Pharmacological treatment for managing bone health in axial spondyloarthropathy: systematic review and meta-analysis

Osteoporosis in Rheumatology

Introduction

Osteoporosis is a common diagnosis and comorbidity observed in patients with rheumatic diseases. It is frequently associated with conditions such as rheumatoid arthritis, spondyloarthropathy, systemic lupus erythematosus, and other autoimmune rheumatic diseases.

Conclusion

The incidence of osteoporosis is influenced by factors such as uncontrolled disease, prolonged and higher doses of steroid use, immobility, advanced age, and postmenopausal status. Achieving good control of the underlying disease, minimizing or avoiding the use of steroids for extended periods, and ensuring adequate supplementation of vitamin D and calcium are crucial in reducing the incidence of osteoporosis. Regular screening and appropriate management of osteoporosis can significantly decrease the associated morbidity and mortality.

Management of Specific Clinical Profiles in Axial Spondyloarthritis: An Expert's Document Based on a Systematic Literature Review and Extended Delphi Process

INTRODUCTION

The management of specific clinical scenarios is not adequately addressed in national and international guidelines for axial spondyloarthritis (axSpA). Expert opinions could serve as a valuable complement to these documents.

METHODS

Seven expert rheumatologists identified controversial areas or gaps of current recommendations for the management of patients with axSpA. A systematic literature review (SLR) was performed to analyze the efficacy and safety of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, conventional synthetic, biologic and targeted synthetic disease-modifying antirheumatic drugs (csDMARDs, b/tsDMARDs) in axSpA regarding controversial areas or gaps. In a nominal group meeting, the results of the SLR were discussed and a set of statements were proposed. A Delphi process inviting 150 rheumatologists was followed to define the final statements. Agreement was defined as if at least 70% of the participants voted ≥ 7 (from 1, totally disagree, to 10, totally agree).

RESULTS

Three overarching principles and 17 recommendations were generated. All reached agreement. According to them, axSpA care should be holistic and individualized, taking into account objective findings, comorbidities, and patients' opinions and preferences. Integrating imaging and clinical assessment with biomarker analysis could also help in decision-making. Connected to treatments, in refractory enthesitis, b/tsDMARDs are recommended. If active peripheral arthritis, csDMARD might be considered before b/tsDMARDs. The presence of significant structural damage, long disease duration, or HLA-B27-negative status do not contraindicate for the use of b/tsDMARDs.

CONCLUSIONS

These recommendations are intended to complement guidelines by helping health professionals address and manage specific groups of patients, particular clinical scenarios, and gaps in axSpA.

Prevalence and Factors of Osteoporosis and High Risk of Osteoporotic Fracture in Patients with Ankylosing Spondylitis: A Multicenter Comparative Study of Bone Mineral Density and the Fracture Risk Assessment Tool

Background: We investigated the prevalence of and the factors associated with a high risk of osteoporotic fractures in Korean patients with ankylosing spondylitis (AS). Methods: This was a multicenter, retrospective study including 219 AS patients from five university hospitals; the control group was selected by matching age and sex with those of the AS patients. The fracture risk was evaluated based on bone mineral density (BMD) measured by dual-energy X-ray absorptiometry and the fracture risk assessment tool (FRAX) with/without BMD. Results: The mean age of the patients was 47.6 years, and 144 (65.8%) patients were men. According to the WHO criteria and FRAX with/without BMD, the candidates for pharmacological treatment were 44 (20.1%), 20 (13.2%), and 23 (15.1%) patients, respectively, significantly more than those in the healthy control group. Among them, the proportion of patients receiving osteoporosis treatment was 39.1–75%. In logistic regression analysis, menopause was an independent factor for the high risk of fracture according to the WHO criteria and FRAX with/without BMD. C-reactive protein level (odds ratio (OR) 3.8 and OR 6) and glucocorticoid use (OR 1.5 and OR 1.7) were associated with a high risk of osteoporotic fracture based on FRAX without BMD and osteoporosis diagnosed according to the WHO criteria. Conclusions: Our study suggests that both FRAX and WHO criteria may be complementary for treatment decisions to reduce osteoporotic fractures in patients with AS.

Trends in fractures in patients with spondyloarthritis: a nationwide population-based study (TREND-EspA study)

Our aim was to analyze trends in fracture rates in SpA patients over an extended time period. Only an increase of axial fractures, more specifically vertebral fractures, is observed in SpA.

PURPOSE

To analyze fracture incidence and trend in patients with spondyloarthritis (SpA) over an extended time period.

METHODS

Retrospective observational population-based study with matched cohorts. Data from the Minimum Basic Data Set (MBDS) of Spain were reviewed. All SpA patient hospitalizations reported from 1999 to 2015 (SpA cohort) were analyzed. A control cohort (non-SpA cohort) matched by age, sex, region, and year of hospitalization was recruited. The age and sex-adjusted crude incidence rate was calculated for any fractures (axial and peripheral). Generalized linear models (GLM) were used for trend analysis. Association between fracture type and SpA (and its subtypes) was assessed using unconditional logistic regression models.

RESULTS

In the SpA cohort, the age and sex-adjusted rates per 100,000 inhabitants/year of total fracture and different types of fracture were 45.72 any fractures, 17.64 axial, and 28.02 peripheral; 29.42 osteoporotic (12.67 vertebra, 12.29 hip, 1.50 pelvis, 1.82 humerus and 2.09 radius). In the non-SpA cohort, they were 65.79 any, 12.08 axial, 51.52 peripheral; 31.17 osteoporotic (4.94 vertebra, 16.15 hip, 2.29 pelvis, 3.64 humerus, 5.38 radius). Between 1999 and 2015, the trend in incidence rate for total fracture and different types of fracture increased similarly for both cohorts. In the SpA cohort, an increase of axial fractures was found (AOR 1.444; 95%CI 1.297-1.609), and specifically of vertebral fractures (AOR 2.440; 95%CI 2.097-2.839). Other types of fractures did not increase.

CONCLUSIONS

Only an increase of axial fractures, more specifically vertebral fractures, is observed in SpA. Trend in incidence is similar in both cohorts.