Assessing periarticular bone mineral density in patients with early psoriatic arthritis or rheumatoid arthritis

Microarchitectural analysis of the metacarpophalangeal joint using HR-pQCT in patients with rheumatoid arthritis: A comparison with healthy controls

OBJECTIVE

To investigate which joint microarchitectural parameters measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) serve as imaging markers for rheumatoid arthritis (RA).

METHODS

The second and third metacarpophalangeal (MCP) joints of 50 patients with RA and 50 healthy controls (HCs) (aged 50-79 years, all females) were scanned using a HR-pQCT. Joint space, trabecular bone microarchitecture, and erosion were measured and compared between RA patients and HCs.

RESULTS

There were no differences in joint space parameters between RA patients and HCs. For bone microarchitecture, RA patients had lower trabecular bone mineral density (127 vs. 167 mg/cm3), thinner trabecular thickness (0.20 vs. 0.21 mm), fewer trabecular number (1.49 vs. 1.55 /mm), more rod-like structure (1.68 vs. 1.23), and poorer trabecular connectivity (4.51 vs. 5.72 /mm3) than HCs. Regarding erosion, RA patients had a higher number of erosions per joint (36/100 vs. 18/100), larger volume (4.62 vs. 1.89 mm3), and longer width (2.40 vs. 1.82 mm) and longer length (2.34 vs. 1.64 mm) than HCs. Most of the erosions in HCs were <5 mm3 in volume (95 %) and located on the radial side (85 %). When erosions <5 mm3 were compared between RA patients and HCs, there were no differences in their location or morphology.

CONCLUSIONS

Deterioration of bone microarchitecture and existences of erosions >5 mm3 in the MCP joints are sensitive imaging markers of RA. Erosions <5 mm3 in RA patients may include not only early pathological erosion but also physiological erosion because even HCs can have erosions <5 mm3.

Increased risk of osteoporosis and femoral neck fractures in patients with familial Mediterranean fever-a large retrospective cohort study

OBJECTIVES

The direct impact of inflammatory conditions and their therapy with corticosteroids contribute to an increased risk of osteoporosis with associated fractures. Familial Mediterranean fever (FMF) is an autoinflammatory disorder not commonly treated with corticosteroids. Evidence regarding FMF association with osteoporosis and femur fractures is anecdotal. We aimed to evaluate the incidence and risk of osteoporosis and femoral neck fracture in FMF patients compared with the general population.

METHODS

A retrospective cohort study using the electronic database of Clalit Health Services of all FMF patients first diagnosed between 2000 and 2016 and controls was conducted including age- and sex-matched controls in a 1:1 ratio. Follow-up continued until the first diagnosis of osteoporosis or fracture. Risk for these conditions was compared using univariate and multivariate Cox regression models.

RESULTS

A total of 9769 FMF patients were followed for a median period of 12.5 years. Of these, 304 FMF patients were diagnosed with osteoporosis compared with 191 controls, resulting in an incidence rate (per 10 000 persons-years) of 28.8 and 17.8, respectively, and a crude hazard ratio of 1.62 (95% CI 1.35, 1.93; P < 0.001). Patients were diagnosed with osteoporosis at a considerably younger age than controls [60.1 (s.d. 12.4) vs 62.5 (s.d. 11.0) years; P = 0.028]. A total of 56 FMF patients were diagnosed with femoral neck fracture compared with 35 controls, resulting in an incidence rate of 5.3 and 3.3, respectively, and a crude HR of 1.60 (95% CI 1.05, 2.44; P < 0.05).

CONCLUSION

FMF patients are at increased risk for osteoporosis and consequently femur fracture. Our findings emphasize the importance of considering bone health in the management of FMF patients.

