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Theander L, Sharma A, Karlsson MK, Åkesson KE, Jacobsson LTH, Turesson C. Risk and predictors of fractures in early rheumatoid arthritis - A long term follow up study of an inception cohort. Semin Arthritis Rheum 2024; 68:152497. [PMID: 39002344 DOI: 10.1016/j.semarthrit.2024.152497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVES To examine the risk of fractures in a cohort of patients with newly diagnosed rheumatoid arthritis (RA), compared to the background population, and predictors of fractures detectable early in RA. METHODS An inception cohort of patients with RA (N = 233; 164 women/69 men, recruited 1995-2005) was evaluated according to a structured program, including repeated clinical assessments and measures of bone mineral density (BMD), from diagnosis to 10 years later. Matched population controls were identified using the national census register. Fractures through 2019 were identified based on ICD codes. Cox regression models were used to assess the risk of fractures in RA patients compared with controls, and for assessment of potential predictors for fractures in the RA population. RESULTS RA patients had an increased risk of fractures (fully adjusted hazard ratio (HR) 1.52, 95 % CI 1.13; 2.06). In the RA cohort, high age, low body mass index, and low BMD were significant baseline predictors of future fractures in multivariate analyses, but baseline RA disease characteristics were not. Worse disability (i.e. higher Health Assessment Questionnaire (HAQ) scores) over time was significantly associated with increased risk of fractures (age-sex-adjusted HR 1.33 per SD, 95 % CI 1.09; 1.63) and there was an inverse association between BMD Z-scores over time and fractures. CONCLUSION Patients with RA had higher risk of fractures than controls. Fracture risk was related to BMD at baseline and over time in patients with RA. In addition, worse disability (measured by HAQ) over time was associated with higher risk of fractures.
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Affiliation(s)
- Lisa Theander
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.
| | - Ankita Sharma
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Magnus K Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Kristina E Åkesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Lennart T H Jacobsson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden; Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden; Department of Rheumatology, Skåne University Hospital, Malmö and Lund, Malmö, Sweden
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Theander L, Willim M, Nilsson JÅ, Karlsson M, Åkesson KE, Jacobsson LTH, Turesson C. Changes in bone mineral density over 10 years in patients with early rheumatoid arthritis. RMD Open 2021; 6:rmdopen-2019-001142. [PMID: 32519976 PMCID: PMC7046965 DOI: 10.1136/rmdopen-2019-001142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives To investigate changes in bone mineral density (BMD) in patients with early rheumatoid arthritis (RA) over a 10-year period. Methods Consecutive patients with early RA (symptom duration <12 months) were followed according to a structured programme and examined with dual-energy X-ray absorptiometry (DXA) at inclusion and after 2, 5 and 10 years. Mean Z-scores over the study period were estimated using mixed linear effect models. Changes in Z-scores between follow-up visits were analysed using paired T-tests. Results At inclusion, 220 patients were examined with DXA. At the femoral neck, the mean Z-score over 10 years was −0.33 (95 % CI −0.57 to −0.08) in men and −0.07 (−0.22 to 0.08) in women. Men had significantly lower BMD at the femoral neck than expected by age at inclusion (intercept Z-score value −0.35; 95 % CI −0.61 to −0.09), whereas there was no such difference in women. At the lumbar spine, the mean Z-score over the study period for men was −0.05 (−0.29 to 0.19) and for women 0.06 (−0.10 to 0.21). In paired comparisons of BMD at different follow-up visits, femoral neck Z-scores for men decreased significantly from inclusion to the 5-year follow-up. After 5 years, no further reduction was seen. Conclusions In this observational study of a limited sample, men with early RA had reduced femoral neck BMD at diagnosis, with a further significant but marginal decline during the first 5 years. Lumbar spine BMD Z-scores were not reduced in men or women with early RA. Data on 10-year follow-up were limited.
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Affiliation(s)
- Lisa Theander
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Minna Willim
- Department of Rheumatology, Skåne University Hospital, Malmö and Lund, Sweden.,Rheumatology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - Jan Åke Nilsson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, Malmö and Lund, Sweden
| | - Magnus Karlsson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Kristina E Åkesson
- Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden.,Department of Orthopedics, Skåne University Hospital, Malmö, Sweden
| | - Lennart T H Jacobsson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, Malmö and Lund, Sweden
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Okano T, Inui K, Tada M, Sugioka Y, Mamoto K, Wakitani S, Koike T, Nakamura H. Loss of lean body mass affects low bone mineral density in patients with rheumatoid arthritis - results from the TOMORROW study. Mod Rheumatol 2017; 27:946-952. [PMID: 28150513 DOI: 10.1080/14397595.2017.1289645] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Osteoporosis is one of the complications for patients with rheumatoid arthritis (RA). Rheumatoid cachexia, the loss of lean body mass, is another. However, the relationship between decreased lean body mass and reduced bone mineral density (BMD) in patients with RA has not been well studied. METHODS This study included 413 participants, comprising 208 patients with RA and 205 age- and sex-matched healthy volunteers. Clinical data, BMD, bone metabolic markers (BMM) and body composition, such as lean body mass and percent fat, were collected. Risk factors for osteoporosis in patients with RA including the relationship BMD and body composition were analyzed. RESULTS Patients with RA showed low BMD and high BMM compared with controls. Moreover, lean body mass was lower and percent fat was higher in patients with RA. Lean body mass correlated positively and percent fat negatively with BMD. Lean body mass was a positive and disease duration was a negative independent factor for BMD in multivariate statistical analysis. CONCLUSION BMD and lean body mass were significantly lower in patients with RA compared to healthy controls. Lean body mass correlated positively with BMD and decreased lean body mass and disease duration affected low BMD in patients with RA. TRIAL REGISTRATION [UMIN Clinical Trials Registry, http://www.umin.ac.jp/ctr/ , UMIN000003876].
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Affiliation(s)
- Tadashi Okano
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
| | - Kentaro Inui
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
| | - Masahiro Tada
- b Department of Orthopaedic Surgery , Osaka City General Hospital , Osaka , Japan
| | - Yuko Sugioka
- c Center for Senile Degenerative Disorders (CSDD) , Osaka City University Medical School , Osaka , Japan
| | - Kenji Mamoto
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
| | - Shigeyuki Wakitani
- d Department of Health and Sports Sciences , Mukogawa Women's University , Hyogo , Japan
| | - Tatsuya Koike
- c Center for Senile Degenerative Disorders (CSDD) , Osaka City University Medical School , Osaka , Japan.,e Search Institute for Bone and Arthritis Disease (SINBAD) , Shirahama Foundation for Health and Welfare , Wakayama , Japan
| | - Hiroaki Nakamura
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
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Okano T, Inui K, Tada M, Sugioka Y, Mamoto K, Wakitani S, Koike T, Nakamura H. High frequency of vertebral fracture and low bone quality in patients with rheumatoid arthritis-Results from TOMORROW study. Mod Rheumatol 2016; 27:398-404. [PMID: 27484855 DOI: 10.1080/14397595.2016.1213943] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Osteoporosis is one of the complications in patients with rheumatoid arthritis (RA). In this study, we researched the morbidity of existing vertebral fractures and the risk factors for vertebral fractures in patients with RA. METHODS This study included 413 participants, 208 patients with RA, and 205 age- and sex-matched controls without RA. Clinical data, radiographic assessment of vertebral fracture from T4 to L4 in thoracic and lumber spine, bone mineral density (BMD), and bone metabolic markers (BMM) were analyzed. RESULTS Vertebral fractures were observed more frequently, severe and multiple in patients with RA. In the logistic regression analysis, age (adjusted odds ratios (OR): 1.07, 95% confidence interval (CI): 1.04-1.09) and RA (adjusted OR: 1.72, 95% CI: 1.04-2.83) were risk factors for existing vertebral fracture. Moreover, two bone matrix-related markers, undercarboxylated osteocalcin (ucOC) (adjusted OR: 1.68, 95% CI: 1.02-2.78), and urinary pentocidine (adjusted OR: 2.51, 95% CI: 1.48-4.24) were associated with existing vertebral fracture. CONCLUSIONS High frequent, multiple, and severe vertebral fractures were found in patients with RA compared to the controls. Low bone quality might be the cause of the frequent prevalence of vertebral fracture in patients with RA.
