Bone loss in males with ankylosing spondylitis: its relation to sex hormone levels

Evaluation of temporomandibular joint components and mandibular bone structure in ankylosing spondylitis patients

OBJECTIVES

The study aimed to investigate the mandible and temporomandibular joint (TMJ) in patients with ankylosing spondylitis (AS) who had no signs or symptoms of TMJ-related disease and compare them with a control group.

STUDY DESIGN

In total, 128 panoramic radiographs (63 patients with AS, 65 controls) were evaluated. Fractal analysis was conducted on the mandibular condyle (ROI1), angle of the mandible (ROI2), and the area adjacent to the mental foramen (ROI3). Articular eminence inclination (AEI) values were measured. Klemetti index (KI) evaluation of the mandibular cortex was also performed.

RESULTS

Fractal dimension (FD) values were significantly lower in the patients with AS than the controls in ROI1 and ROI2 (P = .001), but there were no significant differences between groups for FD in ROI3, AEI, or KI (P ≥ .09). No significant differences were found in any parameters between patients with AS with different disease durations (P ≥ .06).

CONCLUSIONS

Patients with AS displayed significantly lower FD values in condyles and the angle of the mandible and slightly lower AEI values; therefore, they should be examined routinely for TMJ disorders. Clinicians should be aware of the possibility of secondary osteoporosis in patients with AS and consider its probable effects on the mandible.

Advanced ankylosing spondylitis: a multisite, multimodality densitometric analysis for investigation of bone loss in the axial and appendicular skeleton

OBJECTIVE

The aim of this study was to investigate if there is a bias in bone mineral density measurements among major densitometric techniques across multiple skeletal sites.

METHODS

In 25 advanced ankylosing spondylitis patients, bone mineral density measurements were acquired in the lumbar spine, the hip, and the forearm.

RESULTS

In total, 60% of patients had a bone mineral density Z-score of -2 or less at one or more skeletal sites. Dedicated loss of cortical bone was identified at the distal forearm (60% of patients). Differences in bone mineral density measurements across all densitometric techniques were highly significant (p≤0.001). Bone loss was more striking in spinal trabecular bone by three-dimensional quantitative computed tomography [Z-score -2.1] versus dual-energy X-ray absorptiometry [Z-score 0]. A trabecular bone loss quantified by quantitative computed tomography was about twice as much as a cortical bone loss by single-energy X-ray absorptiometry (p=0.001).

CONCLUSIONS

Low bone mineral density is prevalent in advanced ankylosing spondylitis patients, predominating in the spine. Bone mineral density measurements have systematic differences when compared to each other. Knowledge of these offsets is useful for improved diagnosis of regional bone loss that allows for targeted treatment of osteoporosis. Three-dimensional quantitative computed tomography is more suitable for evaluating spinal osteoporosis in advanced ankylosing spondylitis than dual-energy X-ray absorptiometry, which rather underestimates bone loss.

Mechanism of Hip Arthropathy in Ankylosing Spondylitis: Abnormal Myeloperoxidase and Phagosome

Background

The pathogenesis of Ankylosing spondylitis (AS) has not been elucidated, especially involving hip joint disease. The purpose of this study was to analyze the proteome of diseased hip in AS and to identify key protein biomarkers.

Material and Methods

We used label-free quantification combined with liquid chromatography mass spectrometry (LC–MS/MS) to screen for differentially expressed proteins in hip ligament samples between AS and No-AS groups. Key protein was screened by Bioinformatics methods. and verified by in vitro experiments.

Results

There were 3,755 identified proteins, of which 92.916% were quantified. A total of 193 DEPs (49 upregulated proteins and 144 downregulated proteins) were identified according to P < 0.01 and Log|FC| > 1. DEPs were mainly involved in cell compartment, including the vacuolar lumen, azurophil granule, primary lysosome, etc. The main KEGG pathway included Phagosome, Glycerophospholipid metabolism, Lysine degradation, Pentose phosphate pathway. Myeloperoxidase (MPO) was identified as a key protein involved in Phagosome pathway. The experiment of siRNA interfering with cells further confirmed that the upregulated MPO may promote the inflammatory response of fibroblasts.

