Epidemiology of Osteoporosis in Rheumatic Diseases

Role of intravenous immunoglobulins in systemic sclerosis (SSc): A systematic literature review

BACKGROUND

Systemic sclerosis (SSc) is a heterogenous, multi-system autoimmune disease that causes progressive fibrosis of the skin and internal organs, resulting in high morbidity and mortality. Intravenous Immunoglobulin (IVIG) is a therapeutic option for SSc; however, reports of its efficacy have been variable, and its use across multiple organ manifestations of SSc has not been comprehensively reviewed.

AIM

The aim of this study was to systematically assess the existing literature on the role of IVIG use across a range of SSc manifestations.

METHODS

Medline, Embase, Cochrane, Web of Science and Scopus were searched from 01/01/2003-15/04/2024 using terms related to SSc and IVIG. Included studies were English-language full texts, where ≥5 adults with SSc received IVIG, and where a reportable outcome was documented.

RESULTS

Of 418 potentially relevant records, 12 were included in this review, comprising 266 patients across one randomised control trial, two pilot studies, one open label study, seven retrospective studies and one case control study. Eighteen outcomes were documented across five different organ systems: cutaneous, respiratory, musculoskeletal, gastrointestinal, and other (clinical improvement and corticosteroid sparing benefit). Results showed a favourable effect of IVIG in reducing the extent of skin thickening, muscle and joint pain, gastrointestinal symptoms, steroid dosing and improving patient/physician reported quality of life. Whilst IVIG may appear to be less beneficial for respiratory disease, the stabilisation in pulmonary function tests and radiological features may be considered a positive outcome in itself. Limitations included a lack of high-quality studies, and the use of concomitant therapies in many studies, rendering the efficacy of IVIG alone difficult to ascertain.

CONCLUSION

IVIG showed benefit in treating some manifestations of SSc, however there was a lack of convincing evidence for the efficacy in others. The lack of high-quality data highlights the need for further well-designed clinical trials to confirm these findings and inform guidelines for IVIG use.

Osteoporosis in psoriatic arthritis: Risk factors, insufficiency fractures and its association with the disease activity

OBJECTIVE

The prevalence of osteoporosis (OP) and insufficiency fractures in psoriatic arthritis (PsA) remains controversial. The aim of this study was to describe the prevalence of OP and insufficiency fractures in a representative cohort of patients with PsA, and to analyse its association with general risk factors and characteristics of the psoriatic disease in our geographical area.

METHODS

Multi-centric, descriptive study of patients with PsA. We recorded clinical characteristics, as well as protective and risk factors for OP and insufficiency fractures. Hip and lumbar densitometry and lateral X-ray of the spine were evaluated. Descriptive statistics for OP and risk factors were calculated. The patients with OP were compared to those without by univariate analyses, and results were adjusted by age and sex. The association of OP and fractures with clinical characteristics was analysed by logistic regression.

RESULTS

166 patients (50 men; 116 women) were included. OP was present in 26.5%, and it was more frequent in women and patients above 50 years old. Insufficiency fractures occurred in 5.4% of the total sample. In the logistic regression, OP was associated with age over 50 [OR 3.7; 95% CI (1.2-11.6); p=.02]. No association with clinical parameters was found. The most frequent risk factors among patients with OP were vitamin D insufficiency, sedentary behaviour, low calcium intake, and active smoking. In the logistic regression, OP was associated with early menopause [OR 11.7; 95% CI (1.29-106.0); p=.029] and sedentary behaviour [OR 2.3; 95% CI (1.0-5.2); p=.049].

CONCLUSIONS

In patients with PsA, OP is more frequent in women and patients over 50 years old. A sedentary lifestyle and early menopause may add extra risk for OP. Type, duration disease, and treatments are not associated with OP or insufficiency fractures.

Effect of the body mass index, basal metabolic rate, and body fat on the radiofrequency echographic multi-spectrometry (REMS)-based bone mineral density and fracture risk: a cross-sectional study

Radiofrequency echographic multi-spectrometry (REMS) is a method to assess bone mineral density (BMD) of the axial skeleton, fragility score (FS), body mass index (BMI), basal metabolic rate (BMR), and body fat (BF) in %. The aim of the study was to investigate the influence of the BMI, BMR, and BF on the BMD and fracture risk with REMS. We conducted a cross-sectional study among 313 women, aged 20-90 years who underwent a screening for osteoporosis with REMS. Kruskal-Wallis was used to analyze the differences in BMI, BMR, and BF between the groups according to the BMD: normal BMD, osteopenia and osteoporosis and differences in the FS, fracture risk assessment (FRAX) for major osteoporotic fractures and for hip fractures (HF) according to the BMI groups: underweight, normal weight, overweight, obese, and extreme obese. Linear regression was used to assess the correlations BMI-BMD, BMR-BMD, and BF-BMD. BMI, BMR, and BF differed significantly between the groups according to the BMD (p < 0.001, p = 0.028, and p < 0.001, respectively). BMR showed high positive correlation to BMD (R = 0.765) with 95% confidence interval (CI) [0.715, 0.807] and significance of p < 0.001. BMI correlated significantly to BMD (p < 0.001), the correlation was low positive (R = 0.362) with 95% CI [0.262, 0.455]. In the BMI groups, there was significant difference in FRAX for HF and FS with p value 0.014 and < 0.001, respectively. Subjects with low BMI, BMR, and BF are at high risk for osteoporosis. Underweight women show significantly high fracture risk, assessed with FRAX and FS.

Guizhi-Shaoyao-Zhimu decoction attenuates bone erosion in rats that have collagen-induced arthritis via modulating NF-κB signalling to suppress osteoclastogenesis

CONTEXT

Guizhi-Shaoyao-Zhimu decoction (GSZD) is commonly used to treat rheumatoid arthritis (RA), but its mechanism is unclear.

OBJECTIVE

To investigate the effect of GSZD on bone erosion in type II collagen (CII)-induced arthritis (CIA) in rats and to identify the underlying mechanism.

MATERIALS AND METHODS

The CIA model was prepared in male Wistar rats by two subcutaneous injections of CII, 1 mg/mL. Fifty CIA rats were randomized equally into the control group given saline daily, the positive group given saline daily and methotrexate 0.75 mg/kg once a week, and three GSZD-treated groups gavaged daily with 800, 1600 and 3200 mg/kg of GSZD for 21 days. GSZD effects were assessed by paw volume, arthritic severity index and histopathology. Cytokine levels were determined by ELISA. The effects of GSZD on RAW264.7 cells were evaluated by receptor activator of NF-κB ligand (RANKL)-induced osteoclastogenesis and bone resorption assay. Expression of IκB-α and p65 was measured by Western blotting. Major components of GSZD were identified by HPLC.

RESULTS

Arthritis index score, paw volume and bone destruction score showed that GSZD improved inflammatory symptoms and reduced joint tissue erosion (p < 0.01). GSZD decreased RANKL, and the number of osteoclasts (OCs) in joint tissues (p < 0.01) and increased osteoprotegerin levels (p < 0.01). GSZD inhibited RANKL-induced RAW264.7 differentiation and reduced bone resorption by OCs. GSZD upregulated IκB (p < 0.01) and p65 (p < 0.01) in the cytoplasm and downregulated p65 (p < 0.01) in the cell nucleus.

CONCLUSIONS

Guizhi-Shaoyao-Zhimu decoction has an anti-RA effect, suggesting its possible use as a supplement and alternative drug therapy for RA.

The Impact of Rheumatoid Arthritis on Bone Loss: Links to Osteoporosis and Osteopenia

Rheumatoid arthritis (RA) is an autoimmune chronic connective tissue disease that produces persistent systemic inflammation, with joint inflammation leading to function loss and joint destruction. Low bone mass causes skeletal bone loss, commonly referred to as osteopenia or osteoporosis. 

We conducted this literature review to examine the relationship between RA and osteoporosis and the variables contributing to this connection. We used articles from the US National Library of Medicine (PubMed), Google Scholar, Science Direct to access the required information. Eventually, our results concluded that RA could result in local periarticular and generalized bone loss. Many risk factors contribute to this association, such as chronic joints inflammation, glucocorticoid use, genetics, and estrogen hormone effects. Still, it is not clear yet whether this is due to a consequence of treatment, immobility, or the activity of the disease. There are many recommendations by the American College of Rheumatology for RA patients during the disease course to reduce the risk of osteoporosis development, which include early starts of disease-modifying anti-inflammatory drugs (DMARDs), doing a dual-energy x-ray (DXA) or quantitative ultrasound (QUS) for identifying a patient at risk of osteoporosis, taking vitamin D, calcium, and bisphosphonates. Further prospective studies and clinical trials are essential to provide a solid evidence-based recommendation that will help to prevent bone loss in RA patients.