Association between PYTPN22 rs2476601, VEGF rs833070, TNFAIP3 rs6920220 Polymorphisms and Risk for Rheumatoid Arthritis in Early Undifferentiated Arthritis Patients: A Pilot Study

Background and Objectives: About 40% of early undifferentiated arthritis (UA) progresses to rheumatoid (RA) or other chronic arthritis. Novel diagnostic tools predicting the risk for this progression are needed to identify the patients who would benefit from early aggressive treatment. Evidence on the role of single-nucleotide polymorphisms (SNPs) in the development of RA has emerged. The aim of our study was to investigate the association between rs2476601, rs833070, and rs6920220 SNPs and UA progression to RA. Materials and Methods: Ninety-two UA patients were observed for 12 months. At study entry, demographic and clinical characteristics were recorded, musculoskeletal ultrasonography was performed, and blood samples were drawn to investigate levels of inflammatory markers, rheumatoid factor (RF), anti-citrullinated protein antibodies (anti-CCP)detect SNPs. After 12 months, UA outcomes were assessed, and patients were divided into two (RA and non-RA) groups. The association between the risk of progression to chronic inflammatory arthritis and analyzed SNPs was measured by computing odds ratios (OR). Results: After a 12-month follow-up, 27 (29.3%) patients developed RA, and 65 (70.7%) patients were assigned to the non-RA group. The arthritis of 21 patients (22.8%) from the non-RA group resolved completely, while the other 44 (47.2%) patients were diagnosed with another rheumatic inflammatory disease. The patients who developed RA had a significantly greater number of tender and swollen joints (p = 0.010 and p = 0.021 respectively) and were more frequently RF or anti-CCP (p < 0.001), and both RF and anti-CCP positive (p < 0.001) at the baseline as compared with the patients in the non-RA group. No significant association between rs2476601 (OR = 0.99, p = 0.98), rs833070 (OR = 1.0, p = 0.97), and rs6920220 (OR = 0.48, p = 0.13) polymorphisms and the risk of developing RA were found. Conclusions: No association between analyzed SNPs and a greater risk to progress from UA to RA was confirmed, although patients with rs6920220 AA + AG genotypes had fewer tender joints at the disease onset.

The inhibitory effect of tocilizumab on systemic bone loss and tendon inflammation in a juvenile Collagen-Induced arthritis rat model

PURPOSE OF THE STUDY

Reduced Bone Mineral Density (BMD) is a prevalent comorbidity in Juvenile Idiopathic Arthritis (JIA). Enthesitis and other tendon abnormalities, such as tenosynovitis, tendinitis and tendon ruptures are, also, common extra-articular manifestations of the disease. The aim of the present study was to investigate the effect of tocilizumab, an antibody that binds the Interleukin-6 (IL-6) Receptor, on inflammation-related bone loss and tendon inflammation in an animal model of JIA.

MATERIALS AND METHODS

The Collagen-Induced Arthritis (CIA) model was induced in male rats followed by intraperitoneal administration of tocilizumab for 8 weeks. Methotrexate, the most widely used Disease-Modifying Antirheumatic Drug in the management of JIA, was, also, administered, either as a monotherapy or as an add-on therapy to tocilizumab. BMD was evaluated with Micro-Computed Tomography (Micro-CT) and histopathological examination. Tendon damage was, also, assessed histologically. Finally, two pro-inflammatory cytokines, Tumor Necrosis Factor-alpha (TNF-a) and Interleukin-23 (IL-23) were quantified in tendon tissues by ELISA analysis.

RESULTS

Tocilizumab-treated animals exhibited a significantly improved trabecular microarchitecture on micro-CT analysis and histological examination. Tendon morphology was also improved. Anti-IL-6 treatment led to a significant decrease in TNF-a and IL-23 expression in tendon tissue.

CONCLUSIONS

The results of the present study provide evidence that tocilizumab reduces inflammation-related bone loss and suppresses tendon inflammation in a juvenile CIA rat model. These findings offer perspectives for the management of osteoporosis and enthesitis in JIA.

In vivo evaluation of mandibular trabecular and cortical bone quality in psoriasis vulgaris

OBJECTIVE

The aim of this study was to evaluate the effects of psoriasis vulgaris on mandibular structure by calculating fractal dimension (FD) and radiomorphometric indices.