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Affiliation(s)
- Tadashi Okano
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
| | - Kentaro Inui
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
| | - Masahiro Tada
- b Department of Orthopaedic Surgery , Osaka City General Hospital , Osaka , Japan
| | - Yuko Sugioka
- c Center for Senile Degenerative Disorders (CSDD), Osaka City University Medical School , Osaka , Japan
| | - Kenji Mamoto
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
| | - Shigeyuki Wakitani
- d Department of Health and Sports Sciences , Mukogawa Women's University , Hyogo , Japan , and
| | - Tatsuya Koike
- c Center for Senile Degenerative Disorders (CSDD), Osaka City University Medical School , Osaka , Japan.,e Shirahama Foundation for Health and Welfare , Search Institute for Bone and Arthritis Disease (SINBAD) , Wakayama , Japan
| | - Hiroaki Nakamura
- a Department of Orthopaedic Surgery , Osaka City University Medical School , Osaka , Japan
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Esaily HA, Hewala AESA, Soliman SG, Galbat EA, Al-Ela DHA. Evaluation of serum undercarboxylated osteocalcin in premenopausal rheumatoid arthritis patients: its correlation with disease activity and bone mineral density. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2016. [DOI: 10.4103/1110-161x.189822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Pavlovic V, Dimic A, Milenkovic S, Krtinic D, Aleksic I. Relation between bone mineral density and IL-17 serum levels in Serbian patients with early Rheumatoid arthritis. Open Med (Wars) 2014; 10:106-112. [PMID: 28352685 PMCID: PMC5152965 DOI: 10.1515/med-2015-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/06/2014] [Indexed: 11/15/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by synovial inflammation and destruction of joint cartilage and bone. Different cytokines play important role in the processes that cause articular destruction and extra-articular manifestations in RA. The contribution of cytokines representing the Th1 (INF-γ), Th2 (IL-4) and IL-17A to the pathogenesis of early RA and bone mineral density (BMD) loss in still poorly understood. Serum samples of 38 early RA patients were evaluated for erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), C-reactive protein (CRP), anti-cyclic citrullinated peptide antibodies (anti-CCP) and for the tested cytokines (IL-17A, IL-4 and INF-γ). BMD was evaluated by dualenergy X-ray absorptiometry (DXA). Disease activity score (DAS28) calculation was assessed for all patients. Control serum samples were obtained from 34 healthy volunteers. The levels of tested cytokines were significantly higher (IL-17A, p<0.001; INF-γ, P<0.001; IL-4, P<0.01) in patients with early RA, compared to the healthy controls. In early RA patients, strong correlation of serum IL-17A was found with DAS28, ESR and CRP. Also, a significant negative correlation was found between serum INF-γ levels and the DAS28 score. Significantly positive correlation of BMD values and CRP, DAS28 IL-17A were also demonstrated. DXA analysis revealed that the most common site for osteoporosis was the lumbar spine followed by the femoral neck. BMD values significantly correlated with CRP, DAS28 score and IL-17A serum levels. The mean serum IL-17A levels, in patients with early RA, corresponded with disease activity, severity and BMD loss, indicating the potential usefulness of serum IL-17A in defining the disease activity and bone remodeling.
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Affiliation(s)
- Voja Pavlovic
- Institute of Physiology, Medical Faculty University of Nis, Nikole Uzunovica 67, 18000 Nis, Serbia; tel.: +381 18 276736; fax: +381 18 4238770
| | - Aleksandar Dimic
- Institute for Treatment and Rehabilitation "Niska Banja", Niska Banja, Serbia
| | - Sasa Milenkovic
- Institute for Treatment and Rehabilitation "Niska Banja", Niska Banja, Serbia
| | | | - Ivana Aleksic
- Institute for Treatment and Rehabilitation "Niska Banja", Niska Banja, Serbia
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van der Goes MC, Jacobs JW, Bijlsma JW. The value of glucocorticoid co-therapy in different rheumatic diseases--positive and adverse effects. Arthritis Res Ther 2014; 16 Suppl 2:S2. [PMID: 25608693 PMCID: PMC4249491 DOI: 10.1186/ar4686] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids play a pivotal role in the management of many inflammatory rheumatic diseases. The therapeutic effects range from pain relief in arthritides, to disease-modifying effects in early rheumatoid arthritis, and to strong immunosuppressive actions in vasculitides and systemic lupus erythematosus. There are multiple indications that adverse effects are more frequent with the longer use of glucocorticoids and use of higher dosages, but high-quality data on the occurrence of adverse effects are scarce especially for dosages above 10 mg prednisone daily. The underlying rheumatic disease, disease activity, risk factors and individual responsiveness of the patient should guide treatment decisions. Monitoring for adverse effects should also be tailored to the patient. Continuously balancing the benefits and risks of glucocorticoid therapy is recommended. There is an ongoing quest for new drugs with glucocorticoid actions without the potential to cause harmful effects, such as selective glucocorticoid receptor agonists, but the application of a new compound in clinical practice will probably not occur within the next few years. In the meantime, basic research on glucocorticoid effects and detailed reports on therapeutic efficacy and occurrence of adverse effects will be valuable in weighing benefits and risks in clinical practice.
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Akar S, Sarı İ, Çömlekci A, Birlik M, Önen F, Göktay Y, Özaksoy D, Akkoç N. Body composition in patients with rheumatoid arthritis is not different than healthy subjects. Eur J Rheumatol 2014; 1:106-110. [PMID: 27708889 DOI: 10.5152/eurjrheumatol.2014.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 06/12/2014] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with an increased risk of cardiovascular disease (CVD). Increased body fat, particularly its central distribution, is a well-known risk factor for CVD. A change in body composition in RA has been described previously. However, in most of these studies, age- and sex- but not body mass index (BMI)-matched controls were used. The aim of this study was to evaluate body composition in RA patients and compare it with age-, sex-, and BMI-matched controls. MATERIAL AND METHODS Sixty-five RA patients (55 females and 10 males; mean age 54.9 ± 10.8) and 31 healthy controls (25 females, 6 males; 53.8±8.6) were included in this study. Mean disease duration was 9.2±9.6 years. Body composition was assessed by anthropometric methods (skinfold thicknesses, body circumferences), bioimpedance analysis, and dual-energy X-ray absorptiometry (DXA). Visceral adipose tissue (VAT) was assessed with computed tomography. RESULTS There were no significant differences for total body fatness, regional fat distribution, and total body water and fat-free mass between RA patients and control subjects. Bone mineral content (BMC), assessed by DXA, was significantly lower in RA patients (p=0.004). Clinical disease activity indices and steroid treatment do not affect soft tissue body composition or BMC. CONCLUSION At least some RA patients do not have soft tissue composition alterations and may have similar health risks in comparison with subjects with similar age, sex, and total adiposity.