Evaluating the Relationship Between Serum Level of Interleukin-6 and Rheumatoid Arthritis Severity and Disease Activity

AIM

The aim of this study was to evaluate the relationship between Interleukin-6 (IL-6) serum level and the severity and activity of Rheumatoid Arthritis (RA).

METHODS

In this cross-sectional study, 120 RA patients referred to the rheumatology clinic, the patients were diagnosed by rheumatologists according to ACR / EULAR 2010 criteria. Based on DAS28 score the patients were divided into 4 groups: Remission, Mild, Moderate and Severe. Each group contained 30 patients. Serum levels of Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), anti-Cyclic Citrullinated Peptide (anti-CCP) and Rheumatoid Factor (RF) and serum levels of IL-6, were measured. The relationship between these factors was measured and compared to the relationship between IL-6 and these factors, and the activity of the disease was evaluated based on DAS-28.

RESULTS

This study showed that the serum level of IL-6 has a significant relationship with RA activity according to DAS-28 (P value <0.001). There is also a significant relationship between the ESR level, the number of painful joints, and the number of swollen joints, and the severity of the disease based on VAS.

CONCLUSION

Generally the findings of this study indicate that serum level of IL-6 plays an important role in the severity and activity of RA disease and can be considered as a determining factor in evaluating the severity of RA in RA patients and it is a good guide for a step up or down of treatment.

3-D microarchitectural properties and rod- and plate-like trabecular morphometric properties of femur head cancellous bones in patients with rheumatoid arthritis, osteoarthritis, and osteoporosis

Objectives

We quantify 3-D microarchitectural properties of femoral head cancellous bones from patients with rheumatoid arthritis (RA, n ​= ​12), osteoarthritis (OA, n ​= ​15), osteoporosis (OP, n ​= ​24), or donor controls (CNT, n ​= ​8); and investigate their rod- and plate-like trabecular morphometric properties of trabecular bone tissues and compare these properties between them.

Methods

Femoral heads were harvested during total hip replacement surgeries or collected from donors. Four cubic cancellous bone samples produced from each femoral head were micro-CT scanned to quantify their microarchitectural and rod- and plate-like trabecular properties. The samples were then tested in compression to determine mechanical properties.

Results

The microarchitectural properties of femoral head cancellous bone revealed significant differences among the 4 groups, but not between RA and OA. Bone volume fraction was significantly greater in the RA and the OA than in the OP and the CNT. Structure model index was significantly lower in the RA and the OA than in the OP. Number of rods in the RA was significantly greater than in the other 3 groups. Number of plates and plate volume density in the RA and the OA were significantly greater than in the OP and the CNT. Mechanical properties were significantly greater in the RA and the OA than in the OP. The single best determinant for mechanical properties was bone volume fraction.

Conclusions

This study demonstrates significant differences in 3-D microarchitectural properties and rod- and plate-like trabecular morphometric properties among patients with RA, OA, or OP. The RA and OA cancellous bones displayed similar patterns of microarchitectural degeneration and pronounced different microarchitectures from the OP. The OP group revealed the weakest cancellous bone strength, while the RA and OA groups exhibited a compensatory effect that maintains bone tissues, and hence mechanical properties.

The translational potential of this article

The study enhances the understanding of microarchitectural degeneration of diseased cancellous bone. The OP group had the weakest cancellous bone strength, while the RA and OA groups exhibited a compensatory effect that maintains bone tissues, and hence mechanical properties. These results are particularly important for design and survival of joint prosthesis.

Systemic Bone Density at Disease Onset Is Associated With Joint Erosion Progression in Early Naive to Treatment Rheumatoid Arthritis: A Prospective 12-Month Follow-Up Open-Label Study

Objectives: Osteoporosis and bone erosions are hallmarks of rheumatoid arthritis (RA) since disease onset is underpinned by the inflammatory burden. In this observational study, we aimed to dissect the putative RA-related parameters and bone-derived biomarkers associated with systemic and focal bone loss at disease onset and with their progression.

Methods: One-hundred twenty-eight patients with early rheumatoid arthritis (ERA) were recruited at disease onset. At study entry, demographic, clinical, and immunological parameters were recorded. Each ERA patient underwent plain X-rays of the hands and feet at study entry and after 12 months to assess the presence of erosions. After enrollment, each patient was treated according to the recommendations for RA management and followed up based on a treat-to-target (T2T) strategy. At baseline, blood samples for soluble biomarkers were collected from each patient, and plasma levels of osteoprotegerin (OPG), receptor activator of nuclear factor κB ligand (RANKL), Dickkopf-1 (DKK1), and interleukin 6 (IL-6) were assessed by enzyme-linked immunosorbent assay (ELISA). Seventy-one ERA patients underwent bone mineral density (BMD) measurement at the left femoral neck and second to fourth lumbar spine vertebrae (L2–L4) by dual-energy X-ray absorptiometry (DXA).

Results: Among the whole cohort, 34 (26.6%) ERA patients with bone erosions at study entry had a higher disease activity (p = 0.02) and IL-6 plasma levels (p = 0.03) than non-erosive ones. Moreover, at DXA, 33 (46.5%) ERA patients had osteopenia, and 16 (22.5%) had osteoporosis; patients with baseline bone erosions were more likely osteopenic/osteoporotic than non-erosive ones (p = 0.03), regardless of OPG, RANKL, and DKK1 plasma levels. Obese ERA patients were less likely osteopenic/osteoporotic than normal weight ones (p = 0.002), whereas anti-citrullinated protein antibodies (ACPA) positive ERA patients were more likely osteopenic/osteoporotic than ACPA negative ones (p = 0.034). At logistic regression analysis, baseline Disease Activity Score measured on 44 joints (DAS44) [OR: 2.46 (1.11–5.44)] and osteopenic/osteoporosis status [OR: 7.13 (1.27–39.94)] arose as independent factors of erosiveness. Baseline osteopenic/osteoporotic status and ACPA positivity were associated with bone damage progression during the follow-up.

Conclusions: Bone erosions presence is associated with systemic bone loss since the earliest phases of RA, suggesting that the inflammatory burden and autoimmune biology, underpinning RA, represent crucial enhancers of bone remodeling either locally as at systemic level.

Prevalence and factors associated with osteoporosis and bone mineral density testing in psoriatic arthritis

OBJECTIVES

To determine bone mineral density (BMD) in psoriatic arthritis (PsA) patients, factors associated with undergoing BMD testing, and the effect of PsA clinical activity on BMD.

METHODS

Patients attending the University of Toronto PsA Clinic with a BMD from cohort inception to January 2019 were included. Descriptive statistics summarized lumbar spine, femoral neck and total hip T-scores. Cox proportional hazard regression identified predictors for BMD testing. Logistic regression analysis determined odds of having normal (T-score ≥ -1.0) versus osteoporotic range BMD (T-score ≤ -2.5). A multi-state model determined factors associated with BMD state changes over time.

RESULTS

Of the 1479 patients, 214 had BMDs. Mean T-scores at the lumbar spine, femoral neck and total hip were -0.30±0.32, -1.10±1.04 and -0.45±0.42 respectively. Osteopenia and osteoporosis occurred in 45.27% and 12.94% of patients. Increasing age, menopause, elevated acute phase reactants, biologic, methotrexate and systemic glucocorticoid use were associated with a higher chance of undergoing BMD testing. Increased BMI and biologic use were associated with a lower chance of having osteoporotic range BMD. In multi-state analysis, polyarthritis may portend lower BMDs over time, although this did not achieve statistical significance due to low patient numbers.

CONCLUSIONS

The prevalence of osteopenia and osteoporosis in the PsA cohort were similar to the general population. Clinicians are using osteoporosis risk factors and PsA disease severity markers to select patients for BMD testing. Polyarticular disease may portend worse BMDs. Biologic use and increased BMI appear to have a protective effect.

Siglec-15 on Osteoclasts Is Crucial for Bone Erosion in Serum-Transfer Arthritis

Siglec-15 is a conserved sialic acid-binding Ig-like lectin, which is expressed on osteoclasts. Deficiency of Siglec-15 leads to an impaired osteoclast development, resulting in a mild osteopetrotic phenotype. The role of Siglec-15 in arthritis is still largely unclear. To address this, we generated Siglec-15 knockout mice and analyzed them in a mouse arthritis model. We could show that Siglec-15 is directly involved in pathologic bone erosion in the K/BxN serum-transfer arthritis model. Histological analyses of joint destruction provided evidence for a significant reduction in bone erosion area and osteoclast numbers in Siglec-15^-/- mice, whereas the inflammation area and cartilage destruction was comparable to wild-type mice. Thus, Siglec-15 on osteoclasts has a crucial function for bone erosion during arthritis. In addition, we generated a new monoclonal anti-Siglec-15 Ab to clarify its expression pattern on immune cells. Whereas this Ab demonstrated an almost exclusive Siglec-15 expression on murine osteoclasts and hardly any other expression on various other immune cell types, human Siglec-15 was more broadly expressed on human myeloid cells, including human osteoclasts. Taken together, our findings show a role of Siglec-15 as a regulator of pathologic bone resorption in arthritis and highlight its potential as a target for future therapies, as Siglec-15 blocking Abs are available.