Conclusions

The overexpression of MPO may contribute to the autoimmune inflammatory response of AS-affected hip joint through the phagosome pathway.

Immunopathophysiology of Juvenile Spondyloarthritis (jSpA): The "Out of the Box" View on Epigenetics, Neuroendocrine Pathways and Role of the Macrophage Migration Inhibitory Factor (MIF)

Juvenile spondyloarthritis (jSpA) is a an umbrella term for heterogeneous group of related seronegative inflammatory disorders sharing common symptoms. Although it mainly affects children and adolescents, it often remains active during adulthood. Genetic and environmental factors are involved in its occurrence, although the exact underlying immunopathophysiology remains incompletely elucidated. Accumulated evidence suggests that, in affected patients, subclinical gut inflammation caused by intestinal dysbiosis, is pivotal to the future development of synovial-entheseal complex inflammation. While the predominant role of IL17/23 axis, TNF-α, and IL-7 in the pathophysiology of SpA, including jSpA, is firmly established, the role of the cytokine macrophage migration inhibitory factor (MIF) is generally overlooked. The purpose of this review is to discuss and emphasize the role of epigenetics, neuroendocrine pathways and the hypothalamic-pituitary (HPA) axis, and to propose a novel hypothesis of the role of decreased NLRP3 gene expression and possibly MIF in the early phases of jSpA development. The decreased NLRP3 gene expression in the latter, due to hypomethylation of promotor site, is (one of) the cause for inflammasome malfunction leading to gut dysbiosis observed in patients with early jSpA. In addition, we highlight the role of MIF in the complex innate, adaptive cellular and main effector cytokine network, Finally, since treatment of advanced bone pathology in SpA remains an unmet clinical need, I suggest possible new drug targets with the aim to ultimately improve treatment efficacy and long-term outcome of jSpA patients.

Association between gonadal hormones and osteoporosis in schizophrenia patients undergoing risperidone monotherapy: a cross-sectional study

Objective

Patients with schizophrenia are at increased risk of osteoporosis. This study first determined the osteoporosis rate in patients with schizophrenia and then then explored the association between serum gonadal hormone levels and osteoporosis among these patients.

Methods

A total of 250 patients with schizophrenia and 288 healthy controls were recruited. Osteoporosis was defined by decreased bone mineral density (BMD) of the calcaneus. Serum fasting levels of gonadal hormones (prolactin, estradiol, testosterone, progesterone, follicle-stimulating hormone, luteinizing hormone) were determined. The relationship between osteoporosis and hormone levels was statistically analyzed by binary logistic regression analysis.

Results

Our results showed that patients with schizophrenia had a markedly higher rate of osteoporosis (24.4% vs. 10.1%) than healthy controls (P < 0.001). Patients with osteoporosis were older, had a longer disease course, and had a lower body mass index (BMI) than patients without osteoporosis (all P < 0.05). Regarding gonadal hormones, we found significantly higher prolactin, but lower estradiol, levels in patients with osteoporosis than in those without osteoporosis (both P < 0.05). The regression analysis revealed that PRL (OR = 1.1, 95% CI [1.08–1.15], P < 0.001) and E2 level (OR = 0.9, 95%CI [0.96–0.99], P = 0.011) were significantly associated with osteoporosis in patients with schizophrenia.

Conclusion

Our results indicate that patients with schizophrenia who are being treated with risperidone have a high rate of osteoporosis. Increased prolactin and reduced estradiol levels are significantly associated with osteoporosis.

A 2-year longitudinal study of bone health in adolescent patients with axial spondyloarthritis

PURPOSE

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that primarily affects the axial skeleton and typically has an early onset. Although earlier onset is associated with worse prognosis, there have been few studies of bone mineral density (BMD) in adolescent patients with axSpA.