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Affiliation(s)
- Servet Akar
- Department of Internal Medicine, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - İsmail Sarı
- Department of Internal Medicine, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Abdurrahman Çömlekci
- Department of Internal Medicine, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Merih Birlik
- Department of Internal Medicine, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Fatoş Önen
- Department of Internal Medicine, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Yiğit Göktay
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Dinc Özaksoy
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
| | - Nurullah Akkoç
- Department of Internal Medicine, Dokuz Eylül University Faculty of Medicine, İzmir, Turkey
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Okano T, Koike T, Tada M, Sugioka Y, Mamoto K, Wakitani S, Nakamura H. The limited effects of anti-tumor necrosis factor blockade on bone health in patients with rheumatoid arthritis under the use of glucocorticoid. J Bone Miner Metab 2014; 32:593-600. [PMID: 24233123 DOI: 10.1007/s00774-013-0535-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 10/23/2013] [Indexed: 11/27/2022]
Abstract
We investigated the effects of biologics for rheumatoid arthritis (RA) patients on bone mineral density (BMD) and bone metabolic markers (BMM), retrospectively, and also clarified the effects of bisphosphonates (alendronate or risedronate 35 mg/week) and glucocorticoids. Participants in this study comprised 219 patients with RA, including 117 patients treated with biologics (infliximab, n = 90; etanercept, n = 27) and 102 patients with conventional disease-modifying anti-rheumatic drugs (DMARDs) for 1 year. Changes in BMD at the lumbar spine and total hip and BMMs [urinary type I collagen cross-linked N-telopeptide (NTX) and bone-specific alkaline phosphatase] were measured. BMD of the lumbar spine in both groups and total hip BMD in the biologics group were unchanged during treatment with biologics. However, BMD of the total hip was significantly decreased in the DMARDs group (from 0.731 ± 0.135 to 0.706 ± 0.135 g/cm2). Patients receiving glucocorticoids without bisphosphonates showed significant decrease in BMD of the total hip compared with patients not receiving glucocorticoids or receiving glucocorticoids with bisphosphonates in both biologics and DMARDs groups. Furthermore, BMD of the lumbar spine increased (p < 0.05) for patients in the biologics group who received bisphosphonates. NTX was significantly decreased only in the biologics group. Multiple regression analysis showed that BMD and bone metabolic marker levels correlated positively with bisphosphonate and biologics use and negatively with glucocorticoid use. BMD of the total hip was maintained in the patients using biologics without glucocorticoids or with bisphosphonates, but it was not maintained in the DMARDs patients, even without glucocorticoids or with bisphosphonates. Even if biologics have protective effect against bone loss of RA patients, we should consider reducing the dose of glucocorticoids and adding bisphosphonates for the treatment of osteoporosis.
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Duru N, van der Goes MC, Jacobs JWG, Andrews T, Boers M, Buttgereit F, Caeyers N, Cutolo M, Halliday S, Da Silva JAP, Kirwan JR, Ray D, Rovensky J, Severijns G, Westhovens R, Bijlsma JWJ. EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis 2013; 72:1905-13. [PMID: 23873876 DOI: 10.1136/annrheumdis-2013-203249] [Citation(s) in RCA: 171] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To develop recommendations for the management of medium to high-dose (ie, >7.5 mg but ≤100 mg prednisone equivalent daily) systemic glucocorticoid (GC) therapy in rheumatic diseases. A multidisciplinary EULAR task force was formed, including rheumatic patients. After discussing the results of a general initial search on risks of GC therapy, each participant contributed 10 propositions on key clinical topics concerning the safe use of medium to high-dose GCs. The final recommendations were selected via a Delphi consensus approach. A systematic literature search of PubMed, EMBASE and Cochrane Library was used to identify evidence concerning each of the propositions. The strength of recommendation was given according to research evidence, clinical expertise and patient preference. The 10 propositions regarded patient education and informing general practitioners, preventive measures for osteoporosis, optimal GC starting dosages, risk-benefit ratio of GC treatment, GC sparing therapy, screening for comorbidity, and monitoring for adverse effects. In general, evidence supporting the recommendations proved to be surprisingly weak. One of the recommendations was rejected, because of conflicting literature data. Nine final recommendations for the management of medium to high-dose systemic GC therapy in rheumatic diseases were selected and evaluated with their strengths of recommendations. Robust evidence was often lacking; a research agenda was created.
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Affiliation(s)
- N Duru
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, , Utrecht, The Netherlands
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van der Goes MC, Jacobs JWG, Jurgens MS, Bakker MF, van der Veen MJ, van der Werf JH, Welsing PMJ, Bijlsma JWJ. Are changes in bone mineral density different between groups of early rheumatoid arthritis patients treated according to a tight control strategy with or without prednisone if osteoporosis prophylaxis is applied? Osteoporos Int 2013; 24:1429-36. [PMID: 23011680 PMCID: PMC3604583 DOI: 10.1007/s00198-012-2073-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 06/25/2012] [Indexed: 01/30/2023]
Abstract
UNLABELLED Addition of 10 mg prednisone daily to a methotrexate-based tight control strategy does not lead to bone loss in early rheumatoid arthritis (RA) patients receiving preventive treatment for osteoporosis. A small increase in lumbar bone mineral density (BMD) during the first year of treatment was recorded, regardless of use of glucocorticoids. INTRODUCTION This study aims to describe effects on BMD of treatment according to EULAR guidelines with a methotrexate-based tight control strategy including 10 mg prednisone daily versus the same strategy without prednisone in early RA patients who received preventive therapy for osteoporosis. METHODS Early RA patients were included in the CAMERA-II trial: a randomized, placebo-controlled, double-blind 2-year trial, in which effects of addition of 10 mg prednisone daily to a methotrexate-based tight control strategy were studied. All patients received calcium, vitamin D and bisphosphonates. Disease activity was assessed every 4 weeks. Radiographs of hands and feet and dual-energy X-ray absorptiometry of lumbar spine and left hip were performed at baseline and after 1 and 2 years of treatment. RESULTS BMD increased significantly over time in both treatment groups at the lumbar spine with a mean of 2.6% during the first year (p<0.001), but not at the hip; at none of the time points did BMD differ significantly between the prednisone and placebo group. Higher age and lower weight at baseline and higher disease activity scores during the trial, but not glucocorticoid therapy, were associated with lower BMD at both the lumbar spine and the hip in mixed-model analyses. CONCLUSION Addition of 10 mg prednisone daily to a methotrexate-based tight control strategy does not lead to bone loss in early RA patients on bisphosphonates. A small increase in lumbar BMD during the first year of treatment was found, regardless of use of glucocorticoids.
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Affiliation(s)
- M C van der Goes
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, The Netherlands.