Understanding the Role of Interleukin-6 (IL-6) in the Joint and Beyond: A Comprehensive Review of IL-6 Inhibition for the Management of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, debilitating autoimmune disorder involving inflammation and progressive destruction of the joints, affecting up to 1% of the population. The majority of patients with RA have one or more comorbid conditions, the most common being cardiovascular disease, osteoporosis, and depression, the presence of which are associated with poorer clinical outcomes and lower health-related quality of life. RA pathogenesis is driven by a complex network of proinflammatory cells and cytokines, and of these, interleukin-6 (IL-6) plays a key role in the chronic inflammation associated with RA. Through cell signaling that can be initiated by both membrane-bound and soluble forms of its receptor, IL-6 acts both locally to promote joint inflammation and destruction, and in the circulation to mediate extra-articular manifestations of RA, including pain, fatigue, morning stiffness, anemia, and weight loss. This narrative review describes the role of IL-6 in the pathogenesis of RA, its comorbidities, and extra-articular systemic manifestations, and examines the effects of the IL-6 receptor inhibitors sarilumab and tocilizumab on clinical endpoints of RA, patient-reported outcomes, and common comorbidities and extra-articular manifestations.

Complex assessment of bone mineral density, fracture risk, vitamin D status, and bone metabolism in Hungarian systemic sclerosis patients

Objective

We wished to determine bone alterations in systemic sclerosis (SSc) patients by conventional densitometry (DXA), peripheral quantitative computed tomography (pQCT), and bone biomarkers.

Methods

We included 44 SSc patients and 33 age-matched healthy controls. Lumbar spine and femoral neck bone mineral density (BMD) was assessed by DXA. Volumetric BMD was measured by pQCT at the radius. FRAX, 25-hydroxyvitamin-D₃ (25-OH-D₃), parathyroid hormone, osteocalcin, C-terminal collagen telopeptide, and procollagen type I amino-terminal propeptide were also assessed.

Results

SSc patients had lower L2–4 BMD (0.880 ± 0.108 vs. 0.996 ± 0.181 g/cm²; p = 0.019) and femoral neck (FN) BMD (0.786 ± 0.134 vs. 0.910 ± 0.090 g/cm²; p = 0.007) by DXA. In SSc vs. controls, pQCT indicated lower mean cortical (328.03 ± 103.32 vs. 487.06 ± 42.45 mg/cm³; p < 0.001) and trabecular density (150.93 ± 61.91 vs. 184.76 ± 33.03 mg/cm³; p = 0.037). Vitamin D₃ deficiency was more common in SSc vs. controls (60.0% vs. 39.3%; p = 0.003). L2–4 (p = 0.002) and FN BMD (p = 0.015) positively correlated with BMI. pQCT assessments confirmed an inverse correlation between pulmonary manifestation and total (p = 0.024), trabecular (p = 0.035), and cortical density (p = 0.015). Anti-Scl70 positivity inversely correlated with pQCT total density (p = 0.015) and the presence of digital ulcers with cortical density (p = 0.001). We also found that vertebral and FN BMD as determined by DXA significantly correlated with pQCT total, trabecular, and cortical density (p < 0.05).

Conclusion

The results of our study suggest that bone loss in SSc patients may be associated with lower BMI, anti-Scl70 positivity, and the presence of pulmonary manifestations and digital ulcers. Both DXA and pQCT are appropriate tools to evaluate the bone alterations in SSc patients.

Prevalence and risk factors associated with vertebral osteoporotic fractures in patients with rheumatoid arthritis

OBJECTIVES

To explore the prevalence and risk factors of osteoporosis (OP) and vertebral osteoporotic fracture (VOPF) in patients with rheumatoid arthritis (RA).

METHODS

Anteroposterior and lateral X-ray examination of the vertebral column (T4-L4) was used for the semi-quantitative assessment of VOPF. Bone mineral density was measured by dual-energy X-ray absorptiometry.

RESULTS

Of 865 RA patients, the prevalence of OP and VOPF was 33.6% and 20.2%, respectively. Patients with OP or VOPF were older, and had longer term use and a larger daily amount and cumulative dose of glucocorticoids (GCs), longer disease duration, and higher Health Assessment Questionnaire (HAQ) scores and Sharp scores than patients without OP or VOPF (P < 0.05). OP was also correlated with higher disease activity. The patients treated with GCs had higher incidences of OP and VOPF than the patients without GCs (P < 0.05). The cutoff values in the area under curve (AUC) of the daily dose or treatment course of GCs-VOPF were 9 mg and 37.5 days. Older age, female sex, and a higher Sharp score were risk factors for OP in RA patients, while higher BMI was a protective factor. Older age and a high GC daily dose were risk factors for VOPF in RA patients.

CONCLUSIONS

RA patients have a high prevalence of OP and VOPF. Older age, female sex, lower BMI, and higher activity and severity of RA are closely related with OP. Older age and a higher GC daily dose are risk factors for VOPF in RA patients. Key Points • Older age, female sex, lower BMI, and a higher Sharp score were risk factors for OP in RA patients. • Older age and a high GC daily dose were risk factors for VOPF in RA patients. • OP and VOPF in RA patients were correlated with longer disease duration and higher severity of RA.

Bone mineral density and serum osteocalcin levels in patients with gout

Objective: The objective of the study is to evaluate the relation of gout with osteoporosis and serum osteocalcin (OC) levels. Material and methods: Seventy-five patients diagnosed with gout and 55 controls were included in the study. Comorbid conditions and drugs associated with osteoporosis were excluded. The T and Z scores from lumbar spine (L2-L4) and femur (neck, ward, trochanter, total) were determined by dual-energy X-ray absorptiometry (DXA). OC levels were measured by enzyme-linked immunosorbent assay. Results: Osteoporosis according to T scores of lumbar vertebrae L2-L4 was found to be significantly higher in patients with gout compared to the control group (p = 0.02). Lumbar spine T-score was -1.6 in gout group and -1.0 in controls. OC level was 7.9 ng/mL in the gout group and 18.9 ng/mL in the control group. There was a significant difference (p < 0.001). In addition, mean OC level was 12.4 ± 6.9 ng/mL in the patients diagnosed with osteoporosis and 17.2 ± 10.6 ng/mL in the patients that were classified as normal and a significant difference was established between the two groups (p = 0.03). A significant negative correlation was found between OC level and body mass index, age, and age at first attack. Similarly, femoral T-score established a negative correlation with parathyroid hormone, age, age at first attack, and allopurinol dose. Conclusion: Serum OC level can be a useful marker in the assessment of bone turnover and clinicians should keep osteoporosis in mind in gout patients.

Osteoporosis Self-Assessment Tool As a Screening Tool for Predicting Osteoporosis in Elderly Chinese Patients With Established Rheumatoid Arthritis

Osteoporosis Self-Assessment Tool for Asians (OSTA) is an indicator for assessing osteoporosis in postmenopausal women. The aim of this study was to investigate the value of OSTA index on predicting osteoporosis in elderly Chinese patients with established rheumatoid arthritis (RA). A total of 320 patients with RA and 158 normal individuals were recruited from January 2015 to October 2017. Bone mineral density (BMD) at the femur and lumbar spine was measured by dual-energy X-ray absorptiometry. RA group and control group were divided into low risk (values≥-1), medium risk (values between -4 and -1), and high risk (values ≤-4) group according to the value of OSTA index. One-way analysis of variance showed that BMD at all detected regions among the 3 groups were obviously different (p < 0.0001). Incidences of osteoporosis among different OSTA groups were 21.76% (47/216), 56.41% (44/78), and 80.77% (21/26), separately (x² = 67.389, p < 0.0001). In RA group including premenspausal or postmenspausal female subgroup, prevalences of osteoporosis among different OSTA groups were different (p < 0.05-0.0001). We also found a positive linear correlation between OSTA index and BMD (p < 0.0001) both in RA and in control groups. Logistic regression revealed OSTA index (odds ratio = 0.734, p < 0.0001, 95% confidence interval: 0.657-0.819) was a protective factor for occurrence of RA-induced osteoporosis. OSTA had the highest discriminatory power, with an estimated Area Under Curve (AUC) of 0.750 (95% confidence interval 0.694-0.807, p < 0.0001), sensitivity of 76.9% and specificity of 66.5%. Our findings indicated that OSTA index was closely associated with BMD in RA patients, the degree of correlation was much stronger than age or BMI. OSTA index was a predictor for osteoporosis in RA, but it might have little relationship with disease status in RA.

