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Park SJ, Sim SY, Jeong DC, Suh BK, Ahn MB. Factors affecting bone mineral density in children and adolescents with systemic lupus erythematosus. Ann Pediatr Endocrinol Metab 2024; 29:191-200. [PMID: 38291762 PMCID: PMC11220398 DOI: 10.6065/apem.2346060.030] [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] [Received: 03/02/2023] [Revised: 05/01/2023] [Accepted: 07/07/2023] [Indexed: 02/01/2024] Open
Abstract
PURPOSE Patients with juvenile-onset systemic lupus erythematosus (JSLE) are at a high risk of entering adulthood with disease-related morbidities like reduced bone mass and osteoporosis. This study aimed to evaluate the clinical characteristics of JSLE and to analyze the factors associated with low bone mineral density (BMD) in these patients. METHODS Children and adolescents diagnosed with JSLE at a single institution in Korea were included. Demographic, clinical, and laboratory data as well as details about the use of glucocorticoids (GCs) and disease-modifying antirheumatic drugs were collected. The lumbar spine (LS) BMD z-score was measured using dual energy x-ray absorptiometry, and lateral thoracolumbar spine radiographs were collected. RESULTS A total of 29 patients with JSLE were included in this study. Of these patients, 7 had a BMD z-score of -2.0 or lower and were designated as the low BMD group. The differences in the clinical parameters and treatment variables between the low BMD and non-low BMD groups were compared. Higher cumulative GC dose, longer GC exposure, and higher cumulative hydroxychloroquine (HCQ) dose were all associated with low BMD; among them, the main factor was the duration of GC exposure. There was no significant correlation between BMD and clinical profile, disease activity, or bone-metabolism markers. CONCLUSION The duration of GC exposure, cumulative GC dose, and cumulative HCQ dose were risk factors for low BMD in patients with JSLE, with the main factor being the duration of GC exposure. Thus, patients with JSLE should be routinely monitored for low BMD and potential fracture risks, and GC-sparing treatment regimens should be considered.
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Affiliation(s)
- Su Jin Park
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo Yeun Sim
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Kyu Suh
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Moon Bae Ahn
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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2
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Phung K, McAdam L, Ma J, McMillan HJ, Jackowski S, Scharke M, Matzinger MA, Shenouda N, Koujok K, Jaremko JL, Smit K, Walker S, Hartigan C, Khan N, Konji VN, MacLeay L, Page M, Sykes E, Robinson ME, Alos N, Cummings EA, Ho J, Sbrocchi AM, Stein R, Saleh D, Craven BC, Dang UJ, Siminoski K, Rauch F, Ward LM. Risk factors associated with prevalent vertebral fractures in Duchenne muscular dystrophy. Osteoporos Int 2023; 34:147-160. [PMID: 36342539 DOI: 10.1007/s00198-022-06578-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
UNLABELLED Patients with Duchenne muscular dystrophy (DMD) have a high fracture burden due to progressive myopathy and steroid-induced osteoporosis. This study in males with DMD showed that markers of systemic glucocorticoid exposure including shorter stature, greater bone age delay, and lower lumbar spine bone mineral density were associated with spine fragility. INTRODUCTION Fragility fractures are frequent in DMD. The purpose of this study was to identify clinical factors associated with prevalent vertebral fractures (VF) in boys, teens/young adults with Duchenne muscular dystrophy (DMD). METHODS This was a cross-sectional study of males aged 4-25 years with DMD. VF were evaluated using the modified Genant semi-quantitative method on T4-L4 lateral spine radiographs. Areal bone mineral density (aBMD) was measured at the lumbar spine (LS) and used to estimate volumetric BMD (vBMD). Clinical factors were analyzed for their association with the Spinal Deformity Index (SDI, the sum of the Genant grades). RESULTS Sixty participants were enrolled (mean age 11.5 years, range 5.4-19.5). Nineteen participants (32%) had a total of 67 VF; 23/67 VF (34%) were moderate or severe. Participants with VF were shorter (mean height Z-score ± standard deviation: - 3.1 ± 1.4 vs. - 1.8 ± 1.4, p = 0.001), had longer glucocorticoid exposure (mean duration 6.0 ± 3.3 vs. 3.9 ± 3.3 years, p = 0.027), greater bone age (BA) delay (mean BA to chronological age difference - 3.2 ± 3.4 vs. - 1.3 ± 1.2 years, p = 0.035), and lower LSaBMD Z-scores (mean - 3.0 ± 1.0 vs. - 2.2 ± 1.2, p = 0.023). There was no difference in LSvBMD Z-scores. Multivariable Poisson regression showed that every 0.1 mg/kg/day increment in average glucocorticoid daily dose was associated with a 1.4-fold SDI increase (95% confidence interval: 1.1-1.7, p = 0.013). Greater BA delay (p < 0.001), higher weight Z-score (p = 0.004), decreased height Z-score (p = 0.025), and lower LSvBMD Z-score (p = 0.025) were also associated with SDI increase. CONCLUSION Readily measurable clinical variables were associated with prevalent VF in males with glucocorticoid-treated DMD. These variables may be useful to identify candidates for primary osteoporosis prevention after glucocorticoid initiation.
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Affiliation(s)
- Kim Phung
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Laura McAdam
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hugh J McMillan
- Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Stefan Jackowski
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Maya Scharke
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | | | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Khaldoun Koujok
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Kevin Smit
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Scott Walker
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Colleen Hartigan
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nasrin Khan
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Victor N Konji
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Lynn MacLeay
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Marika Page
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Elizabeth Sykes
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Marie-Eve Robinson
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Nathalie Alos
- CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | | | - Josephine Ho
- Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | | | - Robert Stein
- London Health Sciences Centre, Western University, London, ON, Canada
| | - David Saleh
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - B Catharine Craven
- Department of Medicine, Temerty Faculty of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Utkarsh J Dang
- Department of Health Sciences, Carleton University, Ottawa, ON, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Frank Rauch
- Shriners Hospital for Children, McGill University, Montreal, QC, Canada
| | - Leanne M Ward
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
- The Ottawa Pediatric Bone Health Research Group, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
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3
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Tsaknakis K, Jäckle K, Lüders KA, Lorenz HM, Braunschweig L, Hell AK. Reduced bone mineral density in adolescents with Duchenne Muscular Dystrophy (DMD) and scoliosis. Osteoporos Int 2022; 33:2011-2018. [PMID: 35583603 PMCID: PMC9463342 DOI: 10.1007/s00198-022-06416-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/28/2022] [Indexed: 11/22/2022]
Abstract
UNLABELLED Duchenne muscular dystrophy is a progressive disease usually associated with loss of ambulation and progressive scoliosis. Immobilisation and glucocorticoid treatment are predisposing factors for reduced bone mineral density (BMD). Analysis of quantitative computed tomography revealed low BMD in thoracic and lumbar vertebrae in comparison to age- and sex-matched healthy controls. INTRODUCTION Evaluation of vertebral bone mineral density (BMD) in Duchenne Muscular Dystrophy (DMD) adolescents with untreated advanced scoliosis and comparison with the BMD values of healthy age-matched controls, based on quantitative computer tomography. METHODS Thirty-seven DMD adolescents (age 15.6 ± 2.5 years) with spinal deformity were evaluated clinically and radiologically prior to definite spinal fusion and compared to 31 male and age-matched healthy individuals (age 15.7 ± 2.3 years). Data related to previous medical treatment, physiotherapy and ambulatory status was also analysed. Scoliotic curves were measured on plain sitting radiographs of the spine. The BMD Z-scores of the thoracic and lumbar vertebrae were calculated with QCTpro® (Mindways Software Inc., USA), based on data sets of preoperative, phantom pre-calibrated spinal computed tomography scans. RESULTS A statistically significant lower BMD could be found in DMD adolescents, when compared to healthy controls, showing an average value for the lumbar spine of 80.5 ± 30.5 mg/cm3. Z-scores deteriorated from the upper thoracic towards the lower lumbar vertebrae. All but the uppermost thoracic vertebrae had reduced BMD values, with the thoracolumbar and lumbar region demonstrating the lowest BMD. No significant correlation was observed between BMD and the severity of the scoliotic curve, previous glucocorticoid treatment, cardiovascular impairment, vitamin D supplementation, non-invasive ventilation or physiotherapy. CONCLUSION DMD adolescents with scoliosis have strongly reduced BMD Z-scores, especially in the lumbar spine in comparison to healthy controls. These findings support the implementation of a standardised screening and treatment protocol. Level of evidence/clinical relevance: therapeutic level III.