METHODS

We analysed the clinical characteristics of 43 adolescent patients with axSpA at a baseline assessment and at a follow-up 2 years later. The baseline assessment included age, disease duration, treatment agents, and clinical, radiologic, and laboratory data. BMD of the lumbar spine, femoral neck, and total hip were measured by dual-energy X-ray absorptiometry during both the baseline assessment and the 2-year follow-up. We performed multivariate linear regression analyses to identify factors independently associated with BMD. We analysed the associations between changes in BMD and reductions in inflammatory markers.

RESULTS

The average age of participants was 17.9 years and the mean disease duration was 2.2 years. Of the 43 patients, 10 (23%) had low BMD at any site (lumbar spine, femoral neck, and/or total hip). At baseline, multivariate analysis showed that body mass index (BMI), erythrocyte sedimentation rate (ESR), and spinal structural damage were associated with lumbar spine Z-scores. Increases in BMD in the lumbar spine were correlated with reductions in ESR (r = 0.40, P = 0.02) and C-reactive protein (CRP) (r = 0.40, P = 0.02). Increases in BMD in the total hip were correlated with reductions in CRP (r = 0.38, P = 0.03).

CONCLUSION

In adolescent axSpA patients, bone health was associated with systemic inflammation and the severity of structural damage. Reduced systemic inflammation was associated with improvements in bone health.

Surgical correction of rigid cervicothoracic deformity in a transgender patient: case report

A number of spinal pathologies result in fusion of the spine, including ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), as well as severe degenerative arthropathies. This fusion of spinal elements may result in spinal deformity affecting any region of the spine. Cervicothoracic deformity resulting in chin on chest deformity is poorly tolerated due to inability to maintain a horizontal gaze. Surgical treatment options for this condition are complex and require extensive discussion between the patient and surgical team. Here we present a case report of a 26-year-old transgender female (male to female) patient with severe chin on chest deformity and a unique pattern of spinal fusion involving only the posterior elements. She underwent C2-T8 posterior spinal fusion with thoracic pedicle subtraction osteotomy and multiple cervical facet osteotomies with good functional result. She did have severe dysphagia and required feeding tube for several weeks but did very well by 1 year postoperatively. While posterior elements of the spine are normally affected first in spondyloarthropathies such as ankylosing spondylitis, the lack of anterior spinal involvement is unique and could be attributed to hormonal therapy in this patient. This case describes a unique pattern of spondyloarthropathy and highlights the importance of a having a multi-disciplinary team for the treatment of patients with complex spinal pathologies.

A Mechanism Underlying Sex-Associated Differences in Ankylosing Spondylitis: Troponin C2, Fast Skeletal Type (TNNC2) and Calcium Signaling Pathway

BACKGROUND Ankylosing spondylitis (AS) is a disease that causes pathological changes in the spine and sacroiliac joints. Numerous studies have shown that the characteristics of AS differ between males and females. The purpose of this study was to discover the key molecules that contribute to sex-associated differences in AS, which may provide a new molecular target for personalized treatment. MATERIAL AND METHODS The gene expression profile of GSE39340 was downloaded from the Gene Expression Comprehensive database, and 2 groups (AS vs. No-AS groups and male AS vs. female AS groups) of differentially expressed genes (EDGs) were obtained by GEO2R. The DAVID database was used for DEGs function and enrichment analysis. Based on data in the STRING online database, a protein-protein interaction (PPI) network was constructed in Cytoscape. Hub genes were selected from CytoHubba. With the intersection of the top 30 hub genes of 2 sets of EDGs, genes coexisting with the KEGG-related pathway were found. RESULTS We screened 560 genes between the AS and No-AS groups, and screened 710 genes that were differentially expressed between the male and female AS groups. GO analysis showed that DEGs were mainly co-enriched in molecular functions, including structural constituent of muscle. The KEGG pathway mainly included the structural constituent of muscle. Seven hub genes were obtained. Troponin C2 and fast skeletal type (TNNC2) were the key genes participating in the calcium signaling pathway. CONCLUSIONS This study contributes to understanding the molecular biological mechanism underlying sex-associated differences in AS. TNNC2 and calcium signaling pathway may be new targets for the individualized treatment of AS.

