kristin Godang
- grid.55325.340000 0004 0389 8485Section of Specialized Endocrinology, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Medical Clinic, Oslo University Hospital, Oslo, Norway
| | - Berit Flatø
- grid.5510.10000 0004 1936 8921Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Ivar Sjaastad
- grid.5510.10000 0004 1936 8921Institute for Experimental Medical Research and KG Jebsen Center for Cardiac Research, University of Oslo and Oslo University Hospital, Ullevål, 0027 Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Jens Bollerslev
- grid.55325.340000 0004 0389 8485Section of Specialized Endocrinology, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Medical Clinic, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute for Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Helga Sanner
- grid.510411.00000 0004 0578 6882Bjørknes University College, Oslo, Norway ,grid.55325.340000 0004 0389 8485Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Galindo-Zavala R, Bou-Torrent R, Magallares-López B, Mir-Perelló C, Palmou-Fontana N, Sevilla-Pérez B, Medrano-San Ildefonso M, González-Fernández MI, Román-Pascual A, Alcañiz-Rodríguez P, Nieto-Gonzalez JC, López-Corbeto M, Graña-Gil J. Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children. Pediatr Rheumatol Online J 2020; 18:20. [PMID: 32093703 PMCID: PMC7041118 DOI: 10.1186/s12969-020-0411-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis incidence in children is increasing due to the increased survival rate of patients suffering from chronic diseases and the increased use of drugs that can damage bones. Recent changes made to the definition of childhood osteoporosis, along with the lack of guidelines or national consensuses regarding its diagnosis and treatment, have resulted in a wide variability in the approaches used to treat this disease. For these reasons, the Osteogenesis Imperfecta and Childhood Osteoporosis Working Group of the Spanish Society of Pediatric Rheumatology has sounded the need for developing guidelines to standardize clinical practice with regard to this pathology. METHODS An expert panel comprised of 6 pediatricians and 5 rheumatologists carried out a qualitative literature review and provided recommendations based on evidence, when that was available, or on their own experience. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A Delphi survey was conducted for those recommendations with an evidence level of IV or V. This survey was sent to all members of the SERPE. All recommendations that had a level of agreement higher or equal to 70% were included. RESULTS Fifty-one recommendations, categorized into eight sections, were obtained. Twenty-four of them presented an evidence level 4 or 5, and therefore a Delphi survey was conducted. This was submitted electronically and received a response rate of 40%. All recommendations submitted to the Delphi round obtained a level of agreement of 70% or higher and were therefore accepted. CONCLUSION In summary, we present herein guidelines for the prevention, diagnosis and treatment of secondary childhood osteoporosis based on the available evidence and expert clinical experience. We believe it can serve as a useful tool that will contribute to the standardization of clinical practice for this pathology. Prophylactic measures, early diagnosis and a proper therapeutic approach are essential to improving bone health, not only in children and adolescents, but also in the adults they will become in the future.
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Affiliation(s)
- Rocío Galindo-Zavala
- UGC Pediatría. Sección Reumatología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - Rosa Bou-Torrent
- 0000 0001 0663 8628grid.411160.3Unidad de Reumatología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Berta Magallares-López
- 0000 0004 1768 8905grid.413396.aServicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Concepción Mir-Perelló
- 0000 0004 1796 5984grid.411164.7Unidad de Pediatría, Sección Reumatología Pediátrica, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Natalia Palmou-Fontana
- 0000 0001 0627 4262grid.411325.0Unidad de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Belén Sevilla-Pérez
- UGC Pediatría, Sección Reumatología Pediátrica, Hospital Campus de la Salud, Granada, Spain
| | | | - Mª. Isabel González-Fernández
- 0000 0001 0360 9602grid.84393.35Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital La Fe, Valencia, Spain
| | | | - Paula Alcañiz-Rodríguez
- Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital Virgen de la Arriaxaca, Murcia, Spain
| | - Juan Carlos Nieto-Gonzalez
- 0000 0001 0277 7938grid.410526.4Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mireia López-Corbeto
- 0000 0001 0675 8654grid.411083.fServicio de Reumatología Hospital Vall d’Hebron, Barcelona, Spain
| | - Jenaro Graña-Gil
- 0000 0004 1771 0279grid.411066.4Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain ,Osteogenesis Imperfecta and Secondary Osteoporosis Working Group from the Spanish Pediatric Rheumatology Society, Madrid, Spain
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Skeie MS, Gil EG, Cetrelli L, Rosén A, Fischer J, Åstrøm AN, Luukko K, Shi X, Feuerherm AJ, Sen A, Frid P, Rygg M, Bletsa A. Oral health in children and adolescents with juvenile idiopathic arthritis - a systematic review and meta-analysis. BMC Oral Health 2019; 19:285. [PMID: 31856793 PMCID: PMC6921440 DOI: 10.1186/s12903-019-0965-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/21/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Observational studies examining the association between oral health and juvenile idiopathic arthritis (JIA) among children and adolescents have reported inconsistent findings. The aims of this systematic review and meta-analysis were to ascertain a potential difference in oral health and oral health-related quality of life (OHRQoL) among children and adolescents with JIA and healthy peers, and to assess the association of prevalence of oral diseases/conditions, temporomandibular disorders (TMD), including temporomandibular joint (TMJ) diseases, in relation to activity and severity of JIA. METHOD Medline Ovid, Embase, CINAHL, SweMed+ and Cochrane Library were searched up to 25 November 2018. All articles published in English, German and Scandinavian languages focusing on children and adolescents with JIA and without JIA in relation to oral health measures, were considered. Two authors independently evaluated observational studies for inclusion. The study quality was assessed using modified Newcastle Ottawa Scale. Meta-analysis was performed for studies focusing on dental caries as an outcome. RESULTS Nineteen articles met the inclusion criteria, covering a range of oral diseases/conditions and OHRQoL. Eighteen studies had cross-sectional design. No mean difference of dmft/DMFT indices (decayed/missed/filled teeth) was observed between the JIA - and healthy group. None of the oral health measures including dental erosive wear, enamel defects, dental maturation and OHRQoL, indicated better oral health among children and adolescents with JIA compared to healthy group. However, periodontal conditions and TMD were more predominant among children and adolescents with JIA compared to healthy peers. CONCLUSIONS Based on the cross-sectional studies, periodontal diseases and TMD were found to be more frequent in children and adolescents with JIA compared to healthy peers. Furthermore, more high-quality studies with large sample size are needed before we infer any concrete conclusion regarding the association between the prevalence of oral and TMJ diseases or oral conditions in relation to activity and severity of JIA.
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Affiliation(s)
- Marit S Skeie
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway.
- Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway.
| | - Elisabeth G Gil
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway
| | - Lena Cetrelli
- Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway
| | - Annika Rosén
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway
- Department of Oral and Maxillofacial Surgery, Haukeland University Hospital, Bergen, Norway
| | - Johannes Fischer
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway
| | - Anne Nordrehaug Åstrøm
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway
| | - Keijo Luukko
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway
| | - Xieqi Shi
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway
- Section of Oral Diagnostics and Surgery, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Astrid J Feuerherm
- Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway
| | - Abhijit Sen
- Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway
- Department of Public health and Nursing, Faculty of Medical and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Paula Frid
- Public Dental Health Service Competence Centre of Northern Norway (TkNN), Tromso, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT, The Arctic University of Norway, Tromso, Norway
- Department of Otorhinolaryngology, Division of Oral and Maxillofacial Surgery, University Hospital North, Tromso, Norway
| | - Marite Rygg
- Department of Clinical and Molecular Medicine, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pediatrics, St. Olavs Hospital, Trondheim, Norway
| | - Athanasia Bletsa
- Department of Clinical Dentistry, Pediatric Dentistry, The Faculty of Medicine, University of Bergen, Norway, Årstadveien 19, N-5009, Bergen, Norway
- Oral Health Centre of Expertise in Western Norway- Hordaland, Trondheim, Norway
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Abstract
PURPOSE OF REVIEW To summarize the literature regarding alterations in bone health in patients with glomerular kidney disease and highlight areas in need of additional investigation. RECENT FINDINGS There is mounting evidence that children and adults with glomerular conditions, with or without compromised kidney function, comprise a distinct subgroup of patients with unique risk factors for altered bone health. Patients with glomerular kidney disease are exposed to both disease-related and treatment-related factors that affect bone structure and function. In addition to chronic kidney disease-related risk factors for impaired bone health, high rates of exposure to osteotoxic medications, varying degrees of systemic inflammation, and altered vitamin D metabolism may contribute to compromised bone health in individuals with glomerular disease. Further study is needed to better understand these risk factors and the complex interaction between the immune system and bone cells in glomerular disease.
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Affiliation(s)
- Dorey A Glenn
- UNC Kidney Center, Universirty of North Carolina at Chapel Hill, 7024 Burnett Womack Building, Chapell Hill, NC, 27599-7155, USA
| | - Michelle R Denburg
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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No radiographic wrist damage after treatment to target in recent-onset juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2019; 17:62. [PMID: 31484539 PMCID: PMC6727344 DOI: 10.1186/s12969-019-0362-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/09/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND To evaluate radiographic progression of patients with new-onset juvenile idiopathic arthritis (JIA) in response to an early, tightly-controlled, treatment-to-target. METHODS Patients with JIA participating in the BeSt-for-Kids-study, randomized to 3 treatment strategy arms, were eligible if at least 1 conventional wrist-radiograph was available. Bone damage as reflected by carpal length was assessed using the Poznanski-score. The BoneXpert-method was used to determine the Bone Age (BA, > 5 years) and bone mineral density (BMD) of the wrist. These scores were evaluated over time and compared between the treatment arms and mean JADAS10-score using linear mixed models corrected for age and symptom duration. RESULTS In 60 patients, 252 radiographs were analysed. Baseline age and symptom duration were different between the arms. No difference in comparison to the healthy reference population was found at baseline for the Poznanski-score (IQR varying from - 0,82; 0.68), nor for BA (varying from - 0.88 to 0.74). Baseline BMD was statistically significantly lower in arm 3 (initial treatment with etanercept and methotrexate) (- 1.48; - 0.68) compared to arm 1 (- 0.84; - 0.04) and arm 2 (- 0.93; 0.15). After treatment to target inactive disease, the Poznanski-scores and the BA remained clinically unchanged, while the BMD in arm 3 improved (p < 0.05 vs arm 1). CONCLUSIONS Recent-onset JIA patients, treated-to-target aimed at inactive disease, showed no signs of radiographic wrist damage (Poznanski-score, BA or BMD) either at baseline or at follow-up, irrespective of treatment arm. A lower BMD at baseline in arm 3, initially treated with methotrexate and etanercept, improved significantly after treatment. TRIAL REGISTRATION NTR, NL1504 (NTR1574). Registered 01-06-2009.
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Shin J, Kang MJ, Kim KN. Prevalence of Lower Bone Mineral Density and Its Associated Factors in Korean Children and Adolescents with Juvenile Idiopathic Arthritis. JOURNAL OF RHEUMATIC DISEASES 2018. [DOI: 10.4078/jrd.2018.25.4.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- JinShik Shin
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Min Jae Kang
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Kwang Nam Kim
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Anyang, Korea
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13
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Abstract
Bone health in children with rheumatic conditions may be compromised due to several factors related to the inflammatory disease state, delayed puberty, altered life style, including decreased physical activities, sun avoidance, suboptimal calcium and vitamin D intake, and medical treatments, mainly glucocorticoids and possibly some disease-modifying anti-rheumatic drugs. Low bone density or even fragility fractures could be asymptomatic; therefore, children with diseases of high inflammatory load, such as systemic onset juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, and those requiring chronic glucocorticoids may benefit from routine screening of bone health. Most commonly used assessment tools are laboratory testing including serum 25-OH-vitamin D measurement and bone mineral density measurement by a variety of methods, dual-energy X-ray absorptiometry as the most widely used. Early disease control, use of steroid-sparing medications such as disease-modifying anti-rheumatic drugs and biologics, supplemental vitamin D and calcium, and promotion of weight-bearing physical activities can help optimize bone health. Additional treatment options for osteoporosis such as bisphosphonates are still controversial in children with chronic rheumatic diseases, especially those with decreased bone density without fragility fractures. This article reviews common risk factors leading to compromised bone health in children with chronic rheumatic diseases and discusses the general approach to prevention and treatment of bone fragility.
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Huber AM, Ward LM. The impact of underlying disease on fracture risk and bone mineral density in children with rheumatic disorders: A review of current literature. Semin Arthritis Rheum 2016; 46:49-63. [PMID: 27020068 DOI: 10.1016/j.semarthrit.2016.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/16/2015] [Accepted: 02/20/2016] [Indexed: 11/17/2022]
Abstract
Childhood rheumatic diseases are associated with negative impacts on the skeleton, related to both the underlying illness and complications of therapy. The effects of medications like corticosteroids are well recognized, leading to reductions in bone mineral density and bone strength and concomitant increases in bone fragility and fracture risk. The impact of factors directly attributable to the underlying disease is not as well recognized. In this article, we review relevant literature to identify data which can contribute to an understanding of the impact of childhood rheumatic disease on the skeleton. We conclude that childhood rheumatic diseases are associated with reductions in bone mineral density and increased risk of vertebral and non-vertebral fractures. These data are strongest for juvenile arthritis, while conclusions are more limited for other rheumatic illnesses, like juvenile systemic lupus erythematosus or juvenile dermatomyositis, due to small numbers of patients studied. Finally, we make recommendations for areas in need of further research. These include the need for long-term longitudinal studies and for data to be collected in patients who have not been treated with corticosteroids.