Vitamin D and Spondyloarthritis: Review of the Literature

Background:

Spondyloarthritides (SpAs) encompass heterogeneous diseases sharing similar genetic background, pathogenic mechanisms, and phenotypic features. Vitamin D is essential for calcium metabolism and skeletal homeostasis. Some recent evidences reported supplemental functions of vitamin D, such as modulation of inflammatory reactions.

Objective:

To analyze published data about a possible association between vitamin D and SpAs.

Results:

Vitamin D could play a role in immune reactions, influencing both immune and adaptive response. Vitamin D deficiency is more frequent in SpAs than in general population: an active and more severe disease infers patients’ mobility and reduces sunlight exposure. Quiescent inflammatory bowel disease, frequently associated with SpAs, could worsen vitamin D deficiency. All the parameters related to UVB exposure are the most important determinants for vitamin D status and need to be considered evaluating the vitamin D levels in SpAs.

Apart from musculoskeletal problems, patients affected by SpAs frequently suffer from other comorbidities, especially cardiovascular diseases and osteoporosis, and vitamin D status could have a relevance in this field. Bone is involved in SpAs with a dualistic role, coexisting trabecular bone resorption and new bone formation.

It seems rational to monitor vitamin D levels in SpA subjects and to target it to global health threshold.

Conclusion:

Literature data were not completely in agreement about a possible relation between poor vitamin D status and onset or worse disease course of SpAs. In fact, these results come from cross-sectional studies, which affect our ability to infer causality. Therefore, large, randomized controlled trials are needed.

Senescent T-Cells Promote Bone Loss in Rheumatoid Arthritis

Objective

T-cells are critical players in the pathogenesis of osteoporosis in patients with rheumatoid arthritis (RA). Premature senescence of lymphocytes including the accumulation of senescent CD4⁺ T-cells is a hallmark feature of RA. Whether T-cell senescence is associated with bone loss in RA patients is elusive so far.

Methods

This includes a prospective study of consecutive patients with RA (n = 107), patients with primary osteopenia/-porosis (n = 75), and healthy individuals (n = 38). Bone mineral density (BMD) was determined by dual-energy X-ray absorptiometry scan. Flow cytometry, magnetic-associated cell sorting, and cell culture experiments were performed to analyze the pro-osteoclastic phenotype and the function of senescent CD4⁺CD28⁻ T-cells.

Results

Patients with osteopenia/-porosis yielded a higher prevalence of senescent CD4⁺CD28⁻ T-cells than individuals with normal BMD, in the RA, as well as in the non-RA cohort. Receptor activator of nuclear factor kappa-B ligand (RANKL) was expressed at higher levels on CD4⁺CD28⁻ T-cells as compared to CD28⁺ T-cells. Stimulation with interleukin-15 led to an up-regulation of RANKL expression, particularly on CD28⁻ T-cells. CD4⁺CD28⁻ T-cells induced osteoclastogenesis more efficiently than CD28⁺ T-cells.

Conclusion

Our data indicate that senescent T-cells promote osteoclastogenesis more efficiently than conventional CD28⁺ T-cells, which might contribute to the pathogenesis of systemic bone loss in RA and primary osteoporosis.

Evaluating osteoporotic fracture risk with the Fracture Risk Assessment Tool in Chinese patients with rheumatoid arthritis

This study aims to evaluate the discriminative and predictive capacity of the Fracture Risk Assessment Tool (FRAX) to determine the 10-year risk of osteoporotic fracture in Chinese rheumatoid arthritis (RA) patients.This study included 168 RA patients and 168 healthy individuals as controls. The Chinese mainland FRAX model was applied to calculate the 10-year risk of osteoporotic fractures, defined as fracture of the spine, forearm, hip, or shoulder.The incidence of osteoporosis was significantly increased in RA patients compared to controls (P < .05). Bone mineral density (BMD), lumbar vertebra T-score, and femoral neck T-score were significantly lower in RA patients compared to controls (P < .05). BMD, disease duration, DAS28, and glucocorticoid use were important risk factors for osteoporotic fractures in Chinese RA patients. Ten-year osteoporotic fracture risk in Chinese RA patients was higher when BMD was incorporated in FRAX.There was a higher incidence of osteoporosis and reduced BMD in RA patients compared to controls. The FRAX model should integrate femoral neck BMD with other risk factors to evaluate osteoporotic fracture risk in RA patients, making it a valuable screening tool.

Case Study: An intraoperative finding of black bone disease in a podiatric surgery patient

Black bone disease has been recognised as a potential consequence of long-term treatment with tetracycline antibiotics. Largely documented affecting structures in the head and skull, there are few reported cases of black bone disease in the foot and ankle. The case of a 55 years old patient, who as a teenager, had undergone treatment with minocycline hydrochloride for chronic acne, and was found to have bone discolouration consistent with minocycline induced black bone disease (MIBBD) during the course of hallux valgus corrective surgery some 40 years later, is presented. In spite of the intraoperative findings, the patient's post-operative recovery and bone healing was uneventful. The literature on minocycline induced black bone disease is reviewed.

Vertebral body or intervertebral disc wedging: which contributes more to thoracolumbar kyphosis in ankylosing spondylitis patients?: A retrospective study

Both vertebral body wedging and disc wedging are found in ankylosing spondylitis (AS) patients with thoracolumbar kyphosis. However, their relative contribution to thoracolumbar kyphosis is not fully understood. The objective of this study was to compare different contributions of vertebral and disc wedging to the thoracolumbar kyphosis in AS patients, and to analyze the relationship between the apical vertebral wedging angle and thoracolumbar kyphosis.From October 2009 to October 2013, a total of 59 consecutive AS patients with thoracolumbar kyphosis with a mean age of 38.1 years were recruited in this study. Based on global kyphosis (GK), 26 patients with GK < 70° were assigned to group A, and the other 33 patients with GK ≥ 70° were included in group B. Each GK was divided into disc wedge angles and vertebral wedge angles. The wedging angle of each disc and vertebra comprising the thoracolumbar kyphosis was measured, and the proportion of the wedging angle to the GK was calculated accordingly. Intergroup and intragroup comparisons were subsequently performed to investigate the different contributions of disc and vertebra to the GK. The correlation between the apical vertebral wedging angle and GK was calculated by Pearson correlation analysis. The duration of disease and sex were also recorded in this study.With respect to the mean disease duration, significant difference was observed between the two groups (P < 0.01). The wedging angle and wedging percentage of discs were significantly higher than those of vertebrae in group A (34.8° ± 2.5° vs 26.7° ± 2.7°, P < 0.01 and 56.6% vs 43.4%, P < 0.01), whereas disc wedging and disc wedging percentage were significantly lower than vertebrae in group B (37.6° ± 7.0° vs 50.1° ± 5.1°, P < 0.01 and 42.7% vs 57.3%, P < 0.01). The wedging of vertebrae was significantly higher in group B than in group A (50.1° ± 5.1° vs 26.7° ± 2.7°, P < 0.01). Additionally, correlation analysis revealed a significant correlation between the apical vertebral wedging angle and GK (R = 0.850, P = 0.001).Various disc and vertebral wedging exist in thoracolumbar kyphosis secondary to AS. The discs wedging contributes more to the thoracolumbar kyphosis in patients with GK < 70° than vertebral wedging, whereas vertebral wedging is more conducive to the thoracolumbar kyphosis in patients with GK ≥ 70°, indicating different biomechanical pathogenesis in varied severity of thoracolumbar kyphosis secondary to AS.

[Effect of tumour necrosis factor α blockade on bone metabolism in chronic inflammatory joint diseases]

BACKGROUND AND OBJECTIVE

To evaluate the effect of anti-TNF treatments on bone mineral density (BMD), bone remodelling markers (BRM) and receptor activator of nuclear factor κB ligand (RANKL) and osteoprotegerin (OPG) in patients with chronic inflammatory joint diseases.

METHODS

A longitudinal prospective study was performed under clinical practice conditions on 31 patients diagnosed of rheumatoid arthritis, psoriatic arthropathy and ankylosing spondylitis who had received treatment with anti-TNF alpha drugs for one year. BMD, OPG and RANKL soluble form (sRANKL) were studied at the onset and end of the study. During the study (0, 3, 6, 9 and 12 month), disease activity (SDAI, BASDAI and CRP), functional capacity (HAQ, BASFI), BRM and vitamin D were studied.