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Affiliation(s)
- K. Tsaknakis
- grid.411984.10000 0001 0482 5331Paediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany
| | - K. Jäckle
- grid.411984.10000 0001 0482 5331Department of Trauma Surgery, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany
| | - K. A. Lüders
- grid.411984.10000 0001 0482 5331Paediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany
| | - H. M. Lorenz
- grid.411984.10000 0001 0482 5331Paediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany
| | - L. Braunschweig
- grid.411984.10000 0001 0482 5331Paediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany
| | - A. K. Hell
- grid.411984.10000 0001 0482 5331Paediatric Orthopaedics, Department of Trauma, Orthopaedic and Plastic Surgery, University Medical Center Goettingen, 37075 Goettingen, Germany
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4
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Rodd C, Kirouac N, Orkin J, Grimes R. Evaluating and optimizing bone health in children with chronic health conditions. Paediatr Child Health 2022; 27:232-242. [PMID: 35859678 DOI: 10.1093/pch/pxac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
Paediatric health care providers (HCPs) play an important role in optimizing bone health. Early intervention is essential to maximize the accrual of peak bone mass in adolescence and young adulthood and to reduce osteoporosis and fracture risk later in life. Children and adolescents with chronic health conditions may have several risk factors for poor bone health, including underlying inflammatory conditions, reduced weight-bearing activity, delayed puberty, and inadequate intake of calcium and vitamin D. Some medications-particularly glucocorticoids-can compromise bone mass and place a child at risk for fragility fractures. This practice point describes a targeted approach to identifying bone health risk factors in children and youth with chronic health conditions, highlights office initiatives aimed at optimizing bone mass accrual, and links HCPs to useful web-based tools and medical references. Indications for referral to a bone health specialist and bone-specific pharmacotherapeutic interventions are also reviewed.
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Affiliation(s)
- Celia Rodd
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Nicole Kirouac
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Julia Orkin
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
| | - Ruth Grimes
- Canadian Paediatric Society, Community Paediatrics Committee, Ottawa, Ontario, Canada
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Rodd C, Kirouac N, Orkin J, Grimes R. L'évaluation et l'optimisation de la santé osseuse chez les enfants ayant des affections chroniques. Paediatr Child Health 2022; 27:232-242. [PMID: 35859683 DOI: 10.1093/pch/pxac035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 11/29/2021] [Indexed: 11/12/2022] Open
Abstract
Les professionnels de la santé des enfants jouent un rôle important dans l'optimisation de la santé osseuse. Il est essentiel d'intervenir rapidement pour maximiser le pic de masse osseuse à l'adolescence et au début de l'âge adulte et d'ainsi réduire le risque d'ostéoporose et de fractures plus tard dans la vie. Les enfants et les adolescents ayant une affection chronique peuvent présenter plusieurs facteurs de risque de mauvaise santé osseuse, notamment des maladies inflammatoires sous-jacentes, des activités avec mise en charge limitées, un retard pubertaire et un apport insuffisant de calcium et de vitamine D. Certains médicaments, et particulièrement les glucocorticoïdes, peuvent compromettre la masse osseuse et exposer l'enfant à un risque de fractures de fragilisation. Le présent point de pratique décrit une approche ciblée pour déterminer les facteurs de risque liés à la santé osseuse chez les enfants et les adolescents ayant une affection chronique, expose les mesures à prendre en cabinet pour optimiser l'acquisition de la masse osseuse et propose des outils en ligne utiles et des références médicales à l'intention des professionnels de la santé des enfants. Les indications pour diriger les patients vers un spécialiste de la santé osseuse et pour procéder à des interventions pharmacologiques visant les os sont également abordées.
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Affiliation(s)
- Celia Rodd
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Nicole Kirouac
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Julia Orkin
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
| | - Ruth Grimes
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire, Ottawa (Ontario) Canada
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6
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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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Missiuna PC, Sarraj M, Bosakhar B, Thornley P, Donnellan J, Kishta W, Darby P, Maizlin ZV. Vertebroplasty for Treatment of Steroid-Induced Osteoporotic Vertebral Compression Fractures in an Adolescent With Duchenne Muscular Dystrophy. HSS J 2021; 17:223-226. [PMID: 34421434 PMCID: PMC8361581 DOI: 10.1177/1556331621990648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/23/2020] [Indexed: 12/03/2022]
Affiliation(s)
- Paul C. Missiuna
- Department of Surgery, Division of Orthopedic Surgery, McMaster University Medical Centre, Hamilton, ON, Canada,Paul C. Missiuna, MD, FRCS (C), Department of Surgery, Division of Orthopedic Surgery, McMaster University Medical Centre, Hamilton, ON L8N 3Z5, Canada.