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Affiliation(s)
- Adam M Huber
- Division of Pediatric Rheumatology, IWK Health Centre and Dalhousie University, 5850 University Ave, Halifax, Nova Scotia, Canada B3K 6R8.
| | - Leanne M Ward
- Division of Pediatric Endocrinology, Children׳s Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
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15
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Hinze C, Gohar F, Foell D. Management of juvenile idiopathic arthritis: hitting the target. Nat Rev Rheumatol 2015; 11:290-300. [DOI: 10.1038/nrrheum.2014.212] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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16
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Brabnikova-Maresova K, Jarosova K, Pavelka K, Stepan JJ. Serum sclerostin in high-activity adult patients with juvenile idiopathic arthritis. Arthritis Res Ther 2014; 16:460. [PMID: 25280749 PMCID: PMC4236454 DOI: 10.1186/s13075-014-0460-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/19/2014] [Indexed: 12/18/2022] Open
Abstract
Introduction Juvenile idiopathic arthritis (JIA) is a disease associated with loss of bone mass, deterioration in bone mass quality and an increased risk of fractures. The objective of this study was to evaluate factors that predict bone mineral density (BMD) alterations in young adult patients with active JIA before and during therapy with tumour necrosis factor α (TNFα) inhibitors. Methods Thirty-one patients (twelve males and nineteen females; mean age =25.1 ± 6.1 years) with active JIA (mean Disease Activity Score in 28 joints (DAS28) =6.36 ± 0.64; mean high-sensitivity C-reactive protein (hsCRP) =18.36 ± 16.95 mg/L) were investigated. The control group consisted of 84 healthy individuals matched by sex and age. BMD, bone turnover markers and serum concentrations of soluble receptor activator of nuclear factor κB ligand, osteoprotegerin, dickkopf Wnt signalling pathway inhibitor 1 (Dkk1) and sclerostin were evaluated. Results Baseline BMD values in the lumbar spine, proximal femur, femoral neck and distal radius were significantly lower in patients with JIA compared to healthy control participants. Baseline sclerostin serum concentrations were significantly higher in patients with JIA compared to control participants. After 2 years of treatment with TNFα inhibitors, BMD was significantly increased in the lumbar spine. This increase correlated with a drop in DAS28 score. A statistically significant correlation between hsCRP and Dkk1 was found at baseline, as well as during the 2-year follow-up period. A significant reduction in serum sclerostin after 1 year of therapy was predictive of a drop in DAS28 score observed with a 1-year delay after reduction of serum sclerostin. Conclusion A significant correlation between the sclerostin serum concentration and the number of tender and swollen joints, but not BMD, supports the hypothesis that chondrocytes and cells of the subchondral bone may contribute to circulating sclerostin in JIA.
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Abstract of the 35th Scandinavian Congress of Rheumatology, September 20-23, 2014, Stockholm, Sweden. Scand J Rheumatol 2014:1-97. [PMID: 25184497 DOI: 10.3109/03009742.2014.946235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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von Scheven E, Corbin KJ, Stagi S, Cimaz R. Glucocorticoid-associated osteoporosis in chronic inflammatory diseases: epidemiology, mechanisms, diagnosis, and treatment. Curr Osteoporos Rep 2014; 12:289-99. [PMID: 25001898 DOI: 10.1007/s11914-014-0228-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Children with chronic illnesses such as Juvenile Idiopathic Arthritis and Crohn's disease, particularly when taking glucocorticoids, are at significant risk for bone fragility. Furthermore, when childhood illness interferes with achieving normal peak bone mass, life-long fracture risk is increased. Osteopenia and osteoporosis, which is increasingly recognized in pediatric chronic disease, likely results from numerous disease- and treatment-related factors, including glucocorticoid exposure. Diagnosing osteoporosis in childhood is complicated by the limitations of current noninvasive techniques such as DXA, which despite its limitations remains the gold standard. The risk:benefit ratio of treatment is confounded by the potential for spontaneous restitution of bone mass deficits and reshaping of previously fractured vertebral bodies. Bisphosphonates have been used to treat secondary osteoporosis in children, but limited experience and potential long-term toxicity warrant caution in routine use. This article reviews the factors that influence loss of normal bone strength and evidence for effective treatments, in particular in patients with gastrointestinal and rheumatologic disorders who are receiving chronic glucocorticoid therapy.
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Affiliation(s)
- Emily von Scheven
- Pediatric Rheumatology, University of California, San Francisco, 505 Parnassus Avenue, Box 0105, San Francisco, CA, 94143, USA,
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Brabnikova Maresova K, Jarosova K, Pavelka K, Stepan JJ. The association between lean mass and bone mineral content in the high disease activity group of adult patients with juvenile idiopathic arthritis. BMC Musculoskelet Disord 2014; 15:51. [PMID: 24558956 PMCID: PMC3974111 DOI: 10.1186/1471-2474-15-51] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 02/12/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The study is aimed to evaluate body composition and bone status in adolescent and adult patients with active juvenile idiopathic arthritis (JIA) untreated with tumor necrosis factor alpha inhibitors. METHODS Adult patients (12 male and 19 female) with active JIA and 84 healthy age- and gender- matched controls were enrolled into the study. Body composition (tissue mass in grams, lean mass, fat mass and bone mineral content as a fraction of tissue mass) and areal bone mineral density parameters (aBMD) at the lumbar spine, proximal femur, femoral neck, distal radius and total body were assessed using dual energy x-ray absorptiometry (DXA), and correlated with clinical characteristics of the disease and physical performance tests. Disease activity was assessed using high-sensitivity C-reactive protein (hsCRP) and disease activity score 28 (DAS 28). Differences between the groups were tested by t-test, and One-way ANOVA. Correlations were assessed using the Pearson correlation coefficients and multiple linear regression analysis. Significances were counted at the 0.05 level. RESULTS In patients with clinically active JIA (DAS 28, 6.36 ± 0.64, hsCRP, 18.36 ± 16.95 mg/l), aBMD at all measured sites, bone mineral content (BMC) and lean mass were reduced, and fat mass was increased as compared with healthy controls. Significant negative correlations were observed between BMC and disease duration, use of glucocorticoids (GCs), and fat mass, respectively. A positive correlation was found between BMC and lean mass, and between the body fat fraction and the use of GCs. Using multiple linear regression analysis, lean mass was the only significant predictor of BMC of total body both in men and women, and of BMC of legs (only in men). Lean mass was also the only predicting factor of total proximal femur BMD and femoral neck BMD. No significant correlations have been determined among the body composition parameters and DAS 28 or hsCRP endpoints. CONCLUSIONS In adult patients with long-term active JIA, lean mass was the main determining factor of total body and leg BMC, and total proximal femur and femoral neck aBMD.
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Bone status in adults with early-onset juvenile idiopathic arthritis following 1-year anti-TNFα therapy and discontinuation of glucocorticoids. Rheumatol Int 2013; 33:2001-7. [DOI: 10.1007/s00296-013-2678-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 01/16/2013] [Indexed: 10/27/2022]
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21
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Long-Term Bone Health in Glucocorticoid-Treated Children with Rheumatic Diseases. Curr Rheumatol Rep 2013; 15:315. [DOI: 10.1007/s11926-012-0315-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Smith EMD, Foster HE, Beresford MW. Adding to complexity: comorbidity in paediatric rheumatic disease. Rheumatology (Oxford) 2012; 52:22-33. [PMID: 23024018 DOI: 10.1093/rheumatology/kes256] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Novel therapies including biologic agents offer paediatric rheumatologists significant opportunity to improve long-term prognosis for children with rheumatic disease. However, comorbidities related to the diseases themselves and their treatments pose specific challenges to be overcome. Prompt recognition and appropriate management will improve quality of life, effectiveness of treatment and overall prognosis. In this review, we discuss key areas of comorbidity frequently encountered in paediatric rheumatology including cardiovascular, renal, genito-urinary and visual comorbidity, bone health, drug-related issues and the influence of rheumatic disease on growth and puberty.
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Affiliation(s)
- Eve M D Smith
- Paediatric Rheumatology, Great North Children's Hospital, Queen Victoria Road, Newcastle Upon Tyne NE1 4LP, UK.