STUDY DESIGN

Panoramic radiographs of 58 patients with psoriasis and 58 healthy participants were assessed. FD was used to analyze trabecular bone architecture in the condyle, angle, and 2 sites in the alveolar bone. Five radiomorphometric indices based on cortical thickness and the mandibular cortical index (MCI) for structure were used to assess cortical bone porosity. Comparisons were made between sites in trabecular and cortical bone. Quantitative and categorical data were statistically analyzed with the significance level at P < .05.

RESULTS

FD was significantly lower in the patients with psoriasis than in the controls in the alveolar bone sites (P ≤ .035). Differences between measurement sites were insignificant in psoriasis (P ≥ .617), but the FD values of some measurement sides in the control group differed significantly (P ≤ .004). All quantitative radiomorphometric indices were significantly lower in patients with psoriasis (P ≤ .034) with significant differences between some sites in both groups. No significant difference was found in MCI frequency distribution between the groups (P = .782).

CONCLUSIONS

Trabecular architecture and cortical thickness were negatively affected in patients with psoriasis, but no differences in cortical porosity were detected between groups.

The influence of vitamin D administration on the clinical presentation, body mass index, and osteoprotegerin (OPG) level in a sample of Egyptian children with familial Mediterranean fever

Background

Familial Mediterranean fever (FMF) is autosomal recessive chronic disease represents by recurring attacks of polyserositis, fever, and joint pain. Vitamin D deficiency in FMF children has been recently mentioned in literature and linked to delayed physical growth. Osteoporosis in FMF patients can be linked to low levels of vitamin D, too. Osteoprotegerin (OPG) might be used as an indicator for osteoporosis. Therefore, this work aimed to investigate the impact of vitamin D administration on clinical status, BMI, and bone mineral density represented by alterations in the OPG serum levels in a group of Egyptian children with FMF. This was a prospective longitudinal study carried out on 33 children, aged 4–16 years, with FMF cases. Patients were on colchicine 0.5–2 mg/day and received vitamin D3 oral drops 2800 IU/ml; each drop contains 100 IU in a dose of 600 IU/day for 6 months. The effect of vitamin D administration was evaluated clinically, anthropometrically and by assessment of serum vitamin D and osteoprotegerin at baseline and 6 months later.

Results

Serum vitamin D levels were below the normal range before intervention and showed significant improvement (p < 0.001) 6 months after intervention. Significant increase in both BMI Z scores (p < 0.05) and OPG serum levels and improvement in the clinical status as illustrated by significant decrease in the number of cases with fever, arthritis, and abdominal pain and significant decrease in the frequency and duration of the attacks (p < 0.001).

Conclusion

Our results intensely indicate that vitamin D supplementation improved the clinical condition, BMI, and bone mineral density in children with FMF.

Effect of Vitamin E Supplement on Bone Turnover Markers in Postmenopausal Osteopenic Women: A Double-Blind, Randomized, Placebo-Controlled Trial

Vitamin E is a strong anti-oxidative stress agent that affects the bone remodeling process. This study evaluates the effect of mixed-tocopherol supplements on bone remodeling in postmenopausal osteopenic women. A double-blinded, randomized, placebo-controlled trial study was designed to measure the effect of mixed-tocopherol on the bone turnover marker after 12 weeks of supplementation. All 52 osteopenic postmenopausal women were enrolled and allocated into two groups. The intervention group received mixed-tocopherol 400 IU/day, while the control group received placebo tablets. Fifty-two participants completed 12 weeks of follow-up. Under an intention-to-treat analysis, vitamin E produced a significant difference in the mean bone resorption marker (serum C-terminal telopeptide of type I collagen (CTX)) compared with the placebo group (-0.003 ± 0.09 and 0.121 ± 0.15, respectively (p < 0.001)). In the placebo group, the CTX had increased by 35.3% at 12 weeks of supplementation versus baseline (p < 0.001), while, in the vitamin E group, there was no significant change of bone resorption marker (p < 0.898). In conclusion, vitamin E (mixed-tocopherol) supplementation in postmenopausal osteopenic women may have a preventive effect on bone loss through anti-resorptive activity.