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Rintelen B, Bobacz K, Höfle G, Peichl P, Rainer F, Weber K, Gaugg M. Prophylaxe und Therapie der Glukokortikoid-induzierten Osteoporose – rezente Leitlinien im Überblick. Wien Klin Wochenschr 2011; 123:633-44. [DOI: 10.1007/s00508-011-0042-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 07/18/2011] [Indexed: 11/27/2022]
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Gheita T, Fawzy S, Rizk A, Hussein H. Impaired bone formation and osteoporosis in postmenopausal elderly onset rheumatoid arthritis patients. THE EGYPTIAN RHEUMATOLOGIST 2011. [DOI: 10.1016/j.ejr.2011.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dao HH, Do QT, Sakamoto J. Bone mineral density and frequency of osteoporosis among Vietnamese women with early rheumatoid arthritis. Clin Rheumatol 2011; 30:1353-61. [PMID: 21547438 DOI: 10.1007/s10067-011-1762-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 03/01/2011] [Accepted: 04/20/2011] [Indexed: 11/25/2022]
Abstract
Generalised bone mineral density (BMD) reduction often occurs in established rheumatoid arthritis (RA); however, in early RA, there is a disagreement with regard to BMD in the femoral neck and lumbar spine, and there is no available information for the whole body. Therefore, the aims of this study were to investigate the BMD, frequency of osteoporosis and the risk factors for BMD reduction in Vietnamese women with early RA. BMD in the femoral neck, lumbar spine L1-4 and whole body was measured in 105 women with early RA (disease duration ≤3 years) and 105 age-matched healthy women (26-73 years) using a dual energy X-ray absorptiometry. Femoral neck and whole body BMD in women with RA were lower (p < 0.05) than controls, while lumbar spine BMD was similar between two groups. The frequency of osteoporosis in the femoral neck, lumbar spine and whole body in women with RA aged ≥50 were higher (p < 0.05) than controls: 41.8% versus 29.5%, 42.2% versus 37.7% and 37.1% versus 28%, respectively. There were associations between the frequencies of osteoporosis at all sites with postmenopausal status, glucocorticoid use, rheumatoid factor positivity and disease activity with lumbar spine BMD and disease disability with femoral neck and whole body BMD. In conclusion, women with early RA had significantly lower femoral neck and whole body BMD, but had similar lumbar spine BMD compared with controls. The frequency of osteoporosis at all sites was significantly higher in women with RA than controls, suggesting that assessment of BMD should be considered in women with early RA.
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Affiliation(s)
- Hanh-Hung Dao
- Rheumatology Division, Outpatient Department, Bach Mai University Hospital, 78 Avenue Giai Phong, Dong Da District, Hanoi, Vietnam.
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15
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Marotte H, Miossec P. Prevention of bone mineral density loss in patients with rheumatoid arthritis treated with anti-TNFalpha therapy. Biologics 2008; 2:663-9. [PMID: 19707447 PMCID: PMC2727908 DOI: 10.2147/btt.s2338] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
This review focuses on recent advances in the effect of anti-TNFalpha therapy on bone metabolism and bone mineral density (BMD) in rheumatoid arthritis (RA). RA is a chronic disease characterized by inflammation of the synovial joint, cartilage degradation, and subsequent bone destruction. Bone damage is often manifested as erosions, localized juxta-articular bone loss, or generalized bone loss. Thus, blockade of TNFa not only serves to block inflammation, but also halts the erosive nature of RA and generalized/localized juxta-articular bone loss. Here, we review recent findings showing that anti-TNFa therapy is also effective on halting systemic bone loss. In vitro, TNFa reduces osteoblast activity and increases osteoclast activity through RANKL-RANK pathway. In arthritis animal models, an imbalance between bone formation and resorption is observed. In humans, this coupling of destruction is restored by anti-TNFalpha therapy early on, but only for a few months. Thus, anti-TNFalpha prevents the BMD loss in RA patients. In summary, TNFa blockade is not only able to prevent joint destruction, but it is also able to prevent bone loss in RA patients. Future studies are needed to address if TNFa blockers have an effect on bone fractures.
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Affiliation(s)
- Hubert Marotte
- Clinical Immunology Unit, Departments of Immunology and Rheumatology, University of Lyon, and Unité Mixte Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Hérriot, Lyon, France
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16
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Abstract
Glucocorticoid-induced osteoporosis (GIOP) is characterized by disturbed bone remodelling with consequent reduced bone mass and abnormally low quality of the bone tissue, resulting in an elevated risk of fracture. Glucocorticoids (GC) inhibit processes of bone formation and accelerate bone degradation, all of which must be taken into account especially in the case of long-term treatment with GC. Appropriate diagnostic procedures must be implemented early in the treatment and throughout the course, as must any preventive (improvement of general condition, calcium, vitamin D) and curative treatment required. When indications are carefully observed and the dosage is constantly checked and adjusted as needed, however, GC are not only helpful and beneficial in the treatment of the basic illnesses they are prescribed for, but on balance can even have a positive effect on bone in phases of high inflammatory activity.
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Affiliation(s)
- G E Hein
- Rheumatologie & Osteologie, Klinik für Innere Medizin III des Klinikums der Friedrich-Schiller-Universität, 07740 Jena.
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17
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Hämäläinen H, Kaarela K, Kröger H, Kauppi M, Järvenpää S, Hakala M, Kotaniemi A. Changes in bone mineral density in premenopausal women with rheumatoid arthritis during a two-year follow-up. Joint Bone Spine 2007; 74:482-7. [PMID: 17905634 DOI: 10.1016/j.jbspin.2007.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2006] [Accepted: 01/04/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To ascertain changes in axial bone mineral in premenopausal women with severe rheumatoid arthritis (RA) treated with and without prednisolone (PRED), we conducted a two-year follow-up study of axial bone mineral density (BMD) and bone mineral content (BMC). METHODS Premenopausal RA women (n=74) attending wards in the Rheumatism Foundation Hospital, Heinola, Finland were consecutively recruited for a follow-up study of BMD. BMD measurements in the lumbar spine and left proximal femur (femoral neck) were performed using dual X-ray absorptiometry at baseline and after two years. BMD is expressed as BMC per projectional area g/cm2. The Larsen score of 0-100 was assessed at the check-ups. Two RA groups were analyzed: patients receiving prednisolone (n=48), RA with PRED group and without prednisolone (n=26), RA without PRED group. The control group (n=43) comprised age-matched, premenopausal healthy women. RESULTS The patients in the RA with PRED group had lower BMD values than those in the RA without PRED group at commencement of follow-up. The mean weight-adjusted BMD percentage change in the lumbar spine to two years was -1.5% in the RA with PRED group, +0.6% in the RA without PRED group and -0.6% among the controls; a significant difference (P=0.030) was found between the RA groups. The mean BMC percentage change to two years in the lumbar spine was -2.2% in the RA with PRED-group (P=0.003), +0.0 in the RA without PRED-group and -0.6% in the control group. Accordingly, the mean weight-adjusted BMD percentage change in the femoral neck to two years was -2.6% in the RA with PRED group, +0.4% in the RA without PRED group and -0.9% among the controls; the difference between the RA groups being again significant (P=0.049). The mean BMC percentage change to two years in the femoral neck was -1.9% (P=0.006), -0.4% and -0.8%, respectively. Mean BMD decreased significantly in both lumbar spine (P=0.002) and femoral neck (P<0.001) only in the RA with PRED group. However, in spite of statistical findings above, when BMD is expressed as BMC per projectional area there was no statistically significant difference between the three groups in the change in BMC or projectional area in the lumbar spine or femoral neck. There was no significant correlation between the change in BMD in lumbar spine or femoral neck and the change in Larsen score among the RA groups. CONCLUSIONS We conclude that according to BMC, premenopausal RA women both with and without prednisolone treatment and controls lost bone statistically similarly. It seems that the role of RA itself in the multifactorial development of axial bone mass during the first decade of severe RA is not the most essential issue. We assume that this role will be less important with better treatment of RA than our patients received. The amount of bone loss during treatment with low-grade prednisolone remains controversial.
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Affiliation(s)
- Harri Hämäläinen
- Department of Physical Medicine and Rehabilitation, Heinola, Finland.