RESULTS

BMD was not modified after one year of treatment. The patients who took corticosteroids had a mean bone mass loss of 3% in the lumbar spine (±1.6, P=.02). In regards to the BRM, did not experience significant changes over the course of the study. Disease activity, both SDAI (P=.002) and BASDAI (P=.002), decreased. OPG was maintained without changes during the year of treatment while both the sRANKL (0.28±0.22, P=.013) and sRANKL/OPG ratio significantly decreased (0.04±0.03, P=.031).

CONCLUSION

The patients being treated with anti-TNF did not present with a significant loss of DMO during the study (one year), at the same time experiencing an improvement in disease activity. This protection has been clearer in the responding patients.

OsteoRheumatology: a new discipline?

This review summarises recent evidence about the interaction between bone, the immune system and cartilage in disabling conditions such as osteoarthritis, rheumatoid arthritis and spondyloarthritis. These topics have been recently discussed at the ‘OsteoRheumatology’ conference held in Genoa in October 2014. The meeting, at its 10th edition, has been conceived to bring together distinguished international experts in the fields of rheumatic and metabolic bone diseases with the aim of discussing emerging knowledge regarding the role of the bone tissue in rheumatic diseases. Moreover, this review focuses on new treatments based on underlying the pathophysiological processes in rheumatic diseases. Although, a number of issues still remain to be clarified, it seems quite clear that in clinical practice, as well as in basic and translational research, there is a need for more knowledge of the interactions between the cartilage, the immune system and the bone. In this context, ‘OsteoRheumatology’ represents a potential new discipline providing a greater insight into this interplay, in order to face the multifactorial and complex issues underlying common and disabling rheumatic diseases.

Height Restoration after Balloon Kyphoplasty in Rheumatoid Patients with Osteoporotic Vertebral Compression Fracture

Study Design

Retrospective study.

Purpose

This study was conducted to compare vertebral body height restoration rate in rheumatoid arthritis (RA) patients who had undergone percutaneous balloon kyphoplasty (KP) with that of control group who had matched age, sex, body mass index, and bone mineral density.

Overview of Literature

There is no report on result of KP in RA patients.

Methods

Postoperative height restoration rate of RA group consisting of 15 patients (18 vertebral bodies) who had undergone KP due to osteoporotic vertebral compression fracture with a 30% or higher vertebral compression rate between May 2005 and January 2013 were compared to control group consisting of 38 patients (39 vertebral bodies) who had matched age, sex, body mass index, and bone mineral density.

Results

No statically significant difference in age (p=0.846), sex (p=0.366), body mass index (p=0.826), bone mineral density (p=0.349), time to surgery (p=0.528), polymethylmethacrylate injection time (p=0.298), or amount (p=0.830) was found between the RA group and the control group. However, preoperative compression rate in the RA group was significantly (p=0.025) higher compared to that in the control group. In addition, postoperative height restoration rate showed significant correlation with the RA group (p=0.008). Although higher incidence of recollapse occurred in the RA group compared to that in the control group, the difference was not statistically significant (p=0.305).

Conclusions

Compared to the control group, RA patients showed higher compression rate and higher vertebral restoration rate after KP, indirectly indicating weaker bone quality in patients with RA. Higher incidence of recollapse occurred in the RA group compared to that in the control group, although it was not statistically significant.

RANKL and OPG gene polymorphisms: associations with vertebral fractures and bone mineral density in premenopausal systemic lupus erythematosus

Premenopausal women with systemic lupus erythematosus (SLE) have a higher prevalence of low bone mineral density and vertebral fractures. Multiple genetic loci for osteoporotic fracture were identified in recent genome-wide association studies. This study provides a novel data demonstrating that receptor activator of NF-κB ligand (RANKL)/osteoprotegerin (OPG) polymorphisms likely plays an important role in the bone remodeling process in SLE premenopausal women.

INTRODUCTION

The purpose of this study was to evaluate single-nucleotide polymorphisms (SNPs) of the RANKL, RANK, and OPG genes in premenopausal SLE patients and their association with sRANKL and OPG serum levels, vertebral fractures, and bone mineral density (BMD).

METHODS

A total of 211 premenopausal SLE patients (American College of Rheumatology (ACR) criteria) and 154 healthy controls were enrolled. SNPs of RANKL 290A>G (rs2277438), OPG 1181G>C (rs2073618), 245T>G (rs3134069), 163A>G (rs3102735), and RANK A>G (rs3018362) were obtained by real-time PCR. sRANKL/OPG serum levels were determined by ELISA. BMD and vertebral fractures were evaluated by dual-energy X-ray absorptiometry (DXA).

RESULTS

SLE patients and controls had similar frequencies of the RANKL 290 G allele (p = 0.94), OPG 1181 C allele (p = 0.85), OPG 245 G allele (p = 0.85), OPG 163 G allele (p = 0.78), and RANK G allele (p = 0.87). Further analysis of the SLE patients revealed that the frequency of the RANKL 290 G allele was lower in patients with fractures than that in patients without fractures (28.1 vs 46.9%, p = 0.01). In addition, the frequency of the OPG 245 G allele was higher in patients with low BMD than that in patients with normal BMD (31.4 vs 18.1%, p = 0.04). No association of OPG 1181 G>C, OPG 163 A>G, and RANK A>G SNPs with BMD/fractures was found. Additionally, no association was observed between RANKL/OPG/RANK SNPs and sRANKL/OPG serum levels.

CONCLUSIONS

Our study provides novel data demonstrating that RANKL/OPG genetic variations appear to play a role in bone remodeling, particularly in its major complication, fracture, in premenopausal patients with SLE.

Trabecular bone score in female patients with systemic sclerosis: comparison with rheumatoid arthritis and influence of glucocorticoid exposure

OBJECTIVE

Systemic sclerosis (SSc) is associated with an increased risk of osteoporosis and fractures. To date, the etiology of bone loss in SSc is unclear. Trabecular bone score (TBS) provides an indirect measurement of bone microarchitecture, independent of areal bone mineral density (aBMD). The aims were to assess bone involvement in SSc using TBS in comparison with a "high-risk" population with rheumatoid arthritis (RA) and controls, and to investigate the determinants of a low TBS.

METHODS

This was a cross-sectional study of 65 women with SSc, 138 age-matched female patients with RA, and 227 age-matched female controls. Spine and hip aBMD were assessed using dual-energy X-ray absorptiometry. TBS was calculated from the anteroposterior image of the spine aBMD.

RESULTS

TBS was significantly lower in SSc compared to controls (p < 0.0001) and did not differ from RA (p = 0.128), despite lower cumulative and daily glucocorticoid (GC) dose (p < 0.0001). Further, patients with SSc receiving GC ≥ 5 mg/day had a significantly lower TBS than those receiving GC < 5 mg/day (p = 0.001). Multivariate analysis revealed that a low TBS was independently associated with daily GC dose (OR 5.6, 95% CI 1.7-19.2) and a T score ≤ -2.5 SD (OR 5.0, 95% CI 1.5-7.0) in SSc. No association between GC and TBS was found in RA.

CONCLUSION

Our results support the development of a combined approach using both TBS and aBMD for the assessment of bone microarchitecture in inflammatory rheumatic diseases. Our study showed that SSc-related bone involvement is characterized by an impairment in bone quality in addition to reduced bone quantity, and highlights that TBS can identify the negative effect of GC on bone microarchitecture.

Effect of sclerostin-neutralising antibody on periarticular and systemic bone in a murine model of rheumatoid arthritis: a microCT study

Introduction

Patients with chronic inflammatory diseases have increased bone loss and bone fragility and are at increased risk of fracture. Although anti-resorptive drugs are effective in blocking inflammation-induced bone loss, they are less effective at rebuilding bone. We have previously shown that treatment with sclerostin antibody (Scl-AbI) builds bone and can prevent or restore bone loss in a murine model of inflammatory bowel disease. In this study, we tested the effect of Scl-AbI in a murine model of rheumatoid arthritis (the collagen-induced arthritis model, CIA). We hypothesised that sclerostin blockade can protect and restore bone both locally and systemically without affecting progression of inflammation.

Methods

CIA was induced in male DBA/1 mice, which were treated with either PBS or Scl-AbI (10 mg/kg, weekly) prophylactically for 55 days or therapeutically for 21 days (starting 14 days post onset of arthritis). Systemic inflammation was assessed by measuring the serum concentration of anti-CII IgG1, IgG2a and IgG2b by ELISA. Changes in bone mass and structure, either at sites remote from the joints or at periarticular sites, were measured using DEXA and microCT. Bone focal erosion was assessed in microCT scans of ankle and knee joints.