Infliximab prevents systemic bone loss and suppresses tendon inflammation in a collagen-induced arthritis rat model

Reduced Bone Mineral Density (BMD) and tendon abnormalities, such as tenosynovitis and enthesitis, are prevalent comorbidities in patients with rheumatoid arthritis (RA). The aim of the present study was to investigate the effect of chronic treatment with infliximab on BMD and tendon inflammation in an animal model of inflammatory arthritis. Collagen-Induced Arthritis (CIA) was induced in rats, followed by long-term intraperitoneal administration of infliximab. Two additional groups of animals received methotrexate either as a monotherapy or as a co-treatment to infliximab. BMD was evaluated by Micro-Computed Tomography (Micro-CT) and bone histological examination. Tendon inflammation was assessed histologically and by quantitative ELISA analysis of pro-inflammatory cytokines in tendon tissues. Both methotrexate and infliximab treatment alleviated joint inflammation and reduced paw edema. Infliximab-treated animals exhibited an improved trabecular microarchitecture on micro-CT and histological analysis compared to both non-treated and methotrexate-treated animals. Infliximab almost reversed the pathological changes in tendons induced by CIA. Finally, we observed statistically significant declines in tendon TNF-a and IL-23 levels after infliximab treatment. Our study provides evidence that infliximab prevents arthritis-related osteoporosis and suppresses tendon inflammation in an animal model of inflammatory arthritis, in addition to controlling disease activity. These findings offer perspectives for the management of osteoporosis and enthesitis in RA.

Effects of Long-Term Methotrexate, Infliximab, and Tocilizumab Administration on Bone Microarchitecture and Tendon Morphology in Healthy Wistar Rats

Objective

Rheumatic diseases are associated with bone loss, both systemic and periarticular, and tendon abnormalities. The aim of this study is to examine the effect of three antiarthritic drugs, methotrexate, an anti-folate metabolite; infliximab, a Tumor Necrosis Factor-alpha (TNF-α) inhibitor; and tocilizumab, an antibody against Interleukin-6 (IL-6) receptor, on bone microarchitecture and tendon morphology in the absence of an inflammatory state.

Materials and methods

Thirty-five, 8- to 9-week-old, male, Wistar rats were randomly allocated into five groups: negative control (CTRL), vehicle (VEH), methotrexate (MTX), infliximab (INFX), and tocilizumab (TCZ). After 8 weeks of antiarthritic drug intraperitoneal administration, animals were euthanized and rat tibiae and patellar tendons were histologically examined.

Results

All sections exhibited normal bone microarchitecture. Histological scores in all groups corresponded to normal bone mineral density. No no apparent differences in tenocyte morphology and architecture of collagen fibers were observed.

Conclusions

The results of this study indicate that long-term administration of methotrexate, infliximab, and tocilizumab had no effect on bone microarchitecture and tendon morphology in rats in the absence of an inflammatory condition.

Characterization of bone metabolism in hungarian psoriatic arthritis patients: a case-control study

Background

Skeletal manifestations are predominant in psoriatic arthritis (PsA). The aim of this cross-sectional, case-control study is the complex assessment of areal and volumetric bone mineral density (BMD), fracture risk, vitamin D status and bone turnover markers, and its association with disease-related variables.

Methods

Lumbar spine (L1-L4) and femoral neck (FN) areal, and distal radius (DR) volumetric BMD, 10-year probability of major and hip osteoporotic fracture as assessed by the fracture risk assessment (FRAX) tool, markers of bone metabolism and disease activity were assessed.