Ankylosing spondylitis: etiology, pathogenesis, and treatments

Ankylosing spondylitis (AS), a common type of spondyloarthropathy, is a chronic inflammatory autoimmune disease that mainly affects spine joints, causing severe, chronic pain; additionally, in more advanced cases, it can cause spine fusion. Significant progress in its pathophysiology and treatment has been achieved in the last decade. Immune cells and innate cytokines have been suggested to be crucial in the pathogenesis of AS, especially human leukocyte antigen (HLA)‑B27 and the interleukin‑23/17 axis. However, the pathogenesis of AS remains unclear. The current study reviewed the etiology and pathogenesis of AS, including genome-wide association studies and cytokine pathways. This study also summarized the current pharmaceutical and surgical treatment with a discussion of future potential therapies.

Low bone mineral density predicts the formation of new syndesmophytes in patients with axial spondyloarthritis

Background

This study aimed to investigate whether the presence of low bone mineral density (BMD) in patients with axial spondyloarthritis (axSpA) predicts formation of new syndesmophytes over 2 years.

Methods

One hundred and nineteen patients fulfilling the imaging arm of the Assessment of SpondyloArthritis International Society axSpA criteria were enrolled. All patients were under 50 years of age. The modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) was assessed by two trained readers blinded to the patients’ data. BMD (lumbar spine, femoral neck or total hip) at baseline was assessed using dual-energy absorptiometry. Low BMD was defined as Z score ≤ − 2.0. Spinal radiographic progression was defined as worsening of the mSASSS by ≥ 2 points over 2 years. Logistic regression analyses were performed to identify predictors associated with development of new syndesmophytes and spinal radiographic progression.

Results

At baseline, 19 (16%) patients had low BMD. New syndesmophytes had developed in 22 (21%) patients at 2-year follow-up. New syndesmophyte formation after 2 years occurred more in patients with low BMD than in those with normal BMD (p = 0.047). In the multivariable analysis, current smoking, existing syndesmophytes and low BMD at baseline were associated with spinal radiographic progression (OR (95% CI) 3.0 (1.1, 7.7), 4.6 (1.8, 11.8) and 3.6 (1.2, 11.2), respectively). The presence of syndesmophytes at baseline and low BMD were predictors of new syndesmophytes over the following 2 years (OR (95% CI) 5.5 (2.0, 15.2) and 3.6 (1.1, 11.8), respectively).

Conclusions

Low BMD and existing syndesmophytes at baseline were independently associated with the development of new syndesmophytes in young axSpA patients.

Gender Differences in Axial Spondyloarthritis: Women Are Not So Lucky

PURPOSE OF REVIEW

Ankylosing spondylitis (AS) was historically seen as a predominantly male disease. However, more recent data showed a more homogenous sex prevalence. Unfortunately, in many studies in axial spondyloarthritis (axSpA), the number of women included is low and the analyses are often not stratified for gender distribution. The purpose of this review is to aggregate the existing data on gender differences in axSpA in order to increase the awareness that female axSpA patients are still under-recognized.