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Abstract
Early juvenile idiopathic arthritis (JIA) is important to recognize as timely diagnosis and treatment improves prognosis. It is a misconception that complications of JIA arise only from long-standing disease and that children will outgrow it. Early aggressive treatment is the paradigm as early disease activity has long-term consequences. There are predictors of persistent disease and joint erosions that may identify patients at higher risk. Control of disease activity within the first 6 months of onset confers improved clinical course and outcomes. The treatment perspective is thus one of early aggressive treatment for induction of disease control and ultimately remission.
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Rodd C, Lang B, Ramsay T, Alos N, Huber AM, Cabral DA, Scuccimarri R, Miettunen PM, Roth J, Atkinson SA, Couch R, Cummings EA, Dent PB, Ellsworth J, Hay J, Houghton K, Jurencak R, Larché M, LeBlanc C, Oen K, Saint-Cyr C, Stein R, Stephure D, Taback S, Lentle B, Matzinger M, Shenouda N, Moher D, Rauch F, Siminoski K, Ward LM. Incident vertebral fractures among children with rheumatic disorders 12 months after glucocorticoid initiation: a national observational study. Arthritis Care Res (Hoboken) 2012; 64:122-31. [PMID: 22213727 DOI: 10.1002/acr.20589] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency of incident vertebral fractures (IVF) 12 months after glucocorticoid (GC) initiation in children with rheumatic diseases and to identify children at higher risk. METHODS Children with rheumatic diseases initiating GC were enrolled in a prospective observational study. Annual spine radiographs were evaluated using the Genant semiquantitative method. Spine areal bone mineral density (aBMD) was measured every 6 months. Clinical features, including cumulative GC dose, back pain, disease and physical activity, calcium and vitamin D intake, and spine aBMD Z scores, were analyzed for association with IVF. RESULTS Seven (6%) of 118 children (95% confidence interval 2.9-11.7%) had IVF. Their diagnoses were: juvenile dermatomyositis (n = 2), systemic lupus erythematosus (n = 3), systemic vasculitis (n = 1), and mixed connective tissue disease (n = 1). One child was omitted from the analyses after 4 months because of osteoporosis treatment for symptomatic IVF. Children with IVF received on average 50% more GC than those without (P = 0.030), had a greater increase in body mass index (BMI) at 6 months (P = 0.010), and had greater decrements in spine aBMD Z scores in the first 6 months (P = 0.048). Four (67%) of 6 children with IVF and data to 12 months had spine aBMD Z scores less than -2.0 at 12 months compared to 16% of children without IVF (P = 0.011). CONCLUSION The incidence of VF 12 months following GC initiation was 6%; most children were asymptomatic. Children with IVF received more GC, had greater increases in BMI, and had greater declines in spine aBMD Z scores in the first 6 months.
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Affiliation(s)
- Celia Rodd
- McGill University, Montreal, Quebec, Canada
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Markula-Patjas KP, Valta HL, Kerttula LI, Soini IH, Honkanen VEA, Toiviainen-Salo SM, Mäkitie OM. Prevalence of vertebral compression fractures and associated factors in children and adolescents with severe juvenile idiopathic arthritis. J Rheumatol 2011; 39:365-73. [PMID: 22133619 DOI: 10.3899/jrheum.110305] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Vertebral fractures occur in patients with juvenile idiopathic arthritis (JIA), but data on their frequency and causes are scarce. Our cross-sectional study evaluated prevalence of compression fractures and associated factors in a high-risk pediatric population with severe JIA. METHODS Children and adolescents with a history of treatment-resistant polyarticular-course JIA for ≥ 5 years or systemic arthritis for ≥ 3 years were recruited. Clinical examination, dietary recall, laboratory measurements, bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry, and spinal radiography were performed. RESULTS Our study included 50 patients (41 girls), of whom 6 (12%) had systemic arthritis, with a median age of 14.8 years (range 7.0-18.7 yrs) and median disease duration of 10.2 years (range 3.9-16.8 years). Ninety-four percent had used systemic glucocorticoids (GC); the median total duration of GC treatment was 7.1 years (range 0-15.5 yrs). The median weight-adjusted cumulative GC dose for the preceding 3 years was 72 mg/kg (range 0-911 mg/kg). The median bone age-corrected lumbar spine and whole-body areal BMD Z-scores were -0.8 and -1.0, respectively. Twenty-two percent had vertebral fractures, mostly thoracic. Compression fractures were associated with high disease activity, high body mass index (BMI), and high recent cumulative GC dose, but not with disease duration or BMD. Thirty percent had sustained at least 1 peripheral low energy fracture. Twenty-six percent were deemed to have significantly compromised bone health. CONCLUSION Severe JIA is associated with a significant risk of vertebral compression fractures. Associated factors include high disease activity, high BMI, and high recent GC exposure. Further studies are needed to establish optimal prevention and treatment guidelines.
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Bechtold-Dalla Pozza S. [Bone density measurements on growing skeletons and the clinical consequences]. Z Rheumatol 2011; 70:844-52. [PMID: 21989975 DOI: 10.1007/s00393-011-0803-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The measurement of bone mineral density (BMD) was established to judge the fracture risk in an individual. The most commonly used densitometric technique DXA is a two-dimensional method and reports BMD (bone mass/projection area), which increases during growth. Bone mineral density (in g/cm(3)), however, is almost stable and does not change with age or height. To analyze the data special pediatric references including data on age, sex and ethnicity are necessary as well as correction for height. Bone forms a unit with muscle. Bone responds to mechanical loading with increase in bone size and therefore adapts to the biomechanical needs. Therefore, interpretation of bone development data requires data on muscle development.The indication for bone mineral density measurement and result reporting should be made by and together with a pediatric specialist. The diagnosis of osteoporosis should not be made based solely on densitometric measurements. History of low trauma fracture is an important aspect for the definition. Besides DXA there exist further methods with advantages and disadvantages.
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Affiliation(s)
- S Bechtold-Dalla Pozza
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität München, München, Deutschland.
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Alkady EA, Rashad SM, Khedr TM, Mosad E, Abdel-Wahab N. Early predictors of increased bone resorption in juvenile idiopathic arthritis: OPG/RANKL ratio, as a key regulator of bone metabolism. EGYPTIAN RHEUMATOLOGIST 2011. [DOI: 10.1016/j.ejr.2011.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Thornton J, Pye SR, O'Neill TW, Rawlings D, Francis RM, Symmons DPM, Ashcroft DM, Foster HE. Bone health in adult men and women with a history of juvenile idiopathic arthritis. J Rheumatol 2011; 38:1689-93. [PMID: 21677004 DOI: 10.3899/jrheum.101232] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our aim was to determine areal bone mineral density (BMD(a)) and disease-related factors linked with BMD(a) in adults with a history of juvenile idiopathic arthritis (JIA). METHODS Men and women with a history of JIA attending a young adult rheumatology clinic in Newcastle, UK, underwent dual energy x-ray absorptiometry (DEXA) of the lumbar spine and total hip. Information was obtained about disease duration and subtype, previous treatment including corticosteroid and methotrexate therapy, and large-joint replacement. Subjects completed the modified Health Assessment Questionnaire (HAQ). Blood was taken for assessment of C-reactive protein, erythrocyte sedimentation rate, and rheumatoid factor (RF). RESULTS Seventy-one women and 16 men, mean age 28.7 and 31.4 years, and mean disease duration 20.6 and 24.0 years, respectively, were studied. Mean BMD(a) was 0.982 (Z-score = -0.328; 95% CI -0.657, 0.001) and 1.028 g/cm(2) (Z-score = -0.251; 95% CI -1.266, 0.764) in women and men, respectively, at the spine and 0.817 (Z-score = -0.542; 95% CI -0.975, -0.109) and 0.857 g/cm(2) (Z-score = -0.176; 95% CI -2.323, 1.971) at the hip. After adjusting for age and sex, increasing HAQ score was associated with both lower spine BMD(a) and hip BMD(a). Compared with patients with oligoarticular disease, those with enthesitis-related arthritis had higher BMD(a) at the spine, while those with extended oligoarticular and polyarticular RF-negative disease had lower hip BMD(a). Oral corticosteroids and the presence of a large-joint replacement were associated with lower BMD(a) at both the spine and hip. CONCLUSION There was a trend toward low BMD(a) in women with a history of JIA. These patients may be at risk of the complications of osteoporosis including fragility fractures and should be considered for targeted preventive measures.