Results

Upon comparison of the disease and age- and sex-matched control groups, there was a statistically significant difference in FN areal (0.952 (0.607–1.292) g/cm² vs. 1.016 (0.760–1.550) g/cm²; p = 0.001) and DR total volumetric (284.3 (138.9–470.3) mg/cm³ vs. 367.0 (287.0–412.0) mg/cm³; p < 0.001) BMD, 10 year probability for major osteoporotic (3.7% (0.7–32%) vs. 2.6% (0–17.5%); p = 0.003) and hip (0.4% (0–16%) vs. 0.05% (0–6.1%); p = 0.002) fracture and 25-hydroxyvitamin D status (47.5 (10–120) nmol/L vs. 64 (10–137; p < 0.001) nmol/L). As compared to areal assessment, volumetric BMD measurements identified a significantly higher number of patients with low bone mineral density (T-Score ≤ − 1.00) (34% vs. 88%, p < 0.001). Upon multiple linear regression analysis, disease activity score, as determined by DAS28 assessment, was an independent predictor of 10-year probability for major osteoporotic fracture (B (95%CI) = 1.351 (0.379–2.323); p = 0.007).

Conclusion

In the studied PsA cohort, disease activity was an independent predictor of 10-year probability for a major osteoporotic fracture, and complemented assessment of volumetric and areal BMD assured better efficacy at identifying those with low bone mineral density.

Intracellular Staphylococcus aureus in bone and joint infections: A mechanism of disease recurrence, inflammation, and bone and cartilage destruction

Bone and joint infections are devastating afflictions. Although medical interventions and advents have improved their care, bone and joint infections still portend dismal outcomes. Indeed, bone and joint infections are associated with extremely high mortality and morbidity rates and, generally, occur secondary to the aggressive pathogen Staphylococcus aureus. The consequences of bone and joint infections are further compounded by the fact that although they are aggressively treated, they frequently recur and result in massive bone and articular cartilage loss. Here, we review the literature and chronicle the fact that the fundamental cellular components of the musculoskeletal system can be internally infected with Staphylococcus aureus, which explains the ready recurrence of bone and joint infections even after extensive administration of antibiotic therapy and debridement and offer potential treatment solutions for further study. Moreover, we review the ramifications of intracellular infection and expound that the massive bone and articular cartilage loss is caused by the sustained proinflammatory state induced by infection and offer potential combination therapies for further study to protect bone and cartilage.

Bone Mineral Density, Osteoporosis, and Fracture Risk in Adult Patients with Psoriasis or Psoriatic Arthritis: A Systematic Review and Meta-Analysis of Observational Studies

INTRODUCTION

Awareness of psoriasis-related comorbidities has been established in the current guidelines; however, evidence regarding the association of bone density or bone fragility with psoriatic disease remains inconclusive.

METHODS

We conducted a systematic review and meta-analysis to assess bone mineral density and the risk of osteoporosis and fractures in patients with psoriatic disease, including those with cutaneous psoriasis and psoriatic arthritis. We searched electronic databases for published observational studies. A meta-analysis was performed using the random-effect model. Pooled estimates and their confidence intervals (CIs) were calculated. Small-study effects were examined using the Doi plot and Luis Furuya-Kanamori index.

RESULTS

The analysis of the standardized mean difference in the absolute value of bone mineral density at different measuring sites (lumbar spine, femoral neck, and total hip) revealed no significant difference between patients with psoriatic disease and non-psoriatic controls. The pooled results of the adjusted odds ratios (ORs) demonstrated no increased risk of osteoporosis in patients with psoriatic disease. Notably, patients with psoriatic disease had a higher OR of developing bone fractures (adjusted OR: 1.09; 95% CI: 1.06 to 1.12; I²: 0%).

CONCLUSION

Patients with psoriatic disease may be more likely to develop fractures compared with non-psoriatic controls. This higher risk for fracture may not necessarily be associated with lower bone mineral density nor a higher risk for osteoporosis.