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18
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Sinigaglia L, Varenna M, Girasole G, Bianchi G. Epidemiology of Osteoporosis in Rheumatic Diseases. Rheum Dis Clin North Am 2006; 32:631-58. [PMID: 17288969 DOI: 10.1016/j.rdc.2006.07.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Much work has been directed at establishing the impact of osteoporosis and related fragility fractures in rheumatic diseases. Several cross-sectional studies reported that disability and reduced motility that are due to functional impairment are among the most important determinants of bone loss in different rheumatic diseases. At the same time, longitudinal studies have confirmed the detrimental effect of uncontrolled disease activity on bone density. In this perspective, the suppression of inflammation probably remains the main concern when considering treatment options. Besides these variables, pharmacologic agents that are used commonly in the treatment of these conditions probably have an adjunctive effect on bone loss in rheumatic patients. Large epidemiologic studies have demonstrated clearly that patients who have RA, SLE, or AS are at an increased risk for fragility fractures. Further studies are required to investigate the effective impact of osteoporosis and fragility fractures in other rheumatic diseases, and to define the relationship between OA and osteoporosis. A better appreciation of the impact and mechanisms of osteoporosis in rheumatic diseases by rheumatologists represents a clinical challenge; however, a greater understanding of this frequent complication will improve the quality of health care and the lives of patients who have rheumatic diseases.
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Affiliation(s)
- Luigi Sinigaglia
- Department of Rheumatology, Gaetano Pini Institute, University of Milan, Via Gaetano Pini 7, 20122 Milan, Italy.
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Dreher R, Buttgereit F, Demary W, Görtz B, Hein G, Kern P, Schulz A. Insuffizienzfrakturen in der Rheumatologie. Z Rheumatol 2006; 65:417-23. [PMID: 16944082 DOI: 10.1007/s00393-006-0089-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stress fractures occur as insufficiency fractures, with a prevalence of 0.8% in patients with rheumatological illness. The main sites of insufficiency fractures are the pelvis and sacrum, parts of the tibia and fibula that are close to the joints, and the calcaneus and hip. Since the painful symptoms overlap with the clinical picture of the painful joint diseases and because of the low sensitivity of conventional diagnostic X-ray, insufficiency fractures are not diagnosed directly or their diagnosis is delayed. The high sensitivity of computer tomography, skeletal scintigraphy and nuclear magnetic resonance imaging should be exploited in the diagnosis of insufficiency fractures. The case report presented describes insufficiency fractures of the distal right tibia and fibula in an elderly female patient with rheumatoid arthritis being treated with long-term glucocorticoids. In addition to advanced age, female gender, immobility and rheumatoid arthritis requiring long-term cortisone, there are further risk factors for insufficiency fractures: fluoride treatment over many years in the past, hypovitaminosis D3, renal failure. The DXA bone density values of the neck of the femur and the lumbar vertebrae do not show any osteoporosis, and the calcium concentration in the serum is low; phosphate is raised and parathormone is normal; osteocalcin, beta crosslaps and alkaline phosphatase are raised. Bone biopsy specimens taken from the iliac crest and the proximal femur and investigated for the purpose of differential diagnosis revealed renal osteopathy with secondary hyperparathyroidism and osteomalacia. In elderly patients with kidney failure, the possibility of renal osteopathy must be considered as the possible cause of reduced bone quality with a raised risk of insufficiency fractures, even when the parathormone levels are normal. In view of the frequency of osteopathies in rheumatological patients, osteology is of enormous significance in rheumatology.
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Arai K, Hanyu T, Sugitani H, Murai T, Fujisawa J, Nakazono K, Kondo N, Endo N. Risk factors for vertebral fracture in menopausal or postmenopausal Japanese women with rheumatoid arthritis: a cross-sectional and longitudinal study. J Bone Miner Metab 2006; 24:118-24. [PMID: 16502118 DOI: 10.1007/s00774-005-0657-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2005] [Accepted: 10/11/2005] [Indexed: 10/25/2022]
Abstract
The occurrence of vertebral fracture was examined cross-sectionally and longitudinally over a 4-year interval in 117 menopausal and postmenopausal Japanese women with rheumatoid arthritis (RA), whose ages ranged from 50 to 64 years. Patients treated with bisphosphonate were excluded. Vertebral fracture was diagnosed by lateral thoracic and lumbar spine radiography at the start and end of a 4-year period. Bone mineral density (BMD) at L2-L4 according to dual-energy X-ray absorptiometry (DXA), the administration of corticosteroids or methotrexate, and urinary excretion of N-telopeptide of type I collagen (NTx) were also recorded. In the cross-sectional study, the prevalence of vertebral fracture in the initial radiographs of RA patients was 21%, while it was 5% in healthy age-matched controls. Among RA patients treated with corticosteroids, 33% had vertebral fracture, which was a significantly higher prevalence than that in RA patients without steroid administration. In the longitudinal study, vertebral fracture prevalence was also increased in patients more than 60 years old. RA patients having steroid treatment and a BMD/YAM (young adult mean) ratio below 70% had higher risk of vertebral fracture than patients with a BMD/YAM ratio of 70%-80%, which in turn exceeded the risk with a BMD of 80% or more. No adverse effect of low-dose methotrexate on vertebral fracture was found. Urinary NTx was high in RA patients, as reported previously, and did not differ between patients with or without new fracture after 4 years. In conclusion, Japanese RA patients more than 60 years old who were treated with corticosteroid or had a BMD below 80% had high risk of vertebral fracture.
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Affiliation(s)
- Katsumitsu Arai
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, 1 Asahimachi-dori, Niigata, 951-8510, Japan.
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21
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Chung CP, Russell AS, Segami MI, Ugarte CA. The effect of low-dose prednisone on bone mineral density in Peruvian rheumatoid arthritis patients. Rheumatol Int 2003; 25:114-7. [PMID: 14628151 DOI: 10.1007/s00296-003-0411-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2003] [Accepted: 10/06/2003] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to determine the difference between bone mineral density (BMD) of rheumatoid arthritis (RA) patients on low-dose prednisone and matched RA patients without prior systemic corticosteroid therapy. METHODS Ninety patients attending our clinics and receiving 10 mg/day of prednisone or less for at least the previous 3 consecutive months were studied. The control group comprised 90 selected RA patients without corticosteroid therapy matched for age, race, gender, disease duration, use of methotrexate, postmenopause, and Health Assessment Questionnaire score. The BMD was measured using dual X-ray absorptiometry. RESULTS Patients on prednisone had lower BMD than controls (0.94 +/- 0.17 vs 0.96 +/- 0.17 for L2-4 and 0.73 +/- 0.14 vs 0.76 +/- 0.16 for femoral neck), but these differences were not statistically significant (P > 0.05). In post hoc analysis, postmenopausal women on prednisone had more bone loss in femoral neck than controls (0.68 +/- 0.13 vs 0.74 +/- 0.15). CONCLUSION Bone mineral density was not significantly reduced by low-dose prednisone in this diverse group of RA patients. A reduction in hip BMD was seen in postmenopausal women on prednisone.