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Affiliation(s)
- Judith Thornton
- Arthritis Research UK Epidemiology Unit, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Malviya A, Walker LC, Avery P, Osborne S, Weir DJ, Foster HE, Deehan DJ. The long-term outcome of hip replacement in adults with juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2011; 93:443-8. [DOI: 10.1302/0301-620x.93b4.26078] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is a chronic disease of childhood; it causes joint damage which may require surgical intervention, often in the young adult. The aim of this study was to describe the long-term outcome and survival of hip replacement in a group of adult patients with JIA and to determine predictors of survival for the prosthesis. In this retrospective comparative study patients were identified from the database of a regional specialist adult JIA clinic. This documented a series of 47 hip replacements performed in 25 adult patients with JIA. Surgery was performed at a mean age of 27 years (11 to 47), with a mean follow-up of 19 years (2 to 36). The mean Western Ontario and McMaster Universities osteoarthritis index questionnaire (WOMAC) score at the last follow-up was 53 (19 to 96) and the mean Health Assessment Questionnaire score was 2.25 (0 to 3). The mean pain component of the WOMAC score (60 (20 to 100)) was significantly higher than the mean functional component score (46 (0 to 97)) (p = 0.02). Kaplan-Meier survival analysis revealed a survival probability of 46.6% (95% confidence interval 37.5 to 55.7) at 19 years, with a trend towards enhanced survival with the use of a cemented acetabular component and a cementless femoral component. This was not, however, statistically significant (acetabular component, p = 0.76, femoral component, p = 0.45). Cox’s proportional hazards regression analysis showed an implant survival rate of 54.9% at 19 years at the mean of covariates. Survival of the prosthesis was significantly poorer (p = 0.001) in patients who had been taking long-term corticosteroids and significantly better (p = 0.02) in patients on methotrexate.
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Affiliation(s)
- A. Malviya
- Musculoskeletal Unit, Newcastle Hospitals NHS Trust, Freeman Hospital, High Heaton, Newcastle-upon-Tyne NE7 7DN, UK
| | - L. C. Walker
- University of Newcastle, Claremont Road, Newcastle-upon-Tyne NE1 7RU, UK
| | - P. Avery
- University of Newcastle, Claremont Road, Newcastle-upon-Tyne NE1 7RU, UK
| | - S. Osborne
- Musculoskeletal Unit, Newcastle Hospitals NHS Trust, Freeman Hospital, High Heaton, Newcastle-upon-Tyne NE7 7DN, UK
| | - D. J. Weir
- Musculoskeletal Unit, Newcastle Hospitals NHS Trust, Freeman Hospital, High Heaton, Newcastle-upon-Tyne NE7 7DN, UK
| | - H. E. Foster
- University of Newcastle, Claremont Road, Newcastle-upon-Tyne NE1 7RU, UK
| | - D. J. Deehan
- Musculoskeletal Unit, Newcastle Hospitals NHS Trust, Freeman Hospital, High Heaton, Newcastle-upon-Tyne NE7 7DN, UK
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Brabnikova Maresova K. Secondary osteoporosis in patients with juvenile idiopathic arthritis. J Osteoporos 2011; 2011:569417. [PMID: 21403891 PMCID: PMC3043287 DOI: 10.4061/2011/569417] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 01/08/2011] [Indexed: 12/31/2022] Open
Abstract
Bone disease in patients with juvenile idiopathic arthritis (JIA) is associated with focal (joint erosion and juxtaarticular osteopenia) and systemic bone loss (generalized osteopenia or reduction of bone mass density). Pathophysiology of bone loss is multifactorial and involves particularly proinflammatory cytokines and deleterious effects of glucocorticoid therapy. Clinical studies in patients with JIA indicate excessive activation of osteoclastogenesis and reduction of bone formation. Reduction of physical activity, muscle atrophy caused by high disease activity, and compulsory restriction in movements are also associated with bone loss. In patients with JIA, the disease can be complicated by growth cartilage involvement and systemic or local growth retardation. In the absence of preventive measures, fragility fractures can occur even at an early age.
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Affiliation(s)
- Kristyna Brabnikova Maresova
- Institute of Rheumatology, Slupi 4, 128 50, Prague 2, Czech Republic,Department of Rheumatology, First Faculty of Medicine, Charles University in Prague, Kateřinská 32, 121 08 Prague 2, Czech Republic,*Kristyna Brabnikova Maresova:
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Evans S, Cousins L, Tsao JC, Subramanian S, Sternlieb B, Zeltzer LK. A randomized controlled trial examining Iyengar yoga for young adults with rheumatoid arthritis: a study protocol. Trials 2011; 12:19. [PMID: 21255431 PMCID: PMC3033352 DOI: 10.1186/1745-6215-12-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Accepted: 01/21/2011] [Indexed: 01/06/2023] Open
Abstract
Background Rheumatoid arthritis is a chronic, disabling disease that can compromise mobility, daily functioning, and health-related quality of life, especially in older adolescents and young adults. In this project, we will compare a standardized Iyengar yoga program for young people with rheumatoid arthritis to a standard care wait-list control condition. Methods/Design Seventy rheumatoid arthritis patients aged 16-35 years will be randomized into either the 6-week Iyengar yoga program (12 - 1.5 hour sessions twice weekly) or the 6-week wait-list control condition. A 20% attrition rate is anticipated. The wait-list group will receive the yoga program following completion of the first arm of the study. We will collect data quantitatively, using questionnaires and markers of disease activity, and qualitatively using semi-structured interviews. Assessments include standardized measures of general and arthritis-specific function, pain, mood, and health-related quality of life, as well as qualitative interviews, blood pressure/resting heart rate measurements, a medical exam and the assessment of pro-inflammatory cytokines. Data will be collected three times: before treatment, post-treatment, and two months following the treatment. Discussion Results from this study will provide critical data on non-pharmacologic methods for enhancing function in rheumatoid arthritis patients. In particular, results will shed light on the feasibility and potential efficacy of a novel intervention for rheumatoid arthritis symptoms, paving the way for a larger clinical trial. Trial Registration ClinicalTrials.gov NCT01096823
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Affiliation(s)
- Subhadra Evans
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, USA.