| | - Mohamed Sarraj
- Department of Surgery, Division of Orthopedic Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Batool Bosakhar
- Department of Surgery, Division of Orthopedic Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Patrick Thornley
- Department of Surgery, Division of Orthopedic Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | - John Donnellan
- Department of Radiology, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Waleed Kishta
- Department of Surgery, Division of Orthopedic Surgery, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Peter Darby
- Department of Anesthesia, McMaster University Medical Centre, Hamilton, ON, Canada
| | - Zeev V. Maizlin
- Department of Radiology, McMaster University Medical Centre, Hamilton, ON, Canada
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8
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Thandrayen K, Kala UK, Lala N, Okudo G, Parbhoo KB, Moosa FY, Verwey C, Hauptfleisch M, Hajinicolaou C, Ambaram PR, Mistry BJ, Petersen KL, Pettifor JM. Bone mass and vertebral fractures in South African children on prolonged oral glucocorticoids for chronic non-malignant illnesses. Bone Rep 2021; 14:100751. [PMID: 33644265 PMCID: PMC7887385 DOI: 10.1016/j.bonr.2021.100751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/05/2022] Open
Abstract
Introduction We hypothesized that the prevalence of vertebral fractures would be low and that bone mineral density (BMD) would be less severely affected in a black South African (SA) population treated with glucocorticoids (GCs) than that reported in mainly white populations. Methods All children aged 5–17.9 years with chronic non-malignant illnesses who were on GCs (intravenous or oral) for greater than 3 months duration were evaluated. DXA scans were performed using a Hologic Discovery machine (Software version Apex 4.0.2) and the Hologic paediatric reference database. Whole body less head (WBLH) and lumbar spine (LS) bone mineral content (BMC) and density (BMD) Z-scores unadjusted and adjusted for height were calculated using the Zemel equation calculator. Results Seventy-two patients (49% with renal, 24% with rheumatic, 14% with neurological, 11% with hepatic and 3% with respiratory conditions; mean age 11.6 ± 3.3 years, 57% boys, 92% SA black) were enrolled. The mean duration of GC treatment was 34.1 (±25.1) months. Mean WBLH and LS height adjusted BMD Z-scores were −1.2 ± 1.5 and −0.9 ± 1.0 respectively. Eleven percent of patients had a LS height adjusted BMD Z-score ≤ −2. The prevalence of vertebral fractures on lateral vertebral fracture assessment (VFA) was 15% (11 of 72 patients). Conclusion The prevalence of vertebral fractures (15%) in predominantly black children on GCs with chronic non-malignant illnesses is similar to that reported from North America suggesting that routine yearly DXA scans including VFA are warranted in this highly at-risk population. Prevalence of vertebral fractures in black South African children on GCs is 15%. Majority of patients had 25(OH)D levels >30 nmol/L. A quarter of the patients with vitamin D deficiency had a LS BMD Z score ≤ −2. None of the vitamin D deficient patients had vertebral fractures. Routine yearly DXA scans are thus warranted on all children treated with GCs.
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Affiliation(s)
- Kebashni Thandrayen
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Udai Keshav Kala
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nilesh Lala
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Grace Okudo
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kiran Bhagoo Parbhoo
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fatima Yakoub Moosa
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Charl Verwey
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marc Hauptfleisch
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Christina Hajinicolaou
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Priya Ramanlal Ambaram
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bhadrish Jayantkumar Mistry
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Lavinia Petersen
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - John Morley Pettifor
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Cox M, Sandler RD, Matucci-Cerinic M, Hughes M. Bone health in idiopathic inflammatory myopathies. Autoimmun Rev 2021; 20:102782. [PMID: 33609795 DOI: 10.1016/j.autrev.2021.102782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Miriam Cox
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert D Sandler
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence & Division of Rheumatology AOUC, Florence, Italy
| | - Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Shah N, Khadilkar A, Ekbote V, Mughal Z, Gondhalekar K, Khadilkar S, Ramanan V, Khadilkar V, Padidela R. DXA and pQCT derived parameters in Indian children with beta thalassemia major - A case controlled study. Bone 2021; 143:115730. [PMID: 33137537 DOI: 10.1016/j.bone.2020.115730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/26/2020] [Accepted: 10/20/2020] [Indexed: 01/19/2023]
Abstract
Children with beta thalassemia major (BTM) are known to have reduced bone mass which increases incidence of non-traumatic fractures. Few studies have assessed prevalence of fractures and bone health in underprivileged children with BTM. Our objectives were to 1) determine prevalence of fractures in underprivileged Indian children with BTM, 2) assess size corrected bone density and bone geometry using Dual x-ray absorptiometry (DXA) and peripheral quantitative computerized tomography (pQCT) in these children and healthy controls 3) determine predictors of fractures in children with BTM 4) compare differences in bone density between children with BMT with and without fractures. Bone mineral content and areal bone mineral density (aBMD) of lumbar spine and whole body and vertebral fracture assessment (VFA) was performed by DXA in 334 children (3-18 years, 167 BTM + 167 controls). Volumetric BMD (vBMD) and bone geometry were assessed by pQCT (subset, 70 BTM, 70 healthy) at distal radius. Children with BTM had higher prevalence of vertebral and long bone fractures (p < 0.05). DXA aBMD was lower in children with BTM (p < 0.05), whereas, lumbar spine bone mineral apparent density (LSBMAD) was higher (p > 0.05). Children with BTM had lower total distal radial vBMD, cortical vBMD and strength strain index (SSI) at 66% site whereas, distal radial trabecular vBMD at 4% was higher (p < 0.05). On height adjustment, children with BTM had lower muscle area and cortical thickness and higher marrow area (p < 0.05) at 66% site. Age, body size, total body less head (TBLH) aBMD and strength strain index (SSI) were important predictors of fractures in children with BTM. Thus, children with BTM had higher prevalence of non-traumatic fractures. Despite lower areal and volumetric densities, they had higher LSBMAD and trabecular densities which may be attributed to erythroid hyperplasia and iron deposition due to inadequate transfusion and chelation. As LSBMAD is raised in these children, it is unlikely to identify BTM subjects at risk of fracture; VFA thus maybe useful in identifying asymptomatic vertebral fractures.
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Affiliation(s)
- Nikhil Shah
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Anuradha Khadilkar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India.
| | - Veena Ekbote
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Zulf Mughal
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University, NHS Foundation Trust, Manchester, UK
| | - Ketan Gondhalekar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Shachi Khadilkar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Vijay Ramanan
- Clinical Hematology and Transplant, Yashoda Hematology Clinic, Pune, Maharashtra, India
| | - Vaman Khadilkar
- Department of Growth and Pediatric Endocrinology, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University, NHS Foundation Trust, Manchester, UK
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Fiscaletti M, Samoilenko M, Dubois J, Miron MC, Lefebvre G, Krajinovic M, Laverdière C, Sinnett D, Alos N. Predictors of Vertebral Deformity in Long-Term Survivors of Childhood Acute Lymphoblastic Leukemia: The PETALE Study. J Clin Endocrinol Metab 2021; 106:512-525. [PMID: 33150433 DOI: 10.1210/clinem/dgaa806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prevalence of vertebral deformities in long-term survivors of childhood acute lymphoblastic leukemia (ALL) is unknown. Our objectives were to identify the prevalence of vertebral deformities and their risk factors among long-term childhood ALL survivors. METHODS/RESULTS We recruited 245 (49% male) long-term childhood ALL survivors from the Preventing Late Adverse Effects of Leukemia Cohort (French-Canadian ALL survivors treated between the years 1987 and 2010 with the Dana Farber Cancer Institute clinical trials protocols, who did not experience disease relapse and/or receive hematopoietic stem cell transplant). Median age at recruitment was 21.7 years (range, 8.5-41) and median time since diagnosis was 15.1 years (range, 5.4-28.2). All participants underwent spine radiograph and dual-energy X-ray absorptiometry scans. The prevalence of vertebral deformity was 23% with 88% classified as grade 1 according to the Genant method. The majority of vertebral deformities were clinically silent. Regression analysis confirmed male sex (risk ratio [RR] = 1.94; 95% confidence interval [CI], 1.16-3.24; P = 0.011), higher glucocorticoid cumulative dose (RR = 1.05; 95% CI, 1.00-1.10; P = 0.032), and back pain (RR = 2.44; 95% CI, 1.56-3.84; P < 0.001) as predictors of prevalent vertebral deformity. Sex differences in vertebral deformity predictors emerged. CONCLUSIONS We report a significant prevalence of vertebral deformities in this young cohort. Male sex, cumulative glucocorticoid dose, and back pain were identified as predictors of prevalent vertebral deformity. Back pain emerging as a strong predictor of vertebral deformity underscores the importance of ongoing bone health surveillance in survivors with persistent vertebral deformities treated with these earlier protocols.