RECENT FINDINGS

Several studies considering gender differences revealed that female axSpA patients had different disease manifestations due to different immunological, hormonal, and genetic responses. For instance, allelic frequencies of the AHNK-gene and tissue non-specific alkaline phosphatase (TNAP) haplotypes differed between men and women with ankylosing spondylitis (AS). In addition, different levels of tumor necrosis factor (TNF), interleukins IL-6, IL-17, and IL-18, were found between the two sexes. Furthermore, female patients show a higher diagnostic delay compared to males. Several studies indicate a higher frequency of extra-articular manifestations (EAM) in female axSpA patients, such as enthesitis, psoriasis, and inflammatory bowel disease (IBD), whereas acute anterior uveitis is more prevalent in male patients. Male AS patients more frequently show a higher Bath Ankylosing Spondylitis Radiology Index (BASRI) scores and modified Stoke Ankylosing Spondylitis Spine Scores (mSASSS) than females, which indicates that males have higher radiological damage and radiographic progression. However, disease activity (BASDAI) and quality of life (AsQol) scores are significantly higher in women, and more importantly, they have significantly lower response rates to treatment with TNF inhibitors (TNFi) and a significantly lower drug adherence. Despite the fact that men with axial SpA have a worse radiologic prognosis, women have a high disease burden, in part because they have a longer delay in diagnosis, higher disease activity, and significantly less responsiveness to treatment with TNFi.

Prevalence and risk factors for osteoporosis and fractures in axial spondyloarthritis: A systematic review and meta-analysis

OBJECTIVES

To describe the prevalence of osteoporosis, the prevalence and incidence of fractures, and the frequency of risk factors for low bone mineral density (BMD) in axial spondyloarthritis (Ax-SpA).

METHODS

A systematic review and meta-analysis of observational studies was conducted. Medline, Embase, and Cochrane Library databases were searched with a sensitive strategy. Large cross-sectional and longitudinal studies published in the last 10 years (January 2006-2016) with representative samples of patients with Ax-SpA estimating the frequency of osteoporosis, risk factors or fractures were selected.

RESULTS

After screening 3597 titles and abstracts, 46 studies were reviewed in detail, of which 35 studies had a cross-sectional design, 5 were prospective and 6 retrospective; 21 studies compared Ax-SpA patients with a control group-either healthy individuals (18 studies) or subjects with other diseases (6 studies). The prevalence of osteoporosis varied from 11.7% to 34.4% and that of fractures from 11% to 24.6%. Alcohol intake (58-61%), use of corticosteroids (11.7-66.9%), and 25-OH vitamin D deficiency (26-76%) were unexpectedly high in Ax-SpA patients.

CONCLUSION

The prevalence of osteoporosis and fractures in Ax-SpA varies between 11.7% and 34.4% and 11-24.6%, respectively. Alcohol intake, steroid use, and low levels of 25-OH-vitamin D should be taken into account in osteoporosis assessment in patients with Ax-SpA. Inconsistent results, lack of bone quality assessment, and high likelihood of bias of the published studies confirm the need for performing well-designed studies.

Analysis on the situation of subjective well-being and its influencing factors in patients with ankylosing spondylitis

Background

To examine the subjective well-being (SWB) in patients with ankylosing spondylitis (AS) compared with the healthy controls, and to explore the associations between SWB and demographic characteristics, disease-specific variables in AS patients.

Methods

SWB was assessed with General Well-Being Schedule (GWBS) in 200 AS patients and 210 healthy controls. Comparisons among subgroups were performed to investigate how certain aspects operate as favorable or adverse factors in influencing SWB in the patients with AS.

Results

Both men and women with AS reported significantly impaired SWB on all scales of the GWBS except for the Control (O) scale. The results revealed that better sleep, lower disease activity and more family care predicted higher SWB. In AS patients, positive attitude towards therapy prospect was significantly associated with higher SWB. Therapy prospect refers to the hope of patients about the disease treatment.

Conclusions

Compared with general population, SWB might be affected by the onset of AS. There are significant associations between SWB and sleep quality, BASDAI, APGAR, therapy prospect.