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Lien G, Ueland T, Godang K, Selvaag AM, Førre ØT, Flatø B. Serum levels of osteoprotegerin and receptor activator of nuclear factor -κB ligand in children with early juvenile idiopathic arthritis: a 2-year prospective controlled study. Pediatr Rheumatol Online J 2010; 8:30. [PMID: 21134287 PMCID: PMC3014923 DOI: 10.1186/1546-0096-8-30] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Accepted: 12/06/2010] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The clinical relevance of observations of serum levels of osteoprotegerin (OPG) and receptor activator of nuclear factor -κB ligand (RANKL) in juvenile idiopathic arthritis (JIA) is not clear. To elucidate the potential role of OPG and RANKL in JIA we determined serum levels of OPG and RANKL in patients with early JIA compared to healthy children, and prospectively explored changes in relation to radiographic score, bone and lean mass, severity of the disease, and treatment. METHODS Ninety children with early oligoarticular or polyarticular JIA (ages 6-18 years; mean disease duration 19.4 months) and 90 healthy children individually matched for age, sex, race, and county of residence, were examined at baseline and 2-year follow-up. OPG and RANKL were quantified by enzyme-immunoassay. Data were analyzed with the use of t-tests, ANOVA, and multiple regression analyses. RESULTS Serum OPG was significantly lower in patients than controls at baseline, and there was a trend towards higher RANKL and a lower OPG/RANKL ratio. Patients with polyarthritis had significantly higher increments in RANKL from baseline to follow-up, compared to patients with oligoarthritis. RANKL was a significant negative predictor for increments in total body lean mass. Patients who were receiving corticosteroids (CS) or disease-modifying antirheumatic drugs (DMARDs) at follow-up had higher OPG/RANKL ratio compared with patients who did not receive this medication. CONCLUSIONS The data supports that levels of OPG are lower in patients with JIA compared to healthy children, and higher levels of RANKL is associated with more serious disease. RANKL was a significant negative predictor of lean mass in patients with JIA. The OPG/RANKL ratio was higher in patients on DMARDs or CS treatment.
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Affiliation(s)
- Gunhild Lien
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Norway.
| | - Thor Ueland
- Section of Endocrinology, Medical Department, Oslo University Hospital, Rikshospitalet, Norway,Research Institute for Internal Medicine, Oslo University Hospital, Rikshospitalet, Norway
| | - Kristin Godang
- Section of Endocrinology, Medical Department, Oslo University Hospital, Rikshospitalet, Norway
| | - Anne M Selvaag
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Norway
| | - Øystein T Førre
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Norway
| | - Berit Flatø
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Norway
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STAGI STEFANO, MASI LAURA, CAPANNINI SERENA, CIMAZ ROLANDO, TONINI GIULIA, MATUCCI-CERINIC MARCO, de MARTINO MAURIZIO, FALCINI FERNANDA. Cross-sectional and Longitudinal Evaluation of Bone Mass in Children and Young Adults with Juvenile Idiopathic Arthritis: The Role of Bone Mass Determinants in a Large Cohort of Patients. J Rheumatol 2010; 37:1935-43. [DOI: 10.3899/jrheum.091241] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective.To assess the prevalence of reduced spine bone mineral apparent density (BMAD), and to identify the main predictors of reduced spine BMAD in a cross-sectional and longitudinal evaluation of the same large cohort of patients with juvenile idiopathic arthritis (JIA). There are few prospective data on bone mass evaluation in a large number of patients with JIA, and with enthesitis-related arthritis onset.Methods.Two hundred nineteen patients with JIA (median age 8.7 yrs, range 6.1–13.1 yrs; 104 oligoarticular JIA, 61 polyarticular, 20 systemic, and 34 enthesitis-related arthritis onset) were retrospectively evaluated. A dual-energy x-ray absorptiometry (DEXA) scan at the lumbar spine was performed in all subjects. Of these, 89 consecutive patients were followed up randomly and longitudinally with a second and a third DEXA evaluation. The data obtained were compared with 80 age-matched and sex-matched healthy subjects.Results.At the first DEXA, patients with JIA showed a reduced spine BMAD standard deviation score (SDS) in comparison to controls (p < 0.001). These results were confirmed when the subjects were divided into JIA subtypes (p < 0.005) with the exception of enthesitis-related arthritis onset. Spine BMAD SDS significantly correlated with JIA onset type (p < 0.01), age at JIA onset (p < 0.005), and flares (p = 0.008). The longitudinal evaluation showed that spine BMAD SDS did not significantly improve at the followup in comparison to controls, in all subsets with JIA except for systemic onset (p < 0.05). Spine BMAD correlated with sex (p < 0.01), systemic corticosteroid exposure (p < 0.01), the number of intraarticular corticosteroid injections (p < 0.01), the interval from last steroid injection (p < 0.05), erythrocyte sedimentation rate (p < 0.005), and C-reactive protein levels (p < 0.005).Conclusion.Patients with JIA have a low bone mass and, after a first increase due to therapy, do not reach a healthy condition over time despite our current more effective drugs. These patients have a high risk of osteoporosis in early adulthood. To reduce the risk and improve the bone mass, close monitoring of bone mineral density, better control of disease activity, physical activity, and intake of calcium and vitamin D are recommended. In patients with osteoporosis, therapeutic approaches including bisphosphonates should be considered.
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Huber AM, Gaboury I, Cabral DA, Lang B, Ni A, Stephure D, Taback S, Dent P, Ellsworth J, LeBlanc C, Saint-Cyr C, Scuccimarri R, Hay J, Lentle B, Matzinger M, Shenouda N, Moher D, Rauch F, Siminoski K, Ward LM. Prevalent vertebral fractures among children initiating glucocorticoid therapy for the treatment of rheumatic disorders. Arthritis Care Res (Hoboken) 2010; 62:516-26. [PMID: 20391507 DOI: 10.1002/acr.20171] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Vertebral fractures are an under-recognized problem in children with inflammatory disorders. We studied spine health among 134 children (87 girls) with rheumatic conditions (median age 10 years) within 30 days of initiating glucocorticoid therapy. METHODS Children were categorized as follows: juvenile dermatomyositis (n = 30), juvenile idiopathic arthritis (n = 28), systemic lupus erythematosus and related conditions (n = 26), systemic arthritis (n = 22), systemic vasculitis (n = 16), and other conditions (n = 12). Thoracolumbar spine radiograph and dual x-ray absorptiometry for lumbar spine (L-spine) areal bone mineral density (BMD) were performed within 30 days of glucocorticoid initiation. Genant semiquantitative grading was used for vertebral morphometry. Second metacarpal morphometry was carried out on a hand radiograph. Clinical factors including disease and physical activity, calcium and vitamin D intake, cumulative glucocorticoid dose, underlying diagnosis, L-spine BMD Z score, and back pain were analyzed for association with vertebral fracture. RESULTS Thirteen vertebral fractures were noted in 9 children (7%). Of these, 6 patients had a single vertebral fracture and 3 had 2-3 fractures. Fractures were clustered in the mid-thoracic region (69%). Three vertebral fractures (23%) were moderate (grade 2); the others were mild (grade 1). For the entire cohort, mean +/- SD L-spine BMD Z score was significantly different from zero (-0.55 +/- 1.2, P < 0.001) despite a mean height Z score that was similar to the healthy average (0.02 +/- 1.0, P = 0.825). Back pain was highly associated with increased odds for fracture (odds ratio 10.6 [95% confidence interval 2.1-53.8], P = 0.004). CONCLUSION In pediatric rheumatic conditions, vertebral fractures can be present prior to prolonged glucocorticoid exposure.