Role of osteodensitometry in osteoporosis and osteopenia in psoriatic arthritis

Dual-energy X-ray Absorptiometry (DEXA) determines the mineral contents for the spine, the proximal femur and the entire body. A group of 36 patients with psoriatic arthritis were chosen, with different types of arthropathy, from the total 82 patients with psoriatic arthritis in the study group, for which bone mineral density (BMD) was measured, using the DEXA technique. The chosen study group comprised 12 men, 12 premenopausal women and 12 menopausal women, with psoriatic joint damage and a group of 36 healthy individuals, divided based on the same criteria: Men, premenopausal and menopausal women. This study did not emphasize an association between the patient type and the presented bone demineralization type (χ² ₍₂₎=4.473, P=0.107) in men. In premenopausal women, there was a significant association between the patient type and the presented bone demineralization type (χ² ₍₂₎=8.778, P=0.012), as the female patients with psoriatic arthritis presented total and partial demineralization to a larger degree, compared with healthy individuals. In menopausal women, this study did not highlight an association between the patient type and the presented bone demineralization type (χ² ₍₂₎=4.523, P=0.104). Bone demineralization was significant in all three patient groups, both total and partial, in patients with psoriatic arthritis compared with healthy patients. Bone demineralization manifested as osteopenia, with T-scores ranging from -2.5 to -1, and not as osteoporosis. Determining B MD by DEXA technique revealed osteopenia to a higher degree within the group of patients with psoriatic arthritis compared with the healthy patients, as well as the absence of osteoporosis in psoriatic arthritis.

The Adenosine A2B Receptor Drives Osteoclast-Mediated Bone Resorption in Hypoxic Microenvironments

Osteoclast-mediated bone destruction is amplified in the hypoxic synovial microenvironment of rheumatoid arthritis (RA). This increased bone resorption is driven by the hypoxia-inducible transcription factor HIF. We identified hypoxic induction of the HIF-regulated adenosine A_2B receptor in primary human osteoclasts (mRNA, 3.8-fold increase, p < 0.01) and sought to identify the role(s) of purinergic signaling via this receptor in the bone resorption process. Primary human osteoclasts were differentiated from CD14+ monocytes and exposed to hypoxia (2% O₂) and A_2B receptor inhibitors (MRS1754, PSB603). The hypoxic increase in bone resorption was prevented by the inhibition of the A_2B receptor, at least partly by the attenuation of glycolytic and mitochondrial metabolism via inhibition of HIF. A_2B receptor inhibition also reduced osteoclastogenesis in hypoxia by inhibiting early cell fusion (day 3–4, p < 0.05). The A_2B receptor is only functional in hypoxic or inflammatory environments when the extracellular concentrations of adenosine (1.6-fold increase, p < 0.05) are sufficient to activate the receptor. Inhibition of the A_2B receptor under normoxic conditions therefore did not affect any parameter tested. Reciprocal positive regulation of HIF and the A_2B receptor in a hypoxic microenvironment thus enhances glycolytic and mitochondrial metabolism in osteoclasts to drive increased bone resorption. A_2B receptor inhibition could potentially prevent the pathological osteolysis associated with hypoxic diseases such as rheumatoid arthritis.

A comparative analysis of articular bone in large cohort of patients with chronic inflammatory diseases of the joints, the gut and the skin

Chronic inflammatory diseases are associated with bone loss. While the occurrence of systemic bone loss is well described in chronic inflammatory diseases, the impact of these conditions on articular bone has not been systematically investigated. Recent refinements in high-resolution CT assessment of the joints now allow the accurate measure of articular bone composition. In this study 476 subjects comprising healthy individuals and patients with anticitrullinated protein antibody (ACPA)-positive rheumatoid arthritis (RA), ACPA-negative RA, Crohn's disease (CD), ulcerative colitis (UC), psoriasis (PsO) and psoriatic arthritis (PsA) were subjected to high-resolution quantitative computed tomography (HR-pQCT) of the hand. Metacarpal heads were assessed for total, trabecular and cortical volumetric bone mineral density (vBMD). Only ACPA+RA, but not the remaining inflammatory diseases (ACPA-RA, CD, UC, PsO, PsA) showed significant (p < 0.001) loss of articular bone affecting both the trabecular and the cortical compartments. Age and body mass index were also associated with articular bone changes, the former with lower, the latter with higher articular bone mass. In multivariate models, presence of ACPA+RA was an independent factor for articular bone loss. Among chronic inflammatory diseases ACPA+RA is the most potent precipitator for articular bone loss pointing out the role of autoimmunity in the development of articular bone disease in the context of chronic inflammatory disease.