Results

Circulating anti-CII immunoglobulins were significantly elevated in mice with CIA and there were no significant differences in the levels of anti-CII immunoglobulins in mice treated with PBS or Scl-ABI. Prophylactic Scl-AbI treatment prevented the decrease in whole body bone mineral density (BMD) and in the bone volume fraction at axial (vertebral body) and appendicular (tibial proximal metaphysis trabecular and mid-diaphysis cortical bone) sites seen in PBS-treated CIA mice, but did not prevent the formation of focal bone erosions on the periarticular bone in the knee and ankle joints. In the therapeutic study, Scl-AbI restored BMD and bone volume fraction at all assessed sites but was unable to repair focal erosions.

Conclusions

Sclerostin blockade prevented or reversed the decrease in axial and appendicular bone mass in the murine model of rheumatoid arthritis, but did not affect systemic inflammation and was unable to prevent or repair local focal erosion.

Alendronate Effect on the Prevention of Bone loss in Early Stages of Ankylosing Spondylitis: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

BACKGROUND

Ankylosing spondylitis (AS) is an inflammatory rheumatic disease that leads to a progressive ankylosis of vertebras and ossification of paravertebral ligaments. Bone loss and osteoporosis are amongst the important complications of AS, treatment of which is a challenging issue.

OBJECTIVES

This study aimed to clarify the effect of alendronate on the prevention of bone loss in patients with early AS.

PATIENTS AND METHODS

In a randomized, double-blind, placebo-controlled study, 24 patients with early stages of AS were recruited in Emam Reza Hospital, Tabriz University of Medical Sciences. The diagnostic criteria of early AS were Schober's index ≥ 5, normal hip joint in pelvic radiography, and absence or rarity of syndesmophytes in spine radiography (Taylor index ≤ 1). The participants were randomly allocated to the treatment and control groups and received 70 mg/week of alendronate and the same dose of placebo, respectively, for 12 months. Before and 12 months after the intervention, bone densitometry was performed from lumbar and pelvic region using the dual-energy X-ray absorptiometry (DEXA) method with Hologic QDR model instrument. Patients, physicians who prescribed the medications and those who interpreted the outcomes, and densitometry technicians were unaware of the assigned medication to each patient. Both groups received supplemental calcium (1000 mg/day) and vitamin D (400 mg/day).

RESULTS

After 12 months of treatment, hip and lumbar bone mineral density differences were not statistically significant between study groups (P = 0.061 and P = 0.112, respectively). No case of clinically apparent vertebral and nonvertebral fracture were observed in the treatment and control groups.

CONCLUSIONS

Our results suggested that applying alendronate was ineffective in preventing bone loss in patients with early stages of AS.

Joint and bone assessment in hand osteoarthritis

Hand osteoarthritis (OA) is a common disease frequently affecting middle-aged women. Prevalence estimates for OA vary widely depending on the age and sex of the population studied, the assessment tools used, and the specific joint sites analyzed OA is characterized by the degradation of articular cartilage, subchondral bone changes and osteophyte formation at the joint margins leading to joint failure. The pathogenesis of the disease and its evolution are multifactorial involving biomechanical, metabolic, hormonal, and genetic factors. Moreover, the role of inflammation has recently been advanced as pivotal in OA onset and progression. In particular, an uncommon variant of hand OA, erosive hand OA, is characterized by inflammatory and degenerative interphalangeal proximal and distal joints. The diagnosis of different types of hand OA is centered on clinical and laboratory investigations which can distinguish the peculiar aspects of these forms. Joint and bone assessments in hand OA are widely studied but there is no agreement with regard to established parameters to make a definitive diagnosis. This report focuses on the laboratory and clinimetric assessments that can be used to distinguish hand OA subtypes and addresses the debatable association with low bone mineral density in osteoporosis.

Are young women and men with rheumatoid arthritis at risk for fragility fractures? A population-based study

OBJECTIVE

Older women and men with rheumatoid arthritis (RA) are at increased risk for fractures, but limited information is available on fracture risk in younger individuals with RA and whether such risk occurs early in the disease onset or only when older. We determined the risk for fractures in both young and older women and men following RA diagnosis.

METHODS

We studied a population-based inception cohort with RA from Olmsted County, Minnesota, USA. We identified 822 women and 349 men diagnosed with RA between 1955 and 2007 (308 women and 110 men diagnosed before age 50) and an equal number of paired non-RA subjects, matched by sex and birth year. Incident fractures were collected through review of complete (inpatient and outpatient) medical records available through the linkage system of the Rochester Epidemiology Project.

RESULTS

The hazard ratio (HR; 95% CI) for a non-pathologic fracture occurring from no more than moderate trauma was 1.63 (1.36-1.96) for women and 1.40 (1.02-1.93) for men with RA. Findings were consistent for women and men diagnosed with RA at age ≥ 50 years [HR, 1.43 (1.16-1.77) and 1.34 (0.92-1.94), respectively], or at age < 50 years [HR, 2.34 (1.61-3.42) and 1.74 (0.91-3.30), respectively]. However, young women, but not young men, with RA were at increased fracture risk even before age 50 years (HR, 1.95 [1.08-3.51] and 0.82 [0.28-2.45], respectively).

CONCLUSION

Young men with RA are at increased risk for fractures only when older, whereas young women with RA have an elevated fracture risk even while still young.

The epidemiology of osteoporosis and fractures in ankylosing spondylitis

Bone is a target in many inflammatory rheumatic diseases. Inflammation leads to a wide range of changes in bone, and especially bone remodeling. In ankylosing spondylitis (AS) bone loss has been documented, but measuring bone density in the spine is hampered by new bone formation in syndesmophytes, periost and within the vertebrae. The risk of vertebral fractures is increased in AS. The diagnosis of vertebral fractures requires imaging and adequate evaluation of vertebral heights. In addition, in the ankysosed spine segments, additional imaging is often needed to diagnose spinal fractures at unusual locations (cervical spine) or in the posterior arch structures. Risk factors for vertebral fractures are helpful for case finding. Fracture prevention is indicated in high risk patients with AS, especially when they have already a vertebral fracture or in the presence of osteoporosis.

Ten-year Absolute Fracture Risk and Hip Bone Strength in Canadian Women with Systemic Lupus Erythematosus

Objective.

Women with systemic lupus erythematosus (SLE) are at risk of osteoporosis (OP) and fractures because of SLE or its treatments. We aimed to determine in women with SLE (1) the prevalence of low bone mass (LBM) in those < 50 years of age and OP in those > 50 years of age; (2) the 10-year absolute fracture risk in those > 40 years of age using the Canadian Fracture Risk Assessment Tool (FRAX); (3) bone quality using hip structural analysis (HSA); and (4) the associations between HSA and age, SLE duration, and corticosteroid exposure.

Methods.

Women without prior OP fractures were eligible. Bone mineral densities at the hip, spine, and femoral neck were determined using dual-energy x-ray absorptiometry. OP was determined using World Health Organization definitions for participants aged ≥ 50 years (32.8%), and LBM was defined as Z-scores ≤ −2.0 for those aged < 50 years. For those aged ≥ 40 years (63.5%), the 10-year probabilities of a major fracture (FRAX-Major) and hip fracture (FRAX-Hip) were calculated. FRAX-Major ≥ 20% or Hip ≥ 3% was considered high risk. HSA was done in a subgroup (n = 81) of patients.

Results.

The study group was 271 women. Mean (SD) age was 43.8 (13.1) years and SLE duration was 11.6 (10.4) years. OP was diagnosed in 14.6% and LBM in 8.8%. FRAX-Major ≥ 20% was seen in 9 patients (5.3%), of whom 6 were taking OP medications. FRAX-Hip ≥ 3% occurred in 16 patients (9.4%), of whom 9 were taking OP medications. Buckling ratio at the left hip narrow neck was positively correlated with FRAX-Major, FRAX-Hip, SLE duration, and duration of corticosteroid use.

Conclusion.

LBM is prevalent in women with SLE who are < 50 years of age. FRAX may identify those at higher risk of fractures while HSA can assess bone structure noninvasively.

Osteoporotic profiles in elderly patients with symptomatic lumbar spinal canal stenosis

BACKGROUND

The osteoporosis and lumbar canal stenosis, in elderly patients are under diagnosed and under reported. We report a cross sectional study to demonstrate the osteoporotic profile in patients with lumbar spinal stenosis (LSS) and to determine the proportion of patients with LSS who need to be treated for osteoporosis.

MATERIALS AND METHODS

One hundred and six postmenopausal patients with symptomatic LSS were evaluated for osteoporotic profile, which included lumbar and hip bone mineral density (BMD), serum vitamin D concentration, bone resorption and formation markers. Demographic and disease related variables were analyzed to identify the association with the risk of osteoporosis or osteopenia. Statistical analysis used were multivariate logistic regression with a forward stepwise procedure.