Osteoporosis in rheumatic diseases

Rheumatic diseases, characterized by chronic inflammation and damage to various organs and systems, include systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis and other connective tissue diseases. Bone is a target in many inflammatory rheumatic diseases. In recent years, the survival of patients with rheumatic diseases has increased markedly and the relationship between rheumatic diseases and osteoporosis (OP) has become more prominent. OP and related fragility fractures increase the morbidity and mortality of rheumatic disease. The cause of OP in rheumatic diseases is complex. The pathogenesis of OP in rheumatic diseases is multifactorial, including disease and treatment-related factors. Osteoimmunology, a crosstalk between inflammatory and bone cells, provides some insight into the pathogenesis of bone loss in systematic inflammatory diseases. The aim of this article is to review different risk factors in rheumatic diseases. Several factors play a role, such as chronic inflammation, immunological factors, traditional factors, metabolism and drug factors. Chronic inflammation is the most important risk factor and drug treatment is complex in patients with OP and rheumatic disease. Attention should be paid to bone loss in rheumatic disease. Optimal treatment of the underlying rheumatic disease is the first step towards prevention of OP and fractures. Apart from that, a healthy lifestyle is important as well as calcium and vitamin D supplementation. Bisphosphonates or denosumab might be necessary for patients with a low T score.

Prevalence and risk factors of low bone mineral density in juvenile onset ankylosing spondylitis

The objective of this study is to assess the prevalence and risk in patients with juvenile onset ankylosing spondylitis (JoAS) complicated with low bone mineral density (BMD). A total of 112 children and adolescents with JoAS were enrolled in the study. Bone mass was measured from the lumbar spine and the left proximal femur using dual-energy X-ray absorptiometry. According to the 2007 International Society of Clinical Densitometry definitions, a Z score of less than -2 was termed as "low BMD." Stepwise regression analysis was used to investigate associations between low BMD and disease-related factors including gender, age, weight, height, body mass index, disease duration, HLA-B27 antigen, grades of sacroiliitis, Bath AS Disease Activity Index (BASDAI), Bath AS Functional Index (BASFI), patient global assessment (PGA), spine pain, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). Low BMD was found in 18 (16.1 %) cases in at least one of the two measured regions. Lumbar spine BMD had negative correlations with BASDAI, BASFI, spine pain, ESR, and CRP (P < 0.05). Hip BMD significantly negatively correlated with BASDAI and PGA (P < 0.05). In conclusion, patients with JoAS are likely to develop low BMD, which may be related to high disease activity.

Low body mass index and blood loss in primary total hip arthroplasty: results from 236 consecutive ankylosing spondylitis patients

Objective. To evaluate the effect of low body mass index (BMI) on blood loss during primary total hip arthroplasty (THA) in ankylosing spondylitis (AS) patients. Methods. Two hundred seventy-seven consecutive AS patients who underwent primary THA were retrospectively studied. The patients were divided by BMI into an underweight group (BMI < 18.5 kg/m²) and a normal weight group (18.5 kg/m² < BMI < 25 kg/m²). Demographics, perioperative laboratory values, intraoperative data, blood loss, transfusion rate, transfusion reactions, surgical complications, hospitalization cost, and length of stay (LOS) were collected and analyzed. Results. Of 277 AS patients, 236 were eligible for inclusion in the study. A total of 91 (39%) patients were underweight. The hidden blood loss, transfusion rate, transfusion reactions, and hospitalization cost in the underweight group were significantly higher than those in the normal weight group. Conclusions. For AS patients, BMI appears to be correlated with blood loss during primary THA. Compared with patients of normal weight, low BMI patients have the potential to suffer more postoperative hidden blood loss and to require a higher transfusion rate.

Influence of tumor necrosis factor α inhibitors on testicular function and semen in spondyloarthritis patients

OBJECTIVE

To evaluate sperm parameters and sexual hormones in young males affected with spondyloarthritis (SpA) before and after 1 year of anti-tumor necrosis factor (TNF) α treatment.

DESIGN

Prospective case-control study.

SETTING

Rheumatology and human reproduction pathology units at a university hospital.

PATIENTS

Ten SpA outpatients attending the rheumatology clinic; 20 healthy control subjects attending the unit of human reproduction pathology within an infertility prevention program.

INTERVENTIONS

At baseline and after a 12-month treatment, disease activity was assessed and an andrologic evaluation made.