The role of ACPAs in at-risk individuals: Early targeting of the bone and joints

Autoimmunity precedes inflammation in patients with rheumatoid arthritis (RA), opening the possibility to search for early changes in the tissue preceding the onset of systemic inflammation. Autoantibodies are important and early drivers of bone damage in RA. This article summarizes current evidence for the role of RA-related autoantibodies in mediating bone loss. Rheumatoid factor (RF) and antibodies recognizing modified (citrullinated) proteins have been used as diagnostic markers for RA over many years. Their role as pathogenic players, however, has long been unrecognized. Recently, several pieces of evidence suggested that bone-resorbing osteoclasts are highly responsive to RA-related autoantibodies, providing a novel association between autoimmunity and bone. These developments have allowed the unraveling of the underlying mechanisms, which are responsible for the well-known clinical observation that anti-citrullinated protein antibodies and RF are associated with a more severe disease course. Furthermore, these mechanisms also explain the onset of inflammation in the joints of RA patients.

Periarticular Bone Loss in Arthritis Is Induced by Autoantibodies Against Citrullinated Vimentin

Periarticular bone loss is a long known but yet insufficiently understood phenomenon in patients with rheumatoid arthritis. This study investigated whether autoimmunity against citrullinated proteins is causally involved in triggering periarticular bone loss. Periarticular bone loss was studied in the standard antigen-induced arthritis (AIA) mouse model with methylated bovine serum albumin (mBSA) as well as a modified model with mutated citrullinated vimentin (MCV) alone or in combination with mBSA. Periarticular bone loss, subchondral osteoclastogenesis, as well as local expression of cytokines, osteoclast genes, and peptidyl-arginine deiminase (PAD) enzymes were assessed after arthritis induction. Immune cell and osteoclast precursor infiltration were detected in the periarticular bone marrow and local lymph nodes. In addition, periarticular bone loss was assessed upon challenge of mice with purified anti-MCV antibody. Despite inducing a milder form of arthritis than mBSA, MCV triggered significant periarticular bone loss associated with an increased infiltration of osteoclast precursors and mature osteoclasts in the periarticular bone marrow. MCV enhanced the expression of the osteoclast inducers RANKL and M-CSF, the cytokines IL-8, IL-1, IL-6, and TNF-α, as well as PAD2 and PAD4 enzymes in the periarticular bone marrow. Furthermore, also anti-MCV antibody challenge induced significant periarticular bone loss and local osteoclastogenesis in the mice. Autoimmunity against citrullinated vimentin triggers periarticular bone loss by osteoclast activation in the bone marrow. These findings may explain why periarticular bone loss is already found very early in the disease course of patients with rheumatoid arthritis. © 2017 American Society for Bone and Mineral Research.

Bone mineral density in patients with psoriatic arthritis: data from the Nord-Trøndelag Health Study 3

Background

The risk of osteoporosis in patients with psoriatic arthritis (PsA) remains unclear. The aim of this study was to compare bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) in patients with PsA and controls.

Patients and methods

Patients with PsA and controls were recruited from the Nord-Trøndelag Health Study (HUNT) 3.