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Affiliation(s)
- A M Huber
- Dalhousie University, Halifax, Nova Scotia, Canada
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Billiau AD, Loop M, Le PQ, Berthet F, Philippet P, Kasran A, Wouters CH. Etanercept improves linear growth and bone mass acquisition in MTX-resistant polyarticular-course juvenile idiopathic arthritis. Rheumatology (Oxford) 2010; 49:1550-8. [DOI: 10.1093/rheumatology/keq123] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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The role of exercise therapy in the management of juvenile idiopathic arthritis. Curr Opin Rheumatol 2010; 22:213-7. [DOI: 10.1097/bor.0b013e328335d1a2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lilleby V, Haugen M, Mørkrid L, Frey Frøslie K, Holven KB, Førre O. Body composition, lipid and lipoprotein levels in childhood‐onset systemic lupus erythematosus. Scand J Rheumatol 2009; 36:40-7. [PMID: 17454934 DOI: 10.1080/03009740600907881] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Systemic inflammation, corticosteroid therapy, and reduced physical activity are risk factors for altered body composition in patients with systemic lupus erythematosus (SLE). The aim of this study was to assess whether body composition differs between childhood-onset SLE patients and healthy controls, and to investigate the impact of disease characteristics and lifestyle factors on body fat mass, serum lipids, and lipoproteins. METHODS Fat mass and lean tissue mass were measured in a cross-sectional study of 68 childhood-onset SLE patients and 68 matched healthy controls by dual-energy X-ray absorptiometry (DXA). The influence of disease, glucocorticosteroids, disease activity and severity, physical activity, and dietary intake on fat mass was evaluated by multiple linear regression analysis. Serum lipid and lipoprotein levels were measured. RESULTS Patients had a significantly higher fat mass [mean (SD) 35.3 (10.8) vs. 30.9 (11.1)%; p = 0.024] and lower lean mass [39.7 (9.8) vs. 44.4 (1.5) kg; p = 0.003] than controls. Corticosteroid use and the disease itself were significant independent predictors of greater fat mass, while disease activity, physical activity, and dietary intake had only a minor influence. Mean high density lipoprotein (HDL) cholesterol and apolipoprotein A1 (apo A1) levels were significantly lower (p<0.001), and the mean apo B/apo A1 ratio significantly higher (p = 0.004), in patients than in controls. CONCLUSION Childhood-onset SLE patients had a higher fat mass and lower lean mass than healthy controls and corticosteroid use was an independent predictor of increased fat mass. Patients had a more proatherogenic lipid profile, which will contribute to the increased risk of coronary heart disease in SLE patients.
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Affiliation(s)
- V Lilleby
- Department of Rheumatology, Rikshospitalet University Hospital, NO-0027 Oslo, Norway.
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Bone density, structure, and strength in juvenile idiopathic arthritis: importance of disease severity and muscle deficits. ACTA ACUST UNITED AC 2008; 58:2518-27. [PMID: 18668565 DOI: 10.1002/art.23683] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To identify determinants of musculoskeletal deficits (muscle cross-sectional area [mCSA], trabecular volumetric bone mineral density [vBMD], and cortical bone strength [section modulus]) in patients with juvenile idiopathic arthritis (JIA) and to determine if cortical bone strength is appropriately adapted to muscle forces. METHODS Peripheral quantitative computed tomography (pQCT) of the tibia was performed in 101 patients with JIA (79% female; 24 with oligoarticular JIA, 40 with polyarticular JIA, 18 with systemic JIA, and 19 with spondylarthritis [SpA]) and 830 healthy control subjects; all were ages 5-22 years. Outcomes of pQCT were expressed as sex- and race-specific Z scores. Multivariable linear regression models assessed mCSA and bone status in JIA patients compared with controls and identified factors associated with musculoskeletal deficits in JIA. RESULTS The median duration of JIA was 40 months; 29% of the JIA patients had active arthritis, and 28% had received glucocorticoid therapy during the previous year. Compared with the controls, the mCSA and section modulus Z scores were significantly lower in patients with polyarticular JIA and those with SpA. Trabecular vBMD Z scores were significantly lower in patients with polyarticular JIA, those with systemic JIA, and those with SpA. Significant predictors of musculoskeletal deficits included active arthritis in the previous 6 months (mCSA), temporomandibular joint disease (mCSA and section modulus), functional disability (mCSA and vBMD), short stature (vBMD), infliximab exposure (vBMD), and JIA duration (section modulus). The section modulus was significantly reduced relative to mCSA in patients with JIA after adjustment for age and limb length. CONCLUSION Marked deficits in vBMD and bone strength occur in JIA in association with severe and longstanding disease. Contrary to the findings of previous studies, bone deficits were greater than expected relative to the mCSA, which illustrates the importance of adjusting for age and bone length.
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Viswanathan A, Sylvester FA. Chronic pediatric inflammatory diseases: effects on bone. Rev Endocr Metab Disord 2008; 9:107-22. [PMID: 18165904 DOI: 10.1007/s11154-007-9070-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
Abstract
In children, chronic inflammatory diseases present a significant challenge to long-term skeletal health. These conditions are often associated with poor appetite and suboptimal overall nutrition, altered nutrient utilization, delayed puberty, inactivity, and reduced muscle mass, all of which can alter bone metabolism. In addition, bone cell activity is susceptible to the effects of the immune response that characterizes these diseases. Moreover, drugs used to treat these maladies, notably glucocorticoids, may have negative effects on bone formation and on linear growth in developing children. As a result, predicted peak bone mass may not be achieved, and fracture risk may be increased in the short term or in the future. Studies using primarily dual energy X-ray absorptiometry have documented that deficits in bone mass are common in these diseases. However, there are wide variations in the prevalence of low bone mass, largely due to differences in the characteristics of each study population. Recent studies provide insight into the pathogenesis of decreased bone mass in these conditions. In this paper we will provide an overview of the effects of chronic inflammatory conditions on bone mass in children. We will also present relevant data from adult patients, when pediatric data are scant or not available.
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Dubner SE, Shults J, Leonard MB, Zemel BS, Sembhi H, Burnham JM. Assessment of spine bone mineral density in juvenile idiopathic arthritis: impact of scan projection. J Clin Densitom 2008; 11:302-8. [PMID: 18164636 DOI: 10.1016/j.jocd.2007.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 10/15/2007] [Accepted: 10/29/2007] [Indexed: 10/22/2022]
Abstract
Although children with juvenile idiopathic arthritis (JIA) are at risk for vertebral fractures, recent conventional posterior-anterior (PA) spine dual-energy X-ray absorptiometry studies reported minimal areal bone mineral density (aBMD, g/cm2) deficits. Width-adjusted BMD (WA-BMD, g/cm3) represents the bone mineral content (BMC) from the lateral projection, excluding the dense cortical spinous processes, divided by the estimated vertebral body volume based on paired PA-lateral bone dimensions. Therefore, WA-BMD may be more sensitive to JIA effects on the predominantly trabecular vertebral body. Age- and sex-specific Z-scores for spine aBMD and WA-BMD were generated in 84 JIA subjects compared with healthy controls, aged 5-21 yr. JIA was associated with lower mean WA-BMD Z-scores (-0.78, 95% CI: -1.03, -0.53; p<0.001) and aBMD Z-scores (-0.26, 95% CI: -0.49, -0.02; p<0.05), compared with controls. WA-BMD Z-scores were significantly lower than aBMD Z-scores in JIA (p<0.001). A significant JIA by age interaction (p<0.001) indicated that the magnitude of the difference between WA-BMD and aBMD Z-scores was greater in younger subjects. In conclusion, WA-BMD may be more sensitive to disease effects in children because it selectively measures the trabecular-rich vertebral body and is independent of growth-related changes in BMC of the dense spinous processes.