RESULTS

Twenty-four patients (22.6%) had osteoporosis and 60 (56.6%) had osteopenia. Overall, 84 patients (79.2%) with symptomatic LSS had osteoporosis or osteopenia. Fifty-nine patients (55.6%) had hypovitaminosis D. All bone turnover makers [alkaline phosphatase, osteocalcin, urinary-N-terminal telopeptide (u-NTx)] were demonstrated to be within normal range. Only age was associated with the risk of osteoporosis or osteopenia in the hip region. In the lumbar spine, all variables were not associated with osteoporosis or osteopenia. 44 patients (41.5%) required treatment for osteoporosis as per risk factors for osteoporosis. According to the guidelines from the Health Insurance Review Agency, however, only 20 patients (18.8% required) qualified for reimbursement for osteoporosis medications.

CONCLUSIONS

LSS is associated with osteopenia, osteoporosis, and hypovitaminosis D, which should prompt careful screening and treatment in cases of osteoporosis and osteoarthritis.

Relation of interleukin-6 in rheumatoid arthritis patients to systemic bone loss and structural bone damage

IL-6 plays a key role in local and systemic manifestation of RA. IL-6 is not only a pro-inflammatory cytokine, but also interacts in complex ways with the cells involved in bone remodeling. In RA, IL-6 may indirectly promote osteoclastogenesis by increasing the release of RANK-L by osteoblasts, and it diminishes the proliferation of osteoblasts at late differentiation stages. The aims of this work were to evaluate the level of serum IL-6 and to correlate it with the activity, severity, early development of osteoporosis, and early structural bone damage in RA patients. The following parameters were investigated in 40 RA patients and 20 healthy controls: IL-6 level, BMI, ESR, CRP, CBCs, serum ionized calcium, blood urea, serum creatinine, AST, ALT, anti-CCP, and RF. Bone mineral density was measured by dual-energy X-ray absorptiometry at lumbar spines and femoral neck. Drug history was taken stressing on steroid therapy. Data were processed and analyzed using computer-based program. IL-6 was significantly positively correlated with HAQ1, PTGA, grade of pain, ESR, platelet count, blood urea, AST level, and anti-CCP level; IL-6 showed an inverse significant correlation with T-score. IL-6 was positively correlated with TGC, DAS-28 score, and RF level. No correlation was found between T-score and morning stiffness duration, BMI, CRP, RBC, serum creatinine, and ALT. There was an inverse significant correlation between T-score and HAQ1, SJC, pain grade, DAS-28 score, PTGA, ESR, RF, anti-CCP, and IL-6. Patients with RA on steroid therapy had significantly higher TJC, SJC, and DAS-28 score, anti-CCP, and IL-6 than patients with RA not on steroid therapy. Patients with RA on steroid therapy had significantly lower T-score and lower serum ionized calcium than patients with RA not on steroid therapy. IL-6 has an important role in increasing osteoclastic activity and subsequent bone resorption in the patients with RA. Blocking IL-6 by using IL-6 inhibitors and anti-RANK-L therapy may be effective in inhibiting the inflammatory process and preventing the bone complications of RA disease.

Estradiol ameliorates arthritis and protects against systemic bone loss in Staphylococcus aureus infection in mice

INTRODUCTION

Staphylococcus aureus is a common cause of bacterial arthritis, which is associated with progressive bone loss in affected joints. We recently showed that S. aureus infection also induces a significant systemic bone loss in mice. This study was performed to assess the effect of estradiol treatment on the clinical course and outcome of S. aureus arthritis and on infection-induced bone loss in experimental S. aureus infection.

METHODS

Mice were ovariectomized, treated with estradiol or placebo, and S. aureus infection was established by intravenous inoculation of bacteria.

RESULTS

Estradiol treatment was found to decrease significantly the frequency and clinical severity of S. aureus arthritis, a finding that was accompanied with significantly higher serum levels of interleukin-10 in estradiol-treated mice. Estradiol was also highly protective against S. aureus-induced systemic trabecular, and cortical bone loss. Lack of endogenous estrogens and S. aureus infection had additive effects on trabecular bone loss. The S. aureus-infected, ovariectomized mice lost as much as 76% of their trabecular bone mass.

CONCLUSIONS

Treatment with estradiol ameliorates S. aureus arthritis and is protective against infection-induced systemic bone loss in experimental S. aureus infection.

Osteoprotegerin and RANKL in the pathogenesis of rheumatoid arthritis-induced osteoporosis

Osteoporosis represents an important cause of morbidity in adult rheumatoid arthritis (RA) patients who exhibit increased fracture risk. It is thought that osteoclast and its dysfunction which mediated by many cytokines are the principal pathogenesis of this bone disease, although the mechanisms are still not fully understood. Osteoprotegerin (OPG) and receptor activator of nuclear factor-kappa B ligand (RANKL) have been revealed in the pathogenesis of primary osteoporosis and other metabolic bone diseases. Thus, the aim of this study was to investigate the possible role of the OPG/RANKL system in RA-related bone loss. A total of 64 Chinese patients with RA and 60 healthy control subjects were involved. Serum levels of OPG and RANKL were measured by ELISA. BMD of nondominant forearm, lumbar spine(L(1-4)) and proximal femur, including femoral neck, Wards triangle, greater trochanter were assessed using dual-energy X-ray absorptiometry. RA patients had a higher incidence of osteoporosis (23/64, 35.9%) than that in healthy controls (9/60, 15.0%) (P < 0.0001). They displayed lower BMD values than controls at positions of all detected region. Compared with healthy controls, RA group showed significantly higher serum levels of RANKL (48.4 ± 12.5 vs. 23.0 ± 11.2 pmol/l, P < 0.0001), lower serum levels of OPG (106.2 ± 40.6 vs. 231.6 ± 65.6 pg/ml, P < 0.0001), and OPG/RANKL ratio (2.4 ± 0.7 vs. 7.0 ± 1.1, P < 0.0001). Multiple linear regression analysis revealed that in RA group, plasma rheumatoid factor concentration (β = -0.187, P = 0.031), swollen joint count (β = 0.567, P = 0.029), BMD at forearm (β = 0.324, P = 0.002), femoral Wards triangle (β = 0.370, P < 0.0001), and lumbar spine (β = 0.313, P = 0.003) were the contributors for serum OPG (R ( 2 ) = 0.718, P < 0.0001). Age (β = 0.241, P = 0.042) and BMD at femoral Wards triangle (β = -0.441, P < 0.0001) and lumbar spine (β = -0.320, P = 0.013) were the determinants for serum RANKL (R ( 2 ) = 0.616, P < 0.0001), while swollen joint count (β = 1.029, P = 0.019) and BMD at femoral neck (β = 0.285, P = 0.042) for serum OPG/RANKL ratio (R ( 2 ) = 0.279, P < 0.011). Analysis of logistic regression showed age (P = 0.004, OR = 1.156, 95% CI: 1.047-1.276) and the level of C-reactive protein (P = 0.028, OR = 1.019, CI 95%: 1.002-1.036) in peripheral blood of RA were the risk factors for the occurrence of osteoporosis in RA, while OPG/RANKL ratio (P = 0.007, OR = 0.035, CI 95%: 0.003-0.400) was the unique protective factor. These data suggest that, in Chinese RA patients, an altered modulation of the OPG/RANKL system resulting in increased RANKL and decreased OPG in peripheral blood, could contribute to the bone loss characteristic and the generation of osteoporosis in these patients. Changes of ratio of OPG/RANKL might be a protective mechanism against the accelerated bone loss in RA.

Osteoimmunology and osteoporosis

The concept of osteoimmunology is based on growing insight into the links between the immune system and bone at the anatomical, vascular, cellular, and molecular levels. In both rheumatoid arthritis (RA) and ankylosing spondylitis (AS), bone is a target of inflammation. Activated immune cells at sites of inflammation produce a wide spectrum of cytokines in favor of increased bone resorption in RA and AS, resulting in bone erosions, osteitis, and peri-inflammatory and systemic bone loss. Peri-inflammatory bone formation is impaired in RA, resulting in non-healing of erosions, and this allows a local vicious circle of inflammation between synovitis, osteitis, and local bone loss. In contrast, peri-inflammatory bone formation is increased in AS, resulting in healing of erosions, ossifying enthesitis, and potential ankylosis of sacroiliac joints and intervertebral connections, and this changes the biomechanical competence of the spine. These changes in bone remodeling and structure contribute to the increased risk of vertebral fractures (in RA and AS) and non-vertebral fractures (in RA), and this risk is related to severity of disease and is independent of and superimposed on background fracture risk. Identifying patients who have RA and AS and are at high fracture risk and considering fracture prevention are, therefore, advocated in guidelines. Local peri-inflammatory bone loss and osteitis occur early and precede and predict erosive bone destruction in RA and AS and syndesmophytes in AS, which can occur despite clinically detectable inflammation (the so-called 'disconnection'). With the availability of new techniques to evaluate peri-inflammatory bone loss, osteitis, and erosions, peri-inflammatory bone changes are an exciting field for further research in the context of osteoimmunology.