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Affiliation(s)
- Melissa Fiscaletti
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
| | - Mariia Samoilenko
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
- Université du Québec à Montréal (UQAM), Montréal, Québec, Canada
| | - Josée Dubois
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
| | - Marie-Claude Miron
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
| | | | - Maja Krajinovic
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
| | - Caroline Laverdière
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
| | - Daniel Sinnett
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
| | - Nathalie Alos
- CHU Sainte Justine Mother and Child University Hospital Center (CHUSJ), Montréal, Québec, Canada
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Edouard T, Guillaume-Czitrom S, Bacchetta J, Sermet-Gaudelus I, Dugelay E, Martinez-Vinson C, Salles JP, Linglart A. Guidelines for the management of children at risk of secondary bone fragility: Expert opinion of a French working group. Arch Pediatr 2020; 27:393-398. [PMID: 32921532 DOI: 10.1016/j.arcped.2020.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 07/30/2020] [Indexed: 11/30/2022]
Abstract
The current French national guidelines were elaborated by a working group consisting of experts in the field of pediatric endocrinology, rheumatology, hepatogastroenterology, nephrology, and pneumology. A systematic search was undertaken of the literature published between 2008 and 2018 and indexed in PubMed. The recommendations developed were then validated by an external evaluation group comprising representatives from the various highly specialized fields in pediatrics, representatives of the societies and groups supporting the development of the guidelines, and representatives of different healthcare professions. The objective of these guidelines was to detail the current optimal management of children at risk of secondary bone fragility.
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Affiliation(s)
- T Edouard
- Unité d'endocrinologie, maladies osseuses et génétique, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, ERN BOND, hôpital des Enfants, CHU de Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France.
| | - S Guillaume-Czitrom
- AP-HP, médecine des adolescents, GHU Bicêtre Paris-Saclay, 94270 Le Kremlin-Bicêtre cedex, France
| | - J Bacchetta
- Service de néphrologie, rhumatologie et dermatologie pédiatrique, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, CHU de Lyon, 69677 Bron cedex, France
| | | | - E Dugelay
- Service de gastroentérologie et hépatologie pédiatrique, CHU Robert-Debré, 75019 Paris, France
| | - C Martinez-Vinson
- Service de gastroentérologie et hépatologie pédiatrique, CHU Robert-Debré, 75019 Paris, France
| | - J P Salles
- Unité d'endocrinologie, maladies osseuses et génétique, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, ERN BOND, hôpital des Enfants, CHU de Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse cedex 9, France
| | - A Linglart
- AP-HP, endocrinologie et diabète de l'enfant, centre de référence des maladies rares du calcium et du phosphate, filière OSCAR, GHU Bicêtre Paris-Saclay, 94270 Le Kremlin-Bicêtre cedex, France
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13
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Diagnosis of osteoporotic vertebral fractures in children. Pediatr Radiol 2019; 49:283-296. [PMID: 30421000 PMCID: PMC6394483 DOI: 10.1007/s00247-018-4279-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/03/2018] [Accepted: 10/05/2018] [Indexed: 12/11/2022]
Abstract
Osteoporosis is a generalised disorder of the skeleton with reduced bone density and abnormal bone architecture. It increases bone fragility and renders the individual susceptible to fractures. Fractures of the vertebrae are common osteoporotic fractures. Vertebral fractures may result in scoliosis or kyphosis and, because they may be clinically silent, it is imperative that vertebral fractures are diagnosed in children accurately and at an early stage, so the necessary medical care can be implemented. Traditionally, diagnosis of osteoporotic vertebral fractures has been from lateral spine radiographs; however, a small number of studies have shown that dual energy x-ray absorptiometry is comparable to radiographs for identifying vertebral fractures in children, while allowing reduced radiation exposure. The diagnosis of vertebral fractures from dual energy x-ray absorptiometry is termed vertebral fracture assessment. Existing scoring systems for vertebral fracture assessment in adults have been assessed for use in children, but there is no standardisation and observer reliability is variable. This literature review suggests the need for a semiautomated tool that (compared to the subjective and semiquantitative methods available) will allow more reliable and precise detection of vertebral fractures in children.
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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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15
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Harrington J, Holmyard D, Silverman E, Sochett E, Grynpas M. Bone histomorphometric changes in children with rheumatic disorders on chronic glucocorticoids. Pediatr Rheumatol Online J 2016; 14:58. [PMID: 27832795 PMCID: PMC5103510 DOI: 10.1186/s12969-016-0119-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/03/2016] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Rheumatic diseases are associated with an increased fracture risk. The tissue level characteristics of the bone involvement in children have not been well elucidated. Our objectives were to describe the bone micro-architectural characteristics in children with rheumatic diseases on chronic glucocorticoids, and to determine associations between micro-architectural findings with clinical and radiological variables. METHODS Children on chronic glucocorticoids for an underlying rheumatic disease were referred for evaluation of bone fragility given the presence of vertebral compression fractures. A trans-iliac bone biopsy was performed as part of the clinical assessment. Histomorphometric analysis and quantitative backscattered electron imaging (qBSE) of the biopsy samples were undertaken. RESULTS Data of 15 children (14.0 ± 3.2 years) with a duration of glucocorticoid exposure of 6.2 ± 4.1 years and average prednisone dose of 14.1 ± 6.2 mg/m2/day were assessed. Histomorphometric analyses demonstrated significant decrease in trabecular thickness (p = 0.01), osteoid thickness (p < 0.01), osteoblast surface (p = 0.02) and increase in trabecular separation (p = 0.04) compared to published age-matched normative data. Severity of the trabecular deficit was correlated to glucocorticoid dose, height and body mass index Z score, but not bone mineral density or measures of disease activity. Using qBSE to measure bone mineralization, the subjects were shown to have a heterogeneous and hypermineralized profile, with higher cumulative glucocorticoid dose being associated with greater mineralization (p < 0.01). CONCLUSIONS In children with rheumatic diseases presenting with vertebral fractures, there is evidence of abnormal bone matrix mineralization and impairments of bone micro-architecture that correlate to glucocorticoid dose.
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Affiliation(s)
- Jennifer Harrington
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada. .,Division of Endocrinology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G1X8, Canada.
| | - Douglas Holmyard
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Earl Silverman
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada ,Division of Rheumatology, Hospital for Sick Children, Toronto, Canada
| | - Etienne Sochett
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Marc Grynpas
- Samuel Lunenfeld Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada
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16
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Abstract
This article reviews the manifestations and risk factors associated with osteoporosis in childhood, the definition of osteoporosis and recommendations for monitoring and prevention. As well, this article discusses when a child should be considered a candidate for osteoporosis therapy, which agents should be prescribed, duration of therapy and side effects. There has been significant progress in our understanding of risk factors and the natural history of osteoporosis in children over the past number of years. This knowledge has fostered the development of logical approaches to the diagnosis, monitoring, and optimal timing of osteoporosis intervention in this setting. Current management strategies are predicated upon monitoring at-risk children to identify and then treat earlier rather than later signs of osteoporosis in those with limited potential for spontaneous recovery. On the other hand, trials addressing the prevention of the first-ever fracture are still needed for children who have both a high likelihood of developing fractures and less potential for recovery. This review focuses on the evidence that shapes the current approach to diagnosis, monitoring, and treatment of osteoporosis in childhood, with emphasis on the key pediatric-specific biological principles that are pivotal to the overall approach and on the main questions with which clinicians struggle on a daily basis. The scope of this article is to review the manifestations of and risk factors for primary and secondary osteoporosis in children, to discuss the definition of pediatric osteoporosis, and to summarize recommendations for monitoring and prevention of bone fragility. As well, this article reviews when a child is a candidate for osteoporosis therapy, which agents and doses should be prescribed, the duration of therapy, how the response to therapy is adjudicated, and the short- and long-term side effects. With this information, the bone health clinician will be poised to diagnose osteoporosis in children and to identify when children need osteoporosis therapy and the clinical outcomes that gauge efficacy and safety of treatment.
