Protecting Bone Health in Pediatric Rheumatic Diseases: Pharmacological Considerations

Treatment of non-hypertrophic pseudoarthrosis of long bones with a Tissue Engineered Product loaded with autologous bone marrow-derived Mesenchymal Stromal Cells: Results from a phase IIa, prospective, randomized, parallel, pilot clinical trial comparing to iliac crest autograft

BACKGROUND

Atrophic pseudoarthrosis is a serious complication with an incidence of 5-10 % of bone fractures located in the diaphysis of long bones. Standard treatments involve aggressive surgical procedures and re-interventions requiring the use of autografts from the iliac crest as a source of bone-forming biological activity (Standard of Care, SoC). In this context, regenerative ex vivo expanded osteogenic cell-based medicines could be of interest. Particularly, Mesenchymal Stromal Cells (MSC) offer new prospects to promote bone tissue repair in pseudoarthrosis by providing biological activity in an osteoconductive and osteoinductive environment.

METHODS

We conducted a phase IIa, prospective, randomised, parallel, two-arms, open-label with blinded assessor pilot clinical trial to compare SoC vs. a tissue-engineered product (TEP), composed of autologous bone marrow (BM)-derived MSCs loaded onto allogeneic decellularised, lyophilised spongy bone cubes, in a cohort of 20 patients with non-hypertrophic pseudoarthrosis of long bones. Patients were followed up for 12 months. Radiological bone healing was evaluated by standard X-ray and computed tomography (CT) scanning. Quality of life was measured using the EUROQOL-5D questionnaire.

RESULTS

Ten patients were randomized to TEP and 10 to SoC with iliac crest autograft. Manufacturing of TEP was feasible and reproducibly achieved. TEP implantation in the bone defect was successful in all cases and none of the 36 adverse events (AE) reported were related to the treatment. Efficacy analyses were performed in the Full Analysis Set (FAS) population, which included 17 patients after 3 patients withdrew from the study. The degree of consolidation, estimated by measuring Hounsfield units (HU) on CT, showed no significant differences between the two treatment groups at 12 months post treatment (main efficacy variable) (p = 0.4835) or at 6 months.

CONCLUSIONS

Although only a small number of patients were included in our study, it is notable that no significant differences were observed between the experimental treatment and SoC, thus suggesting TEP as an alternative where autograft is not available or contraindicated.

Use of dietary supplements by children and adolescents

OBJECTIVES

Narrative review evaluating the use of dietary supplements by children and adolescents.

DATA SOURCE

The terms "dietary supplements", "children" and "adolescents" were used in combination in the PubMed, MEDLINE, and SciELO databases, between 2000 and 2023, evaluating studies in humans, published in Portuguese, English, French and Spanish.

DATA SYNTHESIS

The use of dietary supplements by children and adolescents has increased in recent decades. The most commonly used supplements are vitamins, minerals, trace elements, proteins, amino acids, melatonin, fatty acids, probiotics and energy drinks.

CONCLUSION

Despite having specific indications, most of the time they are not prescribed by a healthcare professional. The reasons for use are varied. In children, the main reasons are protection against infections, stimulating growth, and poor food intake, with multivitamins and minerals being the most commonly used supplements. In adolescents, they are used to improve athletic performance and attain the "ideal body", with proteins and amino acids being the most often used nutrients. As they are not regulated by health agencies and are sold without a prescription, their unsupervised use can lead to inadequate doses, with inefficiency or overdose risk. As for compounding formulations, or when available in preparations with multiple nutrients, the chance of errors increases. It is essential that pediatricians advise parents and patients about the indications, risks and benefits, prescribing them when necessary.

"Neuroimmunoendocrinology" in Children with Rheumatic Diseases: How Glucocorticoids Are the Orchestra Director

The neural, the endocrine, and the immune systems are studied as distinct districts in physiological and pathological settings. However, these systems must be investigated with an integrative approach, while also considering that therapeutic agents, such as glucocorticoids, can induce a reversible or irreversible change of this homeostasis. Children and adolescents affected by rheumatic diseases frequently need treatment with corticosteroids, and the treatment must sometimes be continued for a long time. In the biological era, the treat-to-target strategy allowed a real revolution in treatment, with significant steroid dose sparing or, in many patients, steroid treatment withdrawal. In this review, the impact of glucocorticoids on endocrine, immune, and neurologic targets is analyzed, and the crosstalk between these systems is highlighted. In this narrative review, we explore the reasoning as to why glucocorticoids can disrupt this homeostasis, we summarize some of the key results supporting the impact of glucocorticoids treatment on endocrine, immune, and neurologic systems, and we discuss the data reported in the international literature.