MAIN OUTCOME MEASURE(S)

Rheumatologists assessed anamnestic, clinical, functional, and biomarker data. Andrologists evaluated semen analysis, fluorescence in situ hybridization for chromosomes X, Y, 13, 18, and 21, FSH, LH, and T plasma levels, and testicular color Doppler ultrasound.

RESULTS

At baseline, SpA patients showed reduced sperm motility, higher plasma LH and FSH, and lower T levels compared with control subjects; a significant correlation between disease activity and sperm quality was found. After treatment, a statistically significant decrease in sperm aneuploidies and normal hormone levels were observed.

CONCLUSIONS

Although inflammation in SpA appears to be related to impaired testicular function, anti-TNF-α agents seem to be safe on testicular function and fertility.

High prevalence of low bone mineral density in patients within 10 years of onset of ankylosing spondylitis: a systematic review

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease. Decreased bone mineral density (BMD) is a common complication of AS, with a prevalence range of 19 to 62 %. Many studies have shown decreased BMD in AS with long disease duration, but only a few studies investigated BMD in early AS. The prevalence of decreased BMD in early disease stages of AS has not yet been clearly described, and for that reason, we reviewed the literature which describes the prevalence of decreased BMD in AS patients with a short disease duration (<10 years). In this review, we included articles which used the modified New York criteria for the diagnosis of AS, included patients with a disease duration of less than 10 years, and used the WHO criteria for osteopenia and osteoporosis. Decreased BMD was defined as a T score < −1.0, including both osteopenia and osteoporosis. For this review, only articles that acquired BMD data of lumbar spine and femoral neck by DXA were used. The literature search provided us 35 articles of which 7 matched all our criteria, and they will be further outlined in this review. The overall prevalence of decreased BMD of the articles reviewed is 54 % (n = 229/424) for lumbar spine and 51 % (n = 224/443) for femoral neck. The prevalence of osteopenia vs. osteoporosis for lumbar spine is 39 vs. 16 % and for femoral neck, 38 vs. 13 %. This review showed a high total prevalence of 51–54 % decreased BMD and 13–16 % osteoporosis in AS with a short disease duration. This high prevalence was not to be expected in a relatively young and predominantly male population. Further research is needed to determine the clinical relevance of this low BMD by investigating the relation between low BMD and vertebral and nonvertebral fractures at this early stage in AS.

The change of bone mineral density according to treatment agents in patients with ankylosing spondylitis

OBJECTIVES

The aim was to access the effects of treatment on bone mineral density (BMD) by treatment agents in patients with ankylosing spondylitis (AS).

METHODS

We analyzed clinical characteristics of 90 AS patients. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and x-ray of lumbar spine (L-spine) and sacroiliac joint were included in the baseline assessment. The BMDs of right femur and L-spine were measured annually using dual x-ray absorptiometry (DXA). The patients were divided into one of the following four groups by agents exposed for the follow-up period: conventional treatment, bisphosphonate, anti-TNF-α agent or bisphosphonate + anti-TNF-α agent. We evaluated the changes of BMD according to treatment groups.

RESULTS

The average age of disease onset was 30 years and the mean disease duration was 8.2 years. The patients who were assigned to the groups of conventional treatment, bisphosphonate, anti-TNF-α agents and bisphosphonate + anti-TNF-α agents were 40, 20, 19 and 11. BMDs values of both L-spine and femur showed tendencies to the most increase in the group treated with concurrent bisphosphonate and anti-TNF-α agent. However, the change of BMD by treatment agents was significant different only in trochanter (P = 0.001). In patients without syndesmophyte, there was significant difference of BMD change in both L-spine and total proximal femur (P = 0.001, 0.004). The BMD change of trochanter was correlated with the reductions of ESR and CRP (r = 0.239, P = 0.035 and r = 0.233, P = 0.040).

CONCLUSIONS

The BMDs of AS patients increased more by the treatment of concurrent bisphosphonate and anti-TNF-α agents. The gain of bone mass was associated with the reduction of inflammation.