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Affiliation(s)
- L M Ward
- Pediatric Bone Health Clinical and Research Programs, Children's Hospital of Eastern Ontario, Ottawa, ON, K1H 8L1, Canada.
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
| | - V N Konji
- Pediatric Bone Health Clinical and Research Programs, Children's Hospital of Eastern Ontario, Ottawa, ON, K1H 8L1, Canada
| | - J Ma
- Pediatric Bone Health Clinical and Research Programs, Children's Hospital of Eastern Ontario, Ottawa, ON, K1H 8L1, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
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17
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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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18
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LeBlanc CMA, Ma J, Taljaard M, Roth J, Scuccimarri R, Miettunen P, Lang B, Huber AM, Houghton K, Jaremko JL, Ho J, Shenouda N, Matzinger MA, Lentle B, Stein R, Sbrocchi AM, Oen K, Rodd C, Jurencak R, Cummings EA, Couch R, Cabral DA, Atkinson S, Alos N, Rauch F, Siminoski K, Ward LM. Incident Vertebral Fractures and Risk Factors in the First Three Years Following Glucocorticoid Initiation Among Pediatric Patients With Rheumatic Disorders. J Bone Miner Res 2015; 30:1667-75. [PMID: 25801315 PMCID: PMC4556451 DOI: 10.1002/jbmr.2511] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/10/2015] [Accepted: 03/13/2015] [Indexed: 12/21/2022]
Abstract
Vertebral fractures are an important yet underrecognized manifestation of osteoporosis in children with chronic, glucocorticoid-treated illnesses. Our goal was to determine the incidence and clinical predictors of vertebral fractures in the 3 years following glucocorticoid initiation among pediatric patients with rheumatic disorders. Incident vertebral fractures were evaluated according to the Genant semiquantitative method on lateral radiographs at baseline and then annually in the 3 years following glucocorticoid initiation. Extended Cox models were used to assess the association between vertebral fractures and clinical risk predictors. A total of 134 children with rheumatic disorders were enrolled in the study (mean ± standard deviation (SD) age 9.9 ± 4.4 years; 65% girls). The unadjusted vertebral fracture incidence rate was 4.4 per 100 person-years, with a 3-year incidence proportion of 12.4%. The highest annual incidence occurred in the first year (6.0%; 95% confidence interval (CI) 2.9% to 11.7%). Almost one-half of the patients with fractures were asymptomatic. Every 0.5 mg/kg increase in average daily glucocorticoid (prednisone equivalents) dose was associated with a twofold increased fracture risk (hazard ratio (HR) 2.0; 95% CI 1.1 to 3.5). Other predictors of increased vertebral fracture risk included: (1) increases in disease severity scores between baseline and 12 months; (2) increases in body mass index Z-scores in the first 6 months of each 12-month period preceding the annual fracture assessment; and (3) decreases in lumbar spine bone mineral density Z-scores in the first 6 months of glucocorticoid therapy. As such, we observed that a clinically significant number of children with rheumatic disorders developed incident vertebral fractures in the 3 years following glucocorticoid initiation. Almost one-half of the children were asymptomatic and thereby would have been undiagnosed in the absence of radiographic monitoring. In addition, discrete clinical predictors of incident vertebral fractures were evident early in the course of glucocorticoid therapy.
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Affiliation(s)
| | - Jinhui Ma
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Johannes Roth
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | | | - Paivi Miettunen
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Adam M Huber
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Kristin Houghton
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | | | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Robert Stein
- Department of Pediatrics, University of Western Ontario, London, ON, Canada
| | | | - Kiem Oen
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Celia Rodd
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Roman Jurencak
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | | | - Robert Couch
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - David A Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | | | - Nathalie Alos
- Department of Pediatrics, Université de Montréal, Montréal, QC, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, and Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
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Kyphoplasty for Intractable Pain Due to Glucocorticosteroid-induced Osteoporotic Vertebra Fracture of a 9-Year-Old Patient With Systemic Lupus Erythematosus: 8-Year Follow-up. J Pediatr Orthop 2015; 35:e55-9. [PMID: 25436482 DOI: 10.1097/bpo.0000000000000346] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT The incidence of glucocorticoid-induced osteoporosis is approximately 50% in patients treated for >6 months, and in the long-term usage fracture risk is approximately 34%. The awareness of pediatric vertebral fractures due to glucocorticoid-induced osteoporosis is increasing. Although most of these fractures are asymptomatic, a small number of children may have severe pain. PURPOSE In this case report we are presenting long-term result of a 9-year-old patient with intractable pain due to glucocorticoid-induced osteoporotic vertebral fracture managed by kyphoplasty. STUDY DESIGN Case report. PATIENT SAMPLE Case report of a 9-year-old girl who had L3 vertebral fracture due to glucocorticoid-induced osteoporosis treated by kyphoplasty. METHODS The patient was a 9-year-old girl with severe back pain, and lupus nephritis. Glucocorticoid-induced L3 vertebral fracture was detected and the case was resistant to conservative treatment. Seeing this, we have performed balloon kyphoplasty procedure to L3 vertebrae. RESULTS No complication and pain was observed after the operation although L3 vertebral height could not restored. On the 8-year control, L3 vertebral height was almost totally restored with a compression index of 10% without any clinical problem. CONCLUSIONS To the best of the authors' knowledge, the patient sample of this case report is the first and the youngest patient who was treated with kyphoplasty for vertebral compression fracture intractable pain due to glucocorticoid-induced osteoporosis, mentioned in literature. During the 8-year follow-up, no adverse effect was reported that was related to kyphoplasty procedure. This case report indicates that kyphoplasty can be an alternative method for selective pediatric intractable painful vertebral glucocorticoid-induced osteoporotic fractures, but it should be performed after careful consideration in pediatric group. We do not advise routine usage of kyphoplasty for pediatric vertebral fractures.
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Buckner JL, Bowden SA, Mahan JD. Optimizing Bone Health in Duchenne Muscular Dystrophy. Int J Endocrinol 2015; 2015:928385. [PMID: 26124831 PMCID: PMC4466394 DOI: 10.1155/2015/928385] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 01/30/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder characterized by progressive muscle weakness, with eventual loss of ambulation and premature death. The approved therapy with corticosteroids improves muscle strength, prolongs ambulation, and maintains pulmonary function. However, the osteoporotic impact of chronic corticosteroid use further impairs the underlying reduced bone mass seen in DMD, leading to increased fragility fractures of long bones and vertebrae. These serious sequelae adversely affect quality of life and can impact survival. The current clinical issues relating to bone health and bone health screening methods in DMD are presented in this review. Diagnostic studies, including biochemical markers of bone turnover and bone mineral density by dual energy X-ray absorptiometry (DXA), as well as spinal imaging using densitometric lateral spinal imaging, and treatment to optimize bone health in patients with DMD are discussed. Treatment with bisphosphonates offers a method to increase bone mass in these children; oral and intravenous bisphosphonates have been used successfully although treatment is typically reserved for children with fractures and/or bone pain with low bone mass by DXA.