Benefits of exercise in rheumatoid arthritis

This paper aims to highlight the importance of exercise in patients with rheumatoid arthritis (RA) and to demonstrate the multitude of beneficial effects that properly designed exercise training has in this population. RA is a chronic, systemic, autoimmune disease characterised by decrements to joint health including joint pain and inflammation, fatigue, increased incidence and progression of cardiovascular disease, and accelerated loss of muscle mass, that is, “rheumatoid cachexia”. These factors contribute to functional limitation, disability, comorbidities, and reduced quality of life. Exercise training for RA patients has been shown to be efficacious in reversing cachexia and substantially improving function without exacerbating disease activity and is likely to reduce cardiovascular risk. Thus, all RA patients should be encouraged to include aerobic and resistance exercise training as part of routine care. Understanding the perceptions of RA patients and health professionals to exercise is key to patients initiating and adhering to effective exercise training.

Bone mineral density and body composition in postmenopausal women with psoriasis and psoriatic arthritis

Introduction

The aim of the present study was to compare bone mineral density (BMD) and body composition (BC) measurements as well as identify risk factors for low BMD and osteoporotic fractures in postmenopausal women with psoriasis (Ps) and psoriatic arthritis (PsA).

Methods

A cross-sectional study was carried out in 45 PsA women, 52 Ps women and 98 healthy female controls (HC). Clinical risk factors for low bone density and osteoporotic fracture were evaluated by a specific questionnaire. An X-ray absorptiometry (DXA) at the lumbar spine, total femur and total body was performed on all patients. Skin and joint outcomes were measured by specific tools (PASI, HAQ and DAS28). Morphometric vertebral fractures were evaluated by lumbar and thoracic spine X-ray, according to Genant's method.

Results

There were no significant differences in age, body mass index (BMI), total lean mass and bone mineral density among the groups. However, the PsA group had a significantly higher body fat percentage (BF%) than the Ps and HC groups. Osteoporotic fractures were more frequently observed in PsA and Ps groups than in the HC group (P = 0.01). Recurrent falls and a longer duration of disease increased the risk of fracture (odds ratio (OR) = 18.3 and 1.08, respectively) in the PsA group (P = 0.02). Disability was the main factor related to osteoporotic fracture in the Ps group (odds ratio (OR) = 11.1) (P = 0.02).

Conclusions

Ps and PsA patients did not present lower BMD. However, they had a higher prevalence of osteoporotic fractures and higher risk of metabolic syndrome. Patients with a longer duration of disease, disability and recurrent falls need preventive measures.

Incidence of symptomatic vertebral fractures in women of childbearing age newly treated with high-dose glucocorticoid

BACKGROUND

The treatment and prevention of glucocorticoid (GC)-induced osteoporosis have been controversial in premenopausal women during their childbearing years.

OBJECTIVE

This study assessed the incidence and risk factors for symptomatic vertebral fracture in women of childbearing age newly treated with high-dose GC.

METHODS

An observational cohort study was conducted at the rheumatic center of Shimoshizu National Hospital in Chiba, Japan, from 1986 to 2006. The prevalence of symptomatic vertebral fractures, as determined by x-rays, was assessed in premenopausal (aged <50 years) women with collagen vascular disease newly treated with high-dose GC (> or =20 mg/d prednisolone equivalent) compared with their counterparts who did not receive GC. Differences in the incidences of vertebral fractures were compared between groups by the Kaplan-Meier method and evaluated by the log-rank test. Hazard ratios (HRs) with 95% CIs were estimated using the Cox proportional hazards regression model.

RESULTS

A total of 373 women were assessed: 292 patients in the high-dose GC treatment group (mean [SD] initial age, 32.4 [8.2] years; initial dose, 43.8 [14.9] mg/d; follow-up time, 124.2 [75.4] months) and 81 patients in the non-GC control group (initial age, 39.3 [7.8] years; follow-up time, 106.5 [79.7] months). Symptomatic vertebral fractures occurred more frequently in the high-dose GC group (11.3%) than in the non-GC group (1.2%). Using the Cox model, the adjusted HR for the high-dose GC group was 13.96 (95% CI, 1.87-104.22) relative to the non-GC group. In the high-dose GC group, Kaplan-Meier analyses revealed that the incidence of fractures in women in their forties was significantly higher in comparison with those in their twenties (P < 0.001) and thirties (P < 0.05), and that the incidence of fractures in those who consumed alcohol (>80 g/wk of pure alcohol) was significantly higher than in those who did not (P < 0.05). The Cox model also revealed that the risk was independently higher with every 10-year increment of initial age (HR = 2.27; 95% CI, 1.46-3.53), with every GC dose increase (HR = 2.28; 95% CI, 1.58-3.31), and with each 1-gram decrease of cumulative GC dose (HR = 0.95; 95% CI, 0.93-0.98).

CONCLUSIONS

In this study, high-dose GC use was associated with a significantly high prevalence of symptomatic vertebral fractures in premenopausal women with collagen vascular disease during their childbearing years. However, the fracture risk was relatively low in women of childbearing age, especially those in their twenties and thirties during the early years of treatment.

The multiple faces of autoimmune-mediated bone loss

Inflammation perturbs normal bone homeostasis and is known to induce bone loss, as it promotes both local cartilage degradation and local and systemic bone destruction by osteoclasts, as well as inhibits bone formation by osteoblasts. Thus, not surprisingly, inflammatory autoimmune diseases often lead to local and/or general bone loss. However, the mechanisms that target the bone in autoimmune disease are complex and diverse, as they range from a direct attack on the bone and cartilage by the immune cells to indirect consequences of disturbances of the systemic control of bone remodeling. This Review discusses current understanding of the mechanisms of autoimmune-mediated bone loss in view of new insight from two new fields of research: osteoimmunology, which analyzes the direct effect of immune cells on bone, and the integrative metabolism approach, which established the existence of neuroendocrine loops that regulate bone remodeling.

A comparison of three different guidelines for osteoporosis treatment in patients with rheumatoid arthritis in Korea

BACKGROUND/AIMS

Osteoporotic fractures are an important comorbidity with rheumatoid arthritis (RA). We determined the overall fracture risk as assessed by the World Health Organization (WHO)'s FRAX® tool in Korean patients with seropositive RA. Additionally, we compared treatment eligibility according to the criteria of the Korean Health Insurance Review Agency (HIRA), FRAX, and the National Osteoporosis Foundation (NOF).

METHODS

Postmenopausal women and men ≥ 50 years of age with seropositive RA were recruited from one rheumatism center in Korea. The FRAX score was estimated using the Japanese model. Patients were classified as eligible for treatment using the HIRA, NOF, and FRAX thresholds for intervention.

RESULTS

The study of 234 patients included 40 men (17%). The mean age was 60 ± 9 years, and 121 (52%) patients had osteoporosis according to the WHO criteria. The overall median 10-year fracture risk was 13% for major osteoporotic fractures and 3.5% for hip fractures. HIRA guidelines identified 130 patients (56%) eligible for treatment, FRAX included 126 patients (54%), and 151 patients (65%) were included according to NOF guidelines. Older patients with a greater number of risk factors were included by FRAX compared to HIRA. The overall concordance between HIRA and FRAX, expressed as the kappa index, was 0.67, but was as low as 0.44 when limited to patients ≥ 60 years of age.

CONCLUSIONS

One-half of the patients had osteoporosis requiring treatment. RA patients have a high risk of fracture, and the adoption of a risk-scoring system should be considered.

The role of interleukin-6 in rheumatoid arthritis-associated osteoporosis

INTRODUCTION

Osteoporosis is highly prevalent in patients with rheumatoid arthritis (RA) and is a frequent cause of fractures, disability, reduced quality of life and increased use of healthcare resources.

DISCUSSION

Factors associated with the development of osteoporosis and fractures in patients with RA include disease activity, inflammation, gender, age, low body mass and glucocorticoid exposure. Several processes contribute towards the pathology of RA-associated osteoporosis, and increased osteoclast activation and subsequent bone resorption mediated by pro-inflammatory cytokines are thought to play major roles. Given the key effects of interleukin-6 (IL-6) in both RA and osteoporosis, and its ability to modulate other inflammatory mediators, IL-6 may be an important factor specifically associated with osteoporosis in patients with RA.

CONCLUSION

The development of agents that modulate the actions of IL-6 and those of other pro-inflammatory mediators of bone loss may provide alternative osteoporosis management strategies for patients with RA than existing general osteoporosis therapies.