Bone Health in Children with Rheumatic Disorders: Focus on Molecular Mechanisms, Diagnosis, and Management

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.

Growth and puberty in children with juvenile idiopathic arthritis

Juvenile Idiopathic Arthritis is one of the most prevalent chronic diseases in children, with an annual incidence of 2-20 cases per 100,000 and a prevalence of 16-150 per 100,000. It is associated with several complications that can cause short-term or long-term disability and reduce the quality of life. Among these, growth and pubertal disorders play an important role. Chronic inflammatory conditions are often associated with growth failure ranging from slight decrease in height velocity to severe forms of short stature. The prevalence of short stature in JIA varies from 10.4% in children with polyarticular disease to 41% of patients with the systemic form, while oligoarthritis is mostly associated with localized excessive bone growth of the affected limb, leading to limb dissymmetry. The pathogenesis of growth disorders is multifactorial and includes the role of chronic inflammation, long-term use of corticosteroids, undernutrition, altered body composition, delay of pubertal onset or slow pubertal progression. These factors can exert a systemic effect on the GH/IGF-1 axis and on the GnRH-gonadotropin-gonadic axis, or a local influence on the growth plate homeostasis and function. Although new therapeutic options are available to control inflammation, there are still 10-20% of patients with severe forms of the disease who show continuous growth impairment, ending in a short final stature. Moreover, delayed puberty is associated with a reduction in the peak bone mass with the possibility of concomitant or future bone fragility. Monitoring of puberty and bone health is essential for a complete health assessment of adolescents with JIA. In these patients, an assessment of the pubertal stage every 6 months from the age of 9 years is recommended. Also, linear growth should be always evaluated considering the patient's bone age. The impact of rhGH therapy in children with JIA is still unclear, but it has been shown that if rhGH is added at high dose in a low-inflammatory condition, post steroids and on biologic therapy, it is able to favor a prepubertal growth acceleration, comparable with the catch-up growth response in GH-deficient patients. Here we provide a comprehensive review of the pathogenesis of puberty and growth disorders in children with JIA, which can help the pediatrician to properly and timely assess the presence of growth and pubertal disorders in JIA patients.

Bone health in idiopathic inflammatory myopathies

OBJECTIVE

To review the extant literature relating to bone health in the idiopathic inflammatory myopathies (IIM) including both adult and juvenile patients.

METHODS

A PubMed search® identified relevant studies from 1966 to 2020 in accordance with PRISMA guidelines. Two independent reviewers screened and extracted the abstracts/full manuscripts, and a third author was consulted in the case of disagreement.

RESULTS

We identified 37 articles (3 review articles, 2 RCTs, 9 cross-sectional, 16 cohort and 7 case-control studies). The prevalence of osteopenia (n = 7) ranges from 7 to 75% and osteoporosis (n = 7) between 13% to 27%. The prevalence of vertebral fractures ranged from 11 to 75%. Systemic inflammation likely contributes to reduced bone mineral density (BMD) in children with IIM but data is currently lacking in adult patients. Association between with impaired BMD and Vitamin D or calcium intake and physical activity has not been demonstrated in IIM. There is no clear consensus regarding the impact of age, menopause or BMI on bone health. Gender, smoking status, disease activity and inflammatory markers are not obvious independent predictors of low BMD. Several studies have demonstrated that glucocorticoids are associated with an increased risk of low BMD. There are no specific guidelines relating to the management of bone health in adult and juvenile patients with IIM.

CONCLUSION

Both adult and juvenile patients with IIM are at high risk of impaired bone health and fracture. The mechanisms behind this are likely multifactorial including systemic inflammation, glucocorticoid treatment, reduced mobility and impaired calcium/vitamin D homeostasis. There are a lack of guidelines and studies relating to the screening, prevention and treatment of impaired bone health in adult and juvenile patients with IIM. Future research is required to understand the complexity of bone health in IIM including to develop much needed disease-specific management recommendations.

Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children

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.

Linear growth and bone metabolism in pediatric patients with inflammatory bowel disease

OBJECTIVE

To review the pathophysiology and evaluation methods of linear growth and bone mineral density in children and adolescents diagnosed with inflammatory bowel disease.

SOURCE OF DATA

Narrative review carried out in the PubMed and Scopus databases through an active search of the terms: inflammatory bowel disease, growth, failure to thrive, bone health, bone mineral density, and children and adolescents, related to the last ten years, searching in the title, abstract, or keyword fields.