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Affiliation(s)
- Jason L. Buckner
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
- *Jason L. Buckner:
| | - Sasigarn A. Bowden
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
| | - John D. Mahan
- Division of Nephrology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA
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Markula-Patjas KP, Ivaska KK, Pekkinen M, Andersson S, Moilanen E, Viljakainen HT, Mäkitie O. High adiposity and serum leptin accompanied by altered bone turnover markers in severe juvenile idiopathic arthritis. J Rheumatol 2014; 41:2474-81. [PMID: 25320222 DOI: 10.3899/jrheum.131107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate interactions between skeleton and adipose tissue, and association of adipokines and bone turnover markers with disease-related factors in patients with severe juvenile idiopathic arthritis (JIA). METHODS Forty-nine patients (median age 14.8 yrs, median disease duration 10.2 yrs) with refractory polyarticular JIA and 89 sex-matched and age-matched healthy controls participated in the study. Study subjects underwent clinical examination, body composition assessment with dual-energy X-ray absorptiometry, and analyses for leptin, adiponectin, and bone turnover markers. RESULTS Patients with JIA were shorter and more often overweight (p = 0.001) or obese (p < 0.001) than controls. They had significantly higher serum leptin, even when adjusted for fat mass (p < 0.001), than did controls. Adiponectin did not differ between the groups. Concentration of carboxyterminal telopeptide of type I collagen was higher (p = 0.006) in patients. The inverse association between leptin and bone turnover markers disappeared in controls but was strengthened in patients when adjusted for fat mass. Leptin, adiponectin, or bone markers did not associate with variables of disease activity. CONCLUSION Patients with severe JIA had high adiposity accompanied by increased bone resorption. Their serum leptin was higher, even independently of fat mass. Leptin tended to associate inversely with bone turnover markers but did not associate with variables of disease activity.
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Affiliation(s)
- Kati P Markula-Patjas
- From the Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere; Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, Turku;Folkhälsan Research Center; Children's Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki; The Immunopharmacology Research Group, University of Tampere School of Medicine, Tampere, Finland.K.P. Markula-Patjas, MD, Pediatric Research Center, University of Tampere and Tampere University Hospital; K.K. Ivaska, PhD, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku; M. Pekkinen, PhD, Folkhälsan Research Center; S. Andersson, MD, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; E. Moilanen, MD, PhD, The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital; H.T. Viljakainen, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; O. Mäkitie, MD, PhD, Folkhälsan Research Center, and Children's Hospital, Helsinki University Central Hospital and University of Helsinki.
| | - Kaisa K Ivaska
- From the Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere; Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, Turku;Folkhälsan Research Center; Children's Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki; The Immunopharmacology Research Group, University of Tampere School of Medicine, Tampere, Finland.K.P. Markula-Patjas, MD, Pediatric Research Center, University of Tampere and Tampere University Hospital; K.K. Ivaska, PhD, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku; M. Pekkinen, PhD, Folkhälsan Research Center; S. Andersson, MD, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; E. Moilanen, MD, PhD, The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital; H.T. Viljakainen, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; O. Mäkitie, MD, PhD, Folkhälsan Research Center, and Children's Hospital, Helsinki University Central Hospital and University of Helsinki
| | - Minna Pekkinen
- From the Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere; Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, Turku;Folkhälsan Research Center; Children's Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki; The Immunopharmacology Research Group, University of Tampere School of Medicine, Tampere, Finland.K.P. Markula-Patjas, MD, Pediatric Research Center, University of Tampere and Tampere University Hospital; K.K. Ivaska, PhD, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku; M. Pekkinen, PhD, Folkhälsan Research Center; S. Andersson, MD, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; E. Moilanen, MD, PhD, The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital; H.T. Viljakainen, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; O. Mäkitie, MD, PhD, Folkhälsan Research Center, and Children's Hospital, Helsinki University Central Hospital and University of Helsinki
| | - Sture Andersson
- From the Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere; Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, Turku;Folkhälsan Research Center; Children's Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki; The Immunopharmacology Research Group, University of Tampere School of Medicine, Tampere, Finland.K.P. Markula-Patjas, MD, Pediatric Research Center, University of Tampere and Tampere University Hospital; K.K. Ivaska, PhD, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku; M. Pekkinen, PhD, Folkhälsan Research Center; S. Andersson, MD, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; E. Moilanen, MD, PhD, The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital; H.T. Viljakainen, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; O. Mäkitie, MD, PhD, Folkhälsan Research Center, and Children's Hospital, Helsinki University Central Hospital and University of Helsinki
| | - Eeva Moilanen
- From the Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere; Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, Turku;Folkhälsan Research Center; Children's Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki; The Immunopharmacology Research Group, University of Tampere School of Medicine, Tampere, Finland.K.P. Markula-Patjas, MD, Pediatric Research Center, University of Tampere and Tampere University Hospital; K.K. Ivaska, PhD, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku; M. Pekkinen, PhD, Folkhälsan Research Center; S. Andersson, MD, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; E. Moilanen, MD, PhD, The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital; H.T. Viljakainen, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; O. Mäkitie, MD, PhD, Folkhälsan Research Center, and Children's Hospital, Helsinki University Central Hospital and University of Helsinki
| | - Heli T Viljakainen
- From the Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere; Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, Turku;Folkhälsan Research Center; Children's Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki; The Immunopharmacology Research Group, University of Tampere School of Medicine, Tampere, Finland.K.P. Markula-Patjas, MD, Pediatric Research Center, University of Tampere and Tampere University Hospital; K.K. Ivaska, PhD, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku; M. Pekkinen, PhD, Folkhälsan Research Center; S. Andersson, MD, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; E. Moilanen, MD, PhD, The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital; H.T. Viljakainen, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; O. Mäkitie, MD, PhD, Folkhälsan Research Center, and Children's Hospital, Helsinki University Central Hospital and University of Helsinki
| | - Outi Mäkitie
- From the Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere; Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku, Turku;Folkhälsan Research Center; Children's Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki; The Immunopharmacology Research Group, University of Tampere School of Medicine, Tampere, Finland.K.P. Markula-Patjas, MD, Pediatric Research Center, University of Tampere and Tampere University Hospital; K.K. Ivaska, PhD, Department of Cell Biology and Anatomy, Institute of Biomedicine, University of Turku; M. Pekkinen, PhD, Folkhälsan Research Center; S. Andersson, MD, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; E. Moilanen, MD, PhD, The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital; H.T. Viljakainen, PhD, Children's Hospital, Helsinki University Central Hospital and University of Helsinki; O. Mäkitie, MD, PhD, Folkhälsan Research Center, and Children's Hospital, Helsinki University Central Hospital and University of Helsinki
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22
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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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23
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Hansen KE, Kleker B, Safdar N, Bartels CM. A systematic review and meta-analysis of glucocorticoid-induced osteoporosis in children. Semin Arthritis Rheum 2014; 44:47-54. [PMID: 24680381 DOI: 10.1016/j.semarthrit.2014.02.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 01/27/2014] [Accepted: 02/07/2014] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To summarize the published effects of systemic glucocorticoid therapy on bone mineral density (BMD) and fractures in children. METHODS We performed a systematic review and meta-analysis of existing literature, using Medline, CINAHL, and Cochrane databases to identify studies of BMD or fractures in children ≤18 years taking systemic glucocorticoid therapy. We excluded studies of inhaled glucocorticoids, chemotherapy, and organ transplantation. Two authors reviewed abstracts for inclusion, read full-text articles to extract data, and rated each study using the Downs-Black scale. RESULTS A total of 16 studies met eligibility criteria, including 10 BMD (287 children) and six fracture (37,819 children) studies. Spine BMD was significantly lower (-0.18; 95% CI = -0.25; -0.10 g/cm(2)) in children taking glucocorticoid therapy, compared to age- and gender-matched healthy controls. Spine BMD was also lower (-0.14; 95% CI = -0.27; 0.00 g/cm(2)) in children taking glucocorticoids, compared to children with the same disease not taking glucocorticoids. Incident clinical fracture rates varied from 2% to 33%. Morphometric vertebral fracture incidence ranged from 6% to 10%, and prevalence was 29-45%. CONCLUSION Published data suggest that children treated with glucocorticoid therapy have lower spine BMD compared to healthy children. Whether children receiving glucocorticoid therapy have lower spine BMD compared to children with milder disease not requiring such therapy is not certain. Clinical and morphometric vertebral fractures are common, although only one study assessed fracture rates in healthy controls. Additional well-designed, prospective studies are needed to evaluate the skeletal effects of glucocorticoid therapy in children.