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Affiliation(s)
- Sarah E Dubner
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Abstract
Osteoporosis is a well-recognized major health problem in adult patients with systemic lupus erythematosus (SLE). Children and adolescents with SLE, however are at even higher risk of developing osteoporosis later in life, since they develop the disease before achieving peak bone mass, which serves as a 'bone bank' for the rest of life. There is still a paucity of studies on bone mass in pediatric SLE, but those studies available provide evidence of reduced bone mass in this age group. A frequency of osteopenia of 40% measured by dual energy X-ray absorptiometry at one or more skeletal sites has been reported, and the lumbar spine is most seriously affected. Peak bone mass seems to be lower in childhood-onset SLE patients compared to healthy controls, and there are no signs of catch-up of bone mass in young adult patients with a history of pediatric SLE. Glucocorticoid therapy has been found to have a major negative effect on bone mass in these patients, thus the importance of keeping corticosteroid doses down to the lowest possible dose whenever possible. Interestingly, studies of oral alendronate therapy in children with rheumatic childhood diseases have shown promising results with increases of 15-33% during one year of treatment with no major side effects reported. Finally, there is a hope that new biologic therapies, which are more specific and steroid-sparing, will also have a beneficial effect on bone health in SLE in the future.
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Affiliation(s)
- V Lilleby
- Department of Rheumatology, Rikshospitalet University Hospital, Oslo, Norway.
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Roth J, Bechtold S, Borte G, Dressler F, Girschick H, Borte M. [Diagnosis, prophylaxis and therapy of osteoporosis in juvenile idiopathic arthritis: consensus statement of the German Association for Pediatric Rheumatology]. Z Rheumatol 2008; 66:434-40. [PMID: 17522871 DOI: 10.1007/s00393-007-0174-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In all subgroups of juvenile idiopathic arthritis (JIA), a pathologic loss of bone or the lack of increase in bone mass has been described in a high percentage of cases, even with new therapeutic approaches. The decrease in bone mass is correlated with the duration of active disease and the number of affected joints (cytokines, inactivity). In several studies, muscle mass was the strongest predictor of bone mass. A standardized diagnostic approach to the musculoskeletal system including measures of prophylaxis and therapy therefore seems to be mandatory for all children with JIA who do not achieve rapid remission. In this review, the diagnostic and therapeutic options are described and summarized in an algorithm.
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Affiliation(s)
- J Roth
- Pädiatrische Pneumologie und Immunologie, SPZ Rheumatologie, Charité Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Binkovitz LA, Henwood MJ, Sparke P. Pediatric dual-energy X-ray absorptiometry: technique, interpretation, and clinical applications. Semin Nucl Med 2007; 37:303-13. [PMID: 17544629 DOI: 10.1053/j.semnuclmed.2007.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article reviews the dual-energy x-ray absorptiometry (DXA) technique, its interpretation, and clinical applications with emphasis on the considerations unique to pediatrics. Specifically, the use of DXA in children requires the radiologist to be a "clinical pathologist," monitoring the technical aspects of the DXA acquisition, a "statistician" knowledgeable in the concepts of Z-scores and least significant changes, and a "bone specialist," aware of the DXA findings in a large number of clinical diseases, providing the referring clinician with a meaningful context for the numeric result obtained with DXA.
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Affiliation(s)
- Larry A Binkovitz
- Department of Radiology, Columbus Children's Hospital, Columbus, OH 43205, USA.
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Roth J, Bechtold S, Borte G, Dressler F, Girschick HJ, Borte M. Osteoporosis in juvenile idiopathic arthritis--a practical approach to diagnosis and therapy. Eur J Pediatr 2007; 166:775-84. [PMID: 17436015 DOI: 10.1007/s00431-007-0484-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 03/22/2007] [Indexed: 10/23/2022]
Abstract
In all subgroups of juvenile idiopathic arthritis, a decrease in bone mass has been described in a high percentage of children. Recently, new pathogenetic concepts have identified muscle mass as the strongest predictor of bone mass and bone is now recognized as part of the musculoskeletal system. In addition, the sophisticated use of bone densitometry in pediatrics, including new measurement techniques, has provided the tools for a reliable assessment. A standardized diagnostic approach to the musculoskeletal system, including prophylaxis and therapy, is, therefore, mandatory in all children with JIA who do not achieve rapid remission. In this review, diagnostic and therapeutic options are being described and possibilities to incorporate them into clinical practice are suggested.
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Affiliation(s)
- Johannes Roth
- Department of Pediatric Pneumology and Immunology, Charite University Medicine, Berlin, Germany.
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Measurement of Health Status, Functional Status, and Quality of Life in Children with Juvenile Idiopathic Arthritis: Clinical Science for the Pediatrician. Rheum Dis Clin North Am 2007; 33:389-402. [DOI: 10.1016/j.rdc.2007.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Compeyrot-Lacassagne S, Tyrrell PN, Atenafu E, Doria AS, Stephens D, Gilday D, Silverman ED. Prevalence and etiology of low bone mineral density in juvenile systemic lupus erythematosus. ACTA ACUST UNITED AC 2007; 56:1966-73. [PMID: 17530722 DOI: 10.1002/art.22691] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Studies of adults with systemic lupus erythematosus (SLE) have frequently demonstrated the presence of decreased bone mineral density (BMD). However, there have been few investigations in pediatric patients to date. This study was undertaken to determine the prevalence of low BMD in patients with juvenile SLE and to identify associated risk factors. METHODS We studied 64 consecutive patients with juvenile SLE in whom routine dual x-ray absorptiometry (DXA) scanning was performed. Lumbar spine osteopenia was defined as a BMD Z score of < -1 and > or = -2.5, and osteoporosis as a BMD Z score of < -2.5. Decreased hip BMD was defined as a value of < 80%. Data on disease activity, quality of life, disease-related damage, sex, ethnicity, body mass index, age at diagnosis, age at DXA, medication use and duration, clinical features, and puberty status were collected at the time of DXA. RESULTS Lumbar spine osteopenia was seen in 24 patients (37.5%) and osteoporosis in 13 (20.3%). Decreased hip BMD was present in 12 patients (18.8%). By univariate analysis, osteopenia was significantly correlated with age, disease duration, duration of corticosteroid use, cumulative corticosteroid dose, azathioprine use, cyclophosphamide use, lupus nephritis, and damage. Two additional variables, mycophenolate mofetil use and class III-IV nephritis, were associated with osteoporosis. Abnormal hip BMD was associated with disease duration, duration of corticosteroid use, and cumulative corticosteroid dose. By multivariate analysis, only disease duration remained in the model for osteoporosis and abnormal hip BMD, while cumulative corticosteroid dose was the variable associated with osteopenia. CONCLUSION These results indicate that osteopenia and osteoporosis are common in juvenile SLE and are associated more closely with increased disease duration than with cumulative corticosteroid dose.
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