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Affiliation(s)
- Cecilia P Chung
- Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
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22
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Haugeberg G, Ørstavik RE, Uhlig T, Falch JA, Halse JI, Kvien TK. Bone loss in patients with rheumatoid arthritis: results from a population-based cohort of 366 patients followed up for two years. ARTHRITIS AND RHEUMATISM 2002; 46:1720-8. [PMID: 12124854 DOI: 10.1002/art.10408] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the extent of and risk factors for bone loss in a population-based cohort of patients with rheumatoid arthritis (RA) receiving conventional health care. METHODS In a longitudinal study, clinical data were collected and bone mineral density (BMD) measurements were performed at baseline and after 2 years. Dual-energy x-ray absorptiometry was used for hip and spine BMD measurements. At baseline, patients received advice about lifestyle adjustments and calcium and vitamin D supplementation; during the followup period they were treated with antirheumatic and bone-sparing drugs, according to clinical judgment. RESULTS After a mean +/- SD of 2.2 +/- 0.2 years, 366 (298 women, 68 men) of the 488 patients who were examined at baseline were reexamined. At that time, 47.9% were current users of corticosteroids and 37.0% were using antiresorptive drugs (hormone replacement therapy, bisphosphonates, or calcitonin). The mean BMD reduction was -0.64% in the femoral neck, -0.77% in the total hip, and -0.29% in the spine at L2-4. BMD was increased at all measurement sites in current users of antiresorptive drugs (0.16-1.64%) but was decreased in patients using calcium and vitamin D alone (-1.99% to -1.39%) and in patients not using any osteoporosis treatment (-1.20% to -0.43%). Current use of corticosteroids was independently associated with increased risk for BMD loss in the total hip (odds ratio [OR] 2.63, 95% confidence interval [95% CI] 1.38-5.00) and spine at L2-4 (OR 2.70, 95% CI 1.30-5.63), whereas current use of antiresorptive drugs was associated with decreased risk for bone loss in the total hip (OR 0.43, 95% CI 0.20-0.89). CONCLUSION Results of this population-based, 2-year followup study indicate that adequate management of patients with RA, addressing both the rheumatic disease and osteoporosis, protects against bone loss.
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23
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Madsen OR, Sørensen OH, Egsmose C. Bone quality and bone mass as assessed by quantitative ultrasound and dual energy x ray absorptiometry in women with rheumatoid arthritis: relationship with quadriceps strength. Ann Rheum Dis 2002; 61:325-9. [PMID: 11874835 PMCID: PMC1754061 DOI: 10.1136/ard.61.4.325] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine relationships of bone quality as assessed by quantitative ultrasound (QUS) and bone mineral density (BMD, g/cm(2)) with quadriceps strength (QS) in women with rheumatoid arthritis (RA). METHODS Sixty seven women with RA according to the 1987 American College of Rheumatology (ACR) criteria were examined. Mean (SD) age was 62 (13) years, mean disease duration 15 years. Most were or had been receiving glucocorticoid treatment. Calcaneal bone quality expressed as speed of sound (SOS, m/s), broadband ultrasound attenuation (BUA, dB/MHz), and stiffness was measured by QUS. BMD of the femoral neck, spine, and distal forearm was measured by dual energy x ray absorptiometry (DXA). Maximal voluntary isokinetic quadriceps strength (Nm) was assessed by isokinetic dynamometry. Pain was recorded on a visual analogue scale (VAS), disability was scored by the Stanford Health Assessment Questionnaire (HAQ), and the degree of physical impairment was expressed by the Steinbrocker index (SI). RESULTS In multiple regression analyses, QS predicted SOS, BUA, and stiffness (r(partial) ranging from 0.36 to 0.45, p<0.005) and femoral neck BMD (r(partial)=0.30, p<0.05) independently of age, height, weight, disease duration, HAQ, VAS, SI, and cumulative steroid dose. BMD of the spine and distal forearm was not associated with QS. After adjustment for covariates, women with subnormal BMD of the femoral neck (T score <-1), had a 20% lower QS than those with normal BMD (p<0.0001). CONCLUSIONS Calcaneal bone quality and femoral neck BMD were associated with QS in women with RA. This finding indicates that physical activity including muscle strengthening exercises may play a part in the prevention of bone loss in these patients.
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Affiliation(s)
- O R Madsen
- Osteoporosis Research Clinic, Hvidovre University Hospital, Denmark.
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24
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Keller C, Hafström I, Svensson B. Bone mineral density in women and men with early rheumatoid arthritis. Scand J Rheumatol 2001; 30:213-20. [PMID: 11578016 DOI: 10.1080/030097401316909558] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To study bone mineral density (BMD) in patients with early rheumatoid arthritis. METHODS Dual x-ray absorptiometry was performed in 227 patients, 149 women and 78 men, with rheumatoid arthritis (RA) of no more than 12 months duration. RESULTS Women, as well as men above 60 years of age, had a BMD at spine and hip comparable with age and sex matched reference populations. Men younger than 60 years had a tendency to lower BMD. Although the proportion of female patients with osteoporosis was not higher than in the reference, population the proportion of patients with reduced bone mass was increased, and this was found also in men. There was no significant association between BMD and disease duration, disease activity or disability. CONCLUSION Untreated patients with early RA have a BMD in spine and hip not significantly different from that of normal reference populations. However, an increased number of the patients had reduced bone mass already at disease onset.
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Affiliation(s)
- C Keller
- Department of Medicine, Helsingborgs lasarett, Sweden
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25
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Abstract
Bone disease in rheumatoid arthritis affects the peri-articular and axial skeleton and is a major cause of disability. Recent studies have shown that pro-inflammatory cytokines stimulate the expression of osteoprotegerin ligand, a transmembrane protein of the tumour necrosis factor ligand superfamily, on synoviocytes and activated T cells. Osteoprotegerin ligand stimulates osteoclast formation and activation, membrane-bound and soluble osteoprotegerin ligand leading to osteoporosis as well as erosions. Bone densitometry using dual energy X-ray absorptiometry is an objective and precise method for monitoring this bone disease. Bone loss is more rapid in patients with early rheumatoid arthritis and correlates well with measures of inflammation and function. Data are emerging that monitoring bone loss of the hands in early rheumatoid arthritis could be an outcome measure and a prognostic indicator of future functional disability. Suppressing inflammation effectively and the use of bone active agents can reduce the rate of loss. In animal models, osteoprotegerin-a decoy receptor of osteoprotegerin ligand-blocks osteoporosis and erosions without affecting inflammation. The use of new biological agents could in future effectively prevent and treat rheumatoid bone disease.
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Affiliation(s)
- M J Green
- Rheumatology Research Unit, University of Leeds, Leeds, LS1 3EX, UK
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Kroot EJ, Nieuwenhuizen MG, de Waal Malefijt MC, van Riel PL, Pasker-de Jong PC, Laan RF. Change in bone mineral density in patients with rheumatoid arthritis during the first decade of the disease. ARTHRITIS AND RHEUMATISM 2001; 44:1254-60. [PMID: 11407683 DOI: 10.1002/1529-0131(200106)44:6<1254::aid-art216>3.0.co;2-g] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) has been reported to be associated with bone loss during the first years of the disease. The magnitude of this problem after the initial years has not yet been evaluated. In the present study, the change in bone mineral density (BMD) in patients with recent-onset RA as well as the effects of inflammation, mobility, and the use of prednisone on this change were studied in the first decade of the disease. METHODS BMD was measured twice in 76 RA patients with mean disease durations of 2.35 years at the first BMD measurement and 8.90 years at the second BMD measurement. BMD was measured in both hips using dual x-ray absorptiometry. Results were expressed as mean +/- SEM Z scores (using age- and sex-matched reference values) and as mean +/- SEM percent change in BMD (in gm/cm2) per year. The effects of inflammation, mobility, and the use of prednisone on change in BMD were evaluated using multiple linear regression analyses. RESULTS At the first BMD measurement, RA patients had lower BMD compared with the reference values (Z score -0.42+/-0.11, 95% confidence interval [95% CI] -0.64, -0.20). Between the 2 measurements, we observed a small decrease in BMD of -0.28+/-0.11%/year (95% CI -0.07 to -0.49). However, the rate of bone loss was smaller than expected. The Z score increased by 0.13+/-0.05 between the 2 BMD measurements (95% CI 0.02, 0.23). Only the use of prednisone was significantly associated with increased bone loss. In a separate analysis that included only postmenopausal women, increased physical activity and longer time since menopause were both associated with decreased bone loss. In this subgroup of patients, the use of prednisone was significantly associated with increased bone loss as well. A high erythrocyte sedimentation rate was associated with increased bone loss, but this did not reach statistical significance. CONCLUSION After the initial years of the disease, bone loss in RA patients is lower than expected compared with age- and sex-matched reference values. Postmenopausal RA patients with low levels of physical activity are at increased risk of losing bone. Use of prednisone was the only variable consistently associated with reduction in BMD in RA patients.