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Affiliation(s)
- Karen E Hansen
- Department of Medicine, Division of Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Brian Kleker
- Department of Dermatology, Kaiser Permanente, La Mesa, CA
| | - Nasia Safdar
- Department of Medicine, Division of Infectious Disease, William S Middleton Veterans Hospital, Madison, WI; Department of Medicine, Division of Infectious Disease, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Christie M Bartels
- Department of Medicine, Division of Rheumatology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Phan V, Blydt-Hansen T, Feber J, Alos N, Arora S, Atkinson S, Bell L, Clarson C, Couch R, Cummings EA, Filler G, Grant RM, Grimmer J, Hebert D, Lentle B, Ma J, Matzinger M, Midgley J, Pinsk M, Rodd C, Shenouda N, Stein R, Stephure D, Taback S, Williams K, Rauch F, Siminoski K, Ward LM. Skeletal findings in the first 12 months following initiation of glucocorticoid therapy for pediatric nephrotic syndrome. Osteoporos Int 2014; 25:627-37. [PMID: 23948876 PMCID: PMC4100956 DOI: 10.1007/s00198-013-2466-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/16/2013] [Indexed: 02/08/2023]
Abstract
UNLABELLED Incident vertebral fractures and lumbar spine bone mineral density (BMD) were assessed in the 12 months following glucocorticoid initiation in 65 children with nephrotic syndrome. The incidence of vertebral fractures was low at 12 months (6 %) and most patients demonstrated recovery in BMD Z-scores by this time point. INTRODUCTION Vertebral fracture (VF) incidence following glucocorticoid (GC) initiation has not been previously reported in pediatric nephrotic syndrome. METHODS VF was assessed on radiographs (Genant method); lumbar spine bone mineral density (LS BMD) was evaluated by dual-energy X-ray absorptiometry. RESULTS Sixty-five children were followed to 12 months post-GC initiation (median age, 5.4 years; range, 2.3-17.9). Three of 54 children with radiographs (6 %; 95 % confidence interval (CI), 2-15 %) had incident VF at 1 year. The mean LS BMD Z-score was below the healthy average at baseline (mean ± standard deviation (SD), -0.5 ± 1.1; p = 0.001) and at 3 months (-0.6 ± 1.1; p < 0.001), but not at 6 months (-0.3 ± 1.3; p = 0.066) or 12 months (-0.3 ± 1.2; p = 0.066). Mixed effect modeling showed a significant increase in LS BMD Z-scores between 3 and 12 months (0.22 SD; 95 % CI, 0.08 to 0.36; p = 0.003). A subgroup (N = 16; 25 %) had LS BMD Z-scores that were ≤-1.0 at 12 months. In these children, each additional 1,000 mg/m(2) of GC received in the first 3 months was associated with a decrease in LS BMD Z-score by 0.39 at 12 months (95 % CI, -0.71 to -0.07; p = 0.017). CONCLUSIONS The incidence of VF at 1 year was low and LS BMD Z-scores improved by 12 months in the majority. Twenty-five percent of children had LS BMD Z-scores ≤-1.0 at 12 months. In these children, LS BMD Z-scores were inversely associated with early GC exposure, despite similar GC exposure compared to the rest of the cohort.
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Affiliation(s)
- V Phan
- Université de Montréal, Montréal, QC, Canada
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25
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Divasta AD, Feldman HA, Gordon CM. Vertebral fracture assessment in adolescents and young women with anorexia nervosa: a case series. J Clin Densitom 2014; 17:207-11. [PMID: 23562364 PMCID: PMC3743948 DOI: 10.1016/j.jocd.2013.02.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 02/20/2013] [Indexed: 11/19/2022]
Abstract
Rates of vertebral fracture (VF) in young women with anorexia nervosa (AN) are not well understood. We sought to determine the rates of asymptomatic VF in patients suffering from AN, hypothesizing that VF rates would be higher in subjects with low bone mineral density (BMD) Z-scores. We recruited young women with AN (n = 80) for participation in a longitudinal trial. Dual-energy X-ray absorptiometry images of the lateral thoracic and lumbar spines were obtained for VF assessment at 0, 6, 12, and 18 mo. Thirteen subjects (16%) had a low spinal BMD at baseline (BMD Z-score ≤-2 standard deviation). Using the Genant semiquantitative technique, 2 of 80 subjects at baseline (2.5%) had evidence of a single Genant grade 1 deformity. One subject had a Genant grade 2 deformity. Over the 18-mo trial, 10 incident VFs occurred in 9 subjects (12.5%). Using quantitative techniques, only 2 subjects had a more than 15% loss in vertebral height. Neither anthropometric data nor markers of disease severity were associated with fracture. In conclusion, ill young women with AN were at low risk for asymptomatic VF in our cohort. VFs were not predicted by duration of illness, severity of malnutrition, or traditional measures of areal BMD at the lumbar spine.