SYNTHESIS OF FINDINGS

Inflammatory bowel diseases of childhood onset may present as part of the clinical picture of delayed linear growth in addition to low bone mineral density. The presence of a chronic inflammatory process with elevated serum levels of inflammatory cytokines negatively interferes with the growth rate and bone metabolism regulation, in addition to increasing energy expenditure, compromising nutrient absorption, and favoring intestinal protein losses. Another important factor is the chronic use of glucocorticoids, which decreases the secretion of growth hormone and the gonadotrophin pulses, causing pubertal and growth spurt delay. In addition to these effects, they inhibit the replication of osteoblastic lineage cells and stimulate osteoclastogenesis.

CONCLUSION

Insufficient growth and low bone mineral density in pediatric patients with inflammatory bowel disease are complex problems that result from multiple factors including chronic inflammation, malnutrition, decreased physical activity, late puberty, genetic susceptibility, and immunosuppressive therapies, such as glucocorticoids.

Glucocorticoid treatment in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of joints in childhood. Glucocorticoids are being used in JIA treatment effectively for decades. Although systemic glucocorticoid use decreased with the introduction of biologic drugs, intraarticular glucocorticoid injections (IAGI) with nonsteroidal anti-inflammatory drugs and non-biologic disease modifying anti-rheumatic drugs (DMARDs) still remain the primary treatment in JIA, especially in oligoarticular subcategory. Systemic glucocorticoids are used mainly for severe JIA-associated complications such as macrophage activation syndrome (MAS), myocarditis, pericarditis, pleuritis, peritonitis, and severe anemia; as bridging therapy while waiting for the full therapeutic effect of DMARDs; and in certain occasions for patients with severe refractory uveitis. Since glucocorticoid administration is associated with many adverse events, it is important to use glucocorticoids in an optimum way balancing the risks and benefits. The aim of this review is to summarize the current knowledge on glucocorticoid treatment in JIA. A comprehensive literature search was conducted utilizing the Cochrane Library and MEDLINE/PubMed databases. The main topics include mechanism of action, dose, duration, adverse events, vaccination during glucocorticoid treatment, the place of glucocorticoids in JIA treatment guidelines and consensus treatment plans, glucocorticoid use in JIA-associated uveitis, MAS, and IAGI. Data from the literature provide guidance on how to use glucocorticoids in JIA treatment especially for IAGI and systemic use in systemic JIA and MAS. However, there is lack of evidence and need for prospective randomized studies in most parts including the indications in different JIA subcategories, optimum dose/route of administration/duration of treatment, and tapering strategies.

General Nutrition and Fitness for the Child with Rheumatic Disease

As a result of new medications and therapeutic approaches, most children with rheumatic diseases are no longer at risk for growth failure which results from chronic inflammation and prolonged corticosteroid treatment. However, obesity, poor nutrition, and insufficient exercise are still problems which increase risks for poor bone, cardiovascular, and general health. Diet should be monitored and modified as appropriate; supplemental calcium and Vitamin D should be provided. Obesity and poor physical fitness can be ameliorated by an exercise program that should become part of a more healthy lifestyle.

Risk factors for low bone mineral density in pediatric inflammatory bowel disease: the positive role of physical activity

OBJECTIVE

In pediatric inflammatory bowel disease (IBD), the prevalence of low bone mineral density (BMD) and bone fractures and the relationship between these are still debated. Our aim was to report data from a cohort of pediatric patients with IBD.

PATIENTS AND METHODS

Cross-sectional assessment of growth and BMD [(dual-energy x-ray absorptiometry (DXA)] and retrospective chart review were performed to report the lifetime prevalence of bone fractures and clinical associations with patients' data.

RESULTS

We examined 216 patients with IBD, 8-25 years old (median: 14 years). Low BMD was found in 12.5% (spine) and 27% (total body). Multiple regression analysis showed that BMD was predicted by Z-scores for height and weight at DXA. History of menstrual irregularities and nasogastric tube feedings was associated with lower BMD, whereas physical activity and higher Z-score for height at DXA were associated with higher BMD.The prevalence of lifetime fractures was 11.8%. Patients with a history of fractures had lower Z-scores for spine BMD (-1.20 vs. -0.69, P=0.020) and total-body BMD (-1.30 vs. -0.75, P=0.014) compared with those without a history of fractures. Patients with spine BMD Z-score of up to -2 SD score had significantly increased prevalence of fractures compared with those with Z-score more than -2 SD score (28 vs. 10%, P=0.015).

CONCLUSION

This study provides further insight into risk factors for low BMD in pediatric IBD. Novel findings were the association between low BMD and fractures, and the positive relationship between BMD and physical activity.