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Affiliation(s)
- E J Kroot
- University of Medical Center Nijmegen, The Netherlands
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27
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Daragon A, Krzanowska K, Vittecoq O, Ménard JF, Hau I, Jouen-Beades F, Lesage C, Bertho JM, Tron F, Le Loët X. Prospective X-ray densitometry and ultrasonography study of the hand bones of patients with rheumatoid arthritis of recent onset. Joint Bone Spine 2001; 68:34-42. [PMID: 11235778 DOI: 10.1016/s1297-319x(00)00227-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Bone demineralization observed in early rheumatoid arthritis is not easily measured. To measure bone loss and to discriminate between rheumatoid arthritis and other rheumatic diseases, we used two methods: dual-energy X-ray absorptiometry and ultrasonography. METHODS From a population-based recruitment, 32 patients with early peripheral polyarthritis (median disease duration: 4 months) were studied. Clinical, laboratory, functional, hand-bone assessments were made at the entry an at months 6 and 12. Bone X-ray densitometry measurements were made on 16 areas of the hand. Speed of sound was measured across the proximal phalanges of the four fingers. X-rays of both hands were scored according to the modified Sharp's score. At 12 months, patients were classified as rheumatoid arthritis (N = 15; 9 F) or as other rheumatic diseases. RESULTS We found: 1) significantly decreased bone mineral density (BMD) of the whole hand, in the rheumatoid arthritis group versus the other rheumatic diseases group, at 6 and 12 months (P < 0.05); 2) no significant decrease of bone mineral density (BMD) in other areas in the rheumatoid arthritis group; 3) no significant change of ultrasounds in either group; and 4) no significant correlation between the decrease of BMD in the rheumatoid arthritis group and clinical, biological or radiologic parameters, except for IFNgamma, whose production in whole blood cell culture was lower at entry in the rheumatoid arthritis group. CONCLUSION DEXA bone assessment in rheumatoid arthritis was able t detect bone loss in the whole hand at 6 months.
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Affiliation(s)
- A Daragon
- Rheumatology department, INSERM U-519 and IFR 23, Centre Hospitalier Universitaire de Rouen, France.
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Haugeberg G, Uhlig T, Falch JA, Halse JI, Kvien TK. Reduced bone mineral density in male rheumatoid arthritis patients: frequencies and associations with demographic and disease variables in ninety-four patients in the Oslo County Rheumatoid Arthritis Register. ARTHRITIS AND RHEUMATISM 2000; 43:2776-84. [PMID: 11145036 DOI: 10.1002/1529-0131(200012)43:12<2776::aid-anr18>3.0.co;2-n] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine reductions in bone mineral density (BMD) and factors associated with reduced BMD in 94 male rheumatoid arthritis (RA) registry patients ages 20-70 years. METHODS Dual-energy x-ray absorptiometry was used to measure BMD in the anteroposterior lumbar spine at L2-LA, the femoral neck, and the total hip, and clinical data were collected. The patients were recruited from a validated county RA registry (completeness 85%) comprising 192 men ages 20-70 years. Age-specific BMD values were compared with a pooled healthy European/United States population. Bivariate and multivariate analyses were performed to determine demographic and disease-related associations with BMD and reduced bone mass (Z score of < or =1 SD below the mean value in controls). RESULTS A statistically significant BMD reduction was found only for the oldest age group (60-70 years): 5.2% reduction in the femoral neck and 6.9% in the total hip. No BMD reduction was found at L2-L4. The proportions (95% confidence intervals) of RA patients with Z scores of < or =1 SD below control (16% expected) were 30.9% (21.6-40.2) for L2-L4, 30.8% (95% CI 21.3-40.3) for the femoral neck, and 33.0% (95% CI 23.3-42.7) for the total hip. Disease activity and severity measures were, in general, not associated with BMD or reduced bone mass. CONCLUSION A 2-fold statistically significant increased frequency of patients with reduced bone mass (Z score of < or =1 SD below control; 16% expected) was found for both the spine and the hip. The only significant reduction in BMD by age group was for the hip in patients who were ages 60-70 years, with no reduction in L2-LA BMD. Multivariate analyses did not reveal consistent associations between reduced BMD and demographic or disease variables.
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Abstract
Bone loss is a hallmark of RA. Factors influencing generalized bone loss include RA-specific factors such as the influence of disease activity and deficient sex hormone status and more general mechanisms (e.g., due to the use of glucocorticoids). Reducing disease activity has a positive effect on bone. Estrogens or androgens can restore deficiency of the sex hormones with a small positive effect on BMD. The more pronounced bone loss occurs when RA patients are being treated with glucocorticoids. This bone loss can be reduced by the concomitant use of calcium and vitamin D and, in most patients, by the use of bisphosphonates as well.
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Affiliation(s)
- J W Bijlsma
- Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, The Netherlands.
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Saario R, Sonninen P, Möttönen T, Viikari J, Toivanen A. Bone mineral density of the lumbar spine in patients with advanced rheumatoid arthritis. Influence of functional capacity and corticosteroid use. Scand J Rheumatol 2000; 28:363-7. [PMID: 10665742 DOI: 10.1080/03009749950155355] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We investigated factors that are related to generalized osteoporosis in advanced rheumatoid arthritis (RA). In this cross-sectional study we measured trabecular bone mineral density (BMD), by quantitative computerized tomography (QCT), in the lumbar spine of 57 patients with RA, most of whom were premenopausal women. In our material, 27 out of 57 patients (47%) had BMD <-1 SD expressed as Z-score and five patients had suffered from fractures. Our study shows that a cumulative corticosteroid dose (r = -0.41, p<0.010) and functional impairment (r = -0.37, p<0.050) were negatively related to spinal BMD, while daily intake of calcium correlated positively on BMD (r = 0.37, p<0.010). Our results indicate that low BMD is common in patients with advanced RA and it is associated with long-term corticosteroid use. Thus, in clinical practice we have to consider the benefits and harms of corticosteroid treatment and preventive therapy to osteoporosis.
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Affiliation(s)
- R Saario
- Department of Medicine, University of Turku, Finland
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Njeh CF, Genant HK. Bone loss. Quantitative imaging techniques for assessing bone mass in rheumatoid arthritis. ARTHRITIS RESEARCH 2000; 2:446-50. [PMID: 11094457 PMCID: PMC128873 DOI: 10.1186/ar126] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/27/2000] [Accepted: 07/17/2000] [Indexed: 02/06/2023]
Abstract
Osteoporosis is associated with low bone mass and microarchitectural deterioration of bone tissue with clinical manifestation of low trauma fractures. Rheumatoid arthritis (RA) is a risk factor due to generalized and articular bone loss. This minireview presents past and current bone mass measurement techniques in RA. These techniques include: plain radiographs, absorptiometry, quantitative computed tomography (QCT) and ultrasound. The most widely used technique is dual x-ray absorptiometry (DXA). RA patients have lower bone mass as compared with normals and substantial bone loss may occur early after the onset of disease. Measurement of bone mineral density (BMD) at the hand using either DXA or ultrasound maybe a useful tool in the management of RA patients.