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Affiliation(s)
- Amy D Divasta
- Division of Adolescent Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Division of Gynecology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Henry A Feldman
- Clinical Research Program and Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Catherine M Gordon
- Division of Adolescent Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Division of Adolescent Medicine, Hasbro Children's Hospital and Brown University, Providence, RI, USA; Division of Endocrinology, Hasbro Children's Hospital and Brown University, Providence, RI, USA
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27
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Abstract
Osteoporosis is a common problem in thalassemics. As the most affected bone is spinal vertebrae, theoretically, it should have the greatest risk of fracture. However, vertebral fracture (VF) in thalassemics was rarely reported. Screening for asymptomatic VF in thalassemics has not been reported. We, therefore, evaluated prevalence of VF in adolescents and young adults with thalassemia. A total of 150 patients with thalassemia, aged 10 years and older were enrolled. Lateral thoracolumbar spine radiography was evaluated. Twenty patients (13%) had VF and 6 of 20 (30%) had multiple VFs. The 2 most common sites of VF were lumbar 1 and thoracic 12 vertebrae. Comparing with the group without VF, thalassemics with VF were older, had more severe degree of thalassemia, history of splenectomy and previous non-VF, more iron chelation use, and longer duration of blood transfusion, but had lower pretransfused hematocrit. Multivariate analysis revealed 2 predictive factors for VF, having severe thalassemia and aged 20 years or older (odds ratio 5.7 and 5.0, respectively). In conclusion, unrecognized asymptomatic VF in thalassemics was not uncommon. Risk factors associated with VF included severe thalassemia and age 20 years or older. Screening for VF in the high-risk patient should be considered.
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28
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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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Siminoski K, Lee KC, Jen H, Warshawski R, Matzinger MA, Shenouda N, Charron M, Coblentz C, Dubois J, Kloiber R, Nadel H, O'Brien K, Reed M, Sparrow K, Webber C, Lentle B, Ward LM. Anatomical distribution of vertebral fractures: comparison of pediatric and adult spines. Osteoporos Int 2012; 23:1999-2008. [PMID: 22109742 PMCID: PMC4067402 DOI: 10.1007/s00198-011-1837-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 08/19/2011] [Indexed: 11/25/2022]
Abstract
SUMMARY We compared the distribution of vertebral fractures in adults and children and found that fractures occurred in different locations in the two age groups. This likely relates to the different shape of the immature spine. INTRODUCTION We hypothesized that the anatomical distribution of vertebral fractures (VF) would be different in children compared to adults. METHODS We compared the distribution of VF defined using the Genant semi-quantitative method (GSQ method) in adults (N = 221; 545 fractures) and in children early in the course of glucocorticoid therapy (N = 44; 94 fractures). RESULTS The average age in the adult cohort was 62.9 years (standard deviation (SD), 13.4 years), 26% was male, the mean lumbar spine Z-score was -1.0 (SD, 1.5), and the corresponding T-score was -2.4 (SD, 1.4). The pediatric cohort median age was 7.7 years (range, 2.1-16.6 years), the mean lumbar spine Z-score was -1.7 (SD, 1.5), 52% was male, and disease categories were acute lymphoblastic leukemia (66%), rheumatological conditions (21%), and nephrotic syndrome (14%). The VF distribution was biphasic in both populations, but the peaks differed in location. In adults, the peaks were at T7/T8 and at T12/L1. In children, the focus was higher in the thoracic spine, at T6/T7, and lower in the lumbar spine, at L1/L2. When children were assessed in two age-defined sub-groups, a biphasic VF distribution was seen in both, but the upward shift of the thoracic focus to T6 was observed only in the older group, with the highest rates of fracture present between ages 7 and 10 years. CONCLUSIONS These results suggest that the anatomical distribution of VF differs between children and adults, perhaps relating to the different shape of the immature spine, notably the changing ratio of kyphosis to lordosis.
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Affiliation(s)
- K Siminoski
- Department of Radiology and Diagnostic Imaging, University of Alberta, 6628-123 Street, Edmonton, AB, Canada, T6H 3T6.
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Godbole TR, Dabadghao P. Glucocorticoid use in children: The problems and solutions. INDIAN JOURNAL OF RHEUMATOLOGY 2012. [DOI: 10.1016/s0973-3698(12)60037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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32
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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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Toiviainen-Salo S, Markula-Patjas K, Kerttula L, Soini I, Valta H, Mäkitie O. The thoracic and lumbar spine in severe juvenile idiopathic arthritis: magnetic resonance imaging analysis in 50 children. J Pediatr 2012; 160:140-6. [PMID: 21839466 DOI: 10.1016/j.jpeds.2011.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 05/10/2011] [Accepted: 06/22/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the prevalence of vertebral fractures as a complication of juvenile idiopathic arthritis (JIA). STUDY DESIGN This cross-sectional study evaluated the prevalence and characteristics of spinal abnormalities in 50 children (aged 7.0-18.7 years) with treatment-resistant JIA by magnetic resonance imaging. Vertebral deformities, endplate irregularities, intervertebral disc involvement, spinal canal, neural foramina, and back muscles were analyzed and correlated with clinical characteristics and bone mineral density. RESULTS Magnetic resonance imaging revealed various abnormalities in 31 patients (62%). Vertebral compression was seen in 28%, disc degeneration in 46%, protrusions in 14%, prolapses in 4%, endplate changes in 26%, and anterior vertebral corner lesions in 16%. Two patients (4%) had mild spinal canal narrowing without medullar involvement; none had neural root compression. Six patients (12%) had mild back muscle atrophy. No correlation was observed between spinal fractures or other vertebral changes and disease activity or duration, pain or bone mineral density; patients with spinal fractures tended to have a higher recent glucocorticoid exposure (P=.086). CONCLUSION Children with severe JIA have a high prevalence of compression fractures and other vertebral, endplate, and disc abnormalities in the thoracic and lumbar spine.
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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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Hero M, Toiviainen-Salo S, Wickman S, Mäkitie O, Dunkel L. Vertebral morphology in aromatase inhibitor-treated males with idiopathic short stature or constitutional delay of puberty. J Bone Miner Res 2010; 25:1536-43. [PMID: 20200972 DOI: 10.1002/jbmr.56] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Aromatase inhibitors (AIs), blockers of estrogen biosynthesis, delay bone maturation and therefore are used increasingly to promote growth in children and adolescents with growth disorders. The effects of treatment on skeletal health are largely unknown. Since estrogen deficiency is associated with various detrimental skeletal effects, we evaluated in this cross-sectional posttreatment study vertebral body morphology, dimensions and endplates, and intervertebral disks by the use of magnetic resonance imaging (MRI) in two cohorts of males previously treated with the AI letrozole or placebo. Males with idiopathic short stature received treatment with letrozole or placebo for 2 years during prepuberty or early puberty; males with constitutional delay of puberty received letrozole or placebo in combination with low-dose testosterone for 1 year during early or midpuberty. In males with idiopathic short stature, mild vertebral body deformities were found in 5 of 11 (45%) letrozole-treated subjects, whereas in the placebo group no deformities were detected (p = .01). In the cohort of males with constitutional delay of puberty, a high prevalence of endplate and intervertebral disk abnormalities was observed in both the letrozole- and the placebo-treated groups. We conclude that AI therapy during prepuberty or early puberty may predispose to vertebral deformities, which probably reflect impaired vertebral body growth rather than impaired bone quality and compression fractures. If AIs are used in growth indications, follow-up of vertebral morphology is indicated.
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Affiliation(s)
- Matti Hero
- Pediatric Endocrinology and Metabolic Bone Diseases, Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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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: 93] [Impact Index Per Article: 6.6] [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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Ward LM, Petryk A, Gordon CM. Use of bisphosphonates in the treatment of pediatric osteoporosis. ACTA ACUST UNITED AC 2009. [DOI: 10.2217/ijr.09.58] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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