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Affiliation(s)
- C F Njeh
- Department of Radiology, University of California, San Francisco, California 94143, USA.
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32
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Abstract
Profound abnormalities of bone are an important component of the morbidity of rheumatoid arthritis and partly determine the orthopaedic treatment of patients. The principal bone abnormality, which is osteoporosis associated with rapid remodeling, degrades the mechanical properties of the skeleton in juxtaarticular bone, in the diaphyses of long bones, in the pelvis, and in the base of skull. Abnormalities of bone affect clinical decision making in the surgical treatment of patients with rheumatoid arthritis and must be considered for the optimal treatment of these patients. Increased fracture risk and compromised bony fixation complicate fracture treatment. Techniques of surgery must be modified to protect bone from intraoperative fracture. Methods of fixation of implants and other devices must be appropriate to the biomechanics of the bone. Bone healing usually is rapid if not compromised by mechanical instability. Specific patterns of bone deformation and failure can be identified in the evolution of rheumatoid arthritis. Bone graft used in reconstruction of the protruded acetabulum is incorporated rapidly. Bone resorption with joint instability is a common feature of rheumatoid arthritis; however, the opposite pattern of bony ankylosis with stiffness is observed in a smaller percentage of patients. Recognition of the tissue type is necessary for the individualization of surgical procedures to achieve optimal joint stability and mobility. Based on growing understanding of the pathophysiology of bone in patients with rheumatoid arthritis, new pharmacologic therapies may become available for the prevention and treatment of bone abnormalities in patients with rheumatoid arthritis.
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Affiliation(s)
- E R Bogoch
- Department of Surgery, St Michael's Hospital, University of Toronto, Canada
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Aman S, Hakala M, Silvennoinen J, Manelius J, Risteli L, Risteli J. Low incidence of osteoporosis in a two year follow-up of early community based patients with rheumatoid arthritis. Scand J Rheumatol 1998; 27:188-93. [PMID: 9645413 DOI: 10.1080/030097498440796] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
52 patients with early rheumatoid arthritis (RA) were followed with regular measurements of bone mineral density (BMD) and serum markers of type I collagen metabolism in order to determine whether they develop osteoporosis during the first two years of the disease course and if the changes in type I collagen metabolites reflect the alterations in BMD. The mean percentage BMD change over the first year of follow-up was -0.91 for lumbar spine (LS) and -0.76 for femoral neck (FN); the corresponding figures from 0 to 24 months was -1.3 and -0.8, respectively. During the follow-up, only five patients developed osteoporosis by the Z-score definition (<-1). If defined by T-score (<-2.5) none of the patients developed osteoporosis. The BMD change correlated neither with the clinical parameters of disease activity nor with the markers of collagen metabolism. However, the BMD change in FN was associated with the cumulative corticosteroid dose (r=-0.31, p <0.05, 95% CI -0.54 to -0.04). Reasons for the lack of accelerated bone loss in our series are open to various interpretations. This series was community based and most of the patients had mild RA. The patients were also actively treated and their physical function did not deteriorate.
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Affiliation(s)
- S Aman
- Division of Rheumatology, University of Oulu, Finland
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Abstract
A body of evidence points towards a close connection between susceptibility to fractures and osteoporosis. The incidence of osteoporotic fractures, both in absolute figures and in age-specific figures, has increased worldwide throughout this century. Although some reports show that the age-specific incidence is levelling-off, there will be a continuously increasing number of individuals with such fractures that will have implications from an economical point of view not only for the affected individual but for society as a whole. The outcome after such fractures, especially those of the hip, is by no means always favourable, partly due to insufficient results after orthopaedic treatment and partly due to an already high comorbidity. Therefore, trying to prevent osteoporotic fractures by non-pharmacological or pharmacological regimens is of utmost importance.
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Affiliation(s)
- O Johnell
- Department of Orthopaedics, Malmö University Hospital, Sweden
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Eggelmeijer F, Papapoulos SE, van Paassen HC, Dijkmans BA, Valkema R, Westedt ML, Landman JO, Pauwels EK, Breedveld FC. Increased bone mass with pamidronate treatment in rheumatoid arthritis. Results of a three-year randomized, double-blind trial. ARTHRITIS AND RHEUMATISM 1996; 39:396-402. [PMID: 8607888 DOI: 10.1002/art.1780390307] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Osteoporosis is a frequent complication of rheumatoid arthritis (RA). We therefore investigated the effect of oral pamidronate therapy as a specific bone-sparing agent in RA. METHODS The study design was a 3-year randomized, double-blind trial of 300 mg oral pamidronate/day compared with placebo in 105 RA patients. Bone mineral density (BMD) measured at 12-month intervals was the primary efficacy parameter. RESULTS In 3 years, lumbar spine and forearm BMD increased significantly in the pamidronate-treated group (by 8.4 +/- 6.9% [mean =/- SEMI] [P < 0.00011 and 5.2 =/- 6.5% [P < 0.005], respectively), compared with nonsignificant changes in the placebo-treated patients (increase of 0.6 =/- 5.2% and decrease of 1.2 =/- 5.8%, respectively). Femoral neck BMD increased in the pamidronate-treated group (by 2.6 =/- 8.6%) and decreased significantly in the placebo-treated group (by 4.0=/- 1.3% [P < 0.005]). The changes in BMD with time at all 3 measurement sites were significantly different between the treatment groups (P < 0.0001). Changes in radiographic signs of joint damage and in disease activity were similar in the 2 groups. CONCLUSION The present study provides the first evidence that long-term treatment with an orally administered bisphosphonate overcomes bone loss and increases bone mass when compared with placebo. This finding may have significance with regard to the treatment of patients with RA.
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Deodhar AA, Brabyn J, Jones PW, Davis MJ, Woolf AD. Longitudinal study of hand bone densitometry in rheumatoid arthritis. ARTHRITIS AND RHEUMATISM 1995; 38:1204-10. [PMID: 7575713 DOI: 10.1002/art.1780380905] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To measure hand bone mineral content (BMC) by dual x-ray absorptiometry and to seek clinical correlates in patients with rheumatoid arthritis (RA), in a prospective, longitudinal study. METHODS Eighty-one patients with non-steroid-treated RA were assessed at baseline and at month 12, for hand BMC and for disease activity and severity. Hand BMC in patients was compared with that in a control group of 95 normal volunteers, and rate of loss was compared with that in 37 controls. RESULTS At the initial assessment, male and female patients with RA had lower hand BMC than controls, after correction for age, height, and weight (mean reduction 7.5% in men [P = 0.003] and 7.8% in women [P = 0.01]). After 1 year, there was a further loss of hand BMC in patients (median loss 3.25% in men [P = 0.001] and 1.46% in women [P = 0.05]), but normal controls did not have significant changes in their hand BMC. In patients with disease duration of < 2 years at study entry, the parameters of disease activity improved over 1 year, but they lost significant amounts of hand BMC. Hand BMC loss correlated with baseline C-reactive protein levels. In those with RA of > 2 years duration at entry, the Health Assessment Questionnaire scores and Larsen scores had worsened after 1 year, but there was no significant loss of hand BMC. CONCLUSION Patients with RA had low hand BMC compared with normal controls, even within 2 years of disease onset. The rate of loss was highest in patients with early disease and correlated with measures of initial disease activity. This loss continued despite clinical improvement.
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Affiliation(s)
- A A Deodhar
- Duke of Cornwall Rheumatology Unit, Royal Cornwall Hospital (City) Truro, UK
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