Results

Patients with PsA (n=69) and controls (n=11 703) were comparable in terms of age (56.8 vs 55.3 years, p=0.32), gender distribution (females 65.2% vs 64.3%, p=0.87) and postmenopausal status (75.6% vs 62.8%, p=0.08). Body mass index (BMI) was higher in patients with PsA compared with controls (28.5 vs 27.2 kg/m², p=0.01). After adjusting for potential confounding factors (including BMI), BMD was higher in patients with PsA compared with controls at lumbar spine 1–4 (1.213 vs 1.147 g/cm², p=0.003) and femoral neck (0.960 vs 0.926 g/cm², p=0.02), but not at total hip (1.013 vs 0.982 g/cm², p=0.11). Controls had significantly higher odds of having osteopenia or osteoporosis based on measurements of BMD in both the femoral neck (p=0.001), total hip (p=0.033) and lumbar spine (p=0.033).

Conclusion

Our population-based data showed comparable BMD in patients with PsA and controls. This supports that the PsA population is not at increased risk of osteoporosis.

Conventional Radiology in Rheumatoid Arthritis

In clinical practice, the conventional radiography is still the radiologic method for the diagnosis of rheumatoid arthritis (RA). Moreover, it provides a quick overview of the symptomatic joints to narrow the differential diagnosis and to evaluate progression. RA is a polyarticular disease with bilateral and symmetric involvement of the peripheral joints, especially small joints, and less frequently, the cervical spine. The radiologic features are soft tissue swelling, periarticular osteoporosis, erosions, loss of joint space, and in advanced disease, osteolysis and typical subluxations or deformities, such as ulnar deviation.

Age- and Sex-Dependent Changes of Intra-articular Cortical and Trabecular Bone Structure and the Effects of Rheumatoid Arthritis

The objective of this cross-sectional study was to define normal sex- and age-dependent values of intra-articular bone mass and microstructures in the metacarpal heads of healthy individuals by high-resolution peripheral quantitative computed tomography (HR-pQCT) and test the effect of rheumatoid arthritis (RA) on these parameters. Human cadaveric metacarpal heads were used to exactly define intra-articular bone. Healthy individuals of different sex and age categories and RA patients with similar age and sex distribution received HR-pQCT scans of the second metacarpal head and the radius. Total, cortical, and trabecular bone densities as well as microstructural parameters were compared between 1) the different ages and sexes in healthy individuals; 2) between metacarpal heads and the radius; and 3) between healthy individuals and RA patients. The cadaveric study allowed exact definition of the intra-articular (intracapsular) bone margins. These data were applied in measuring intra-articular and radial bone parameters in 214 women and men (108 healthy individuals, 106 RA patients). Correlations between intra-articular and radial bone parameters were good (r = 0.51 to 0.62, p < 0.001). In contrast to radial bone, intra-articular bone remained stable until age 60 years (between 297 and 312 mg HA/cm³ ) but decreased significantly (p < 0.001) in women thereafter (237.5 ± 44.3) with loss of both cortical and trabecular bone. Similarly, RA patients showed significant (p < 0.001) loss of intra-articular total (263.0 ± 44.8), trabecular (171.2 ± 35.6), and cortical bone (610.2 ± 62.0) compared with sex- and age-adjusted controls. Standard sex- and age-dependent values for physiological intra-articular bone were defined. Postmenopausal state and RA led to significant decrease of intra-articular bone. © 2016 American Society for Bone and Mineral Research.

Striking difference of periarticular bone density change in early psoriatic arthritis and rheumatoid arthritis following anti-rheumatic treatment as measured by digital X-ray radiogrammetry

OBJECTIVES

To examine changes in hand BMD as measured by digital X-ray radiogrammetry (DXR-BMD) in early PsA compared with RA patients prior to and 3 and 12 months after introducing an antirheumatic treatment. Further, to identify predictors for hand bone loss at the time of disease presentation.

METHODS

Recent-onset, active, treatment-naïve patients were recruited. Clinical assessment, hand X-rays and DXR were obtained at 0, 3 and 12 months. Mean DXR-BMD for both hands and changes in DXR-BMD (mg/cm(2)/month) were compared between the two groups. We compared baseline disease characteristics of patients with normal hand DXR-BMD with those with bone loss. Logistic regression analyses were performed to identify predictors of hand BMD loss.

RESULTS

A total of 64 patients were included. Hand DXR-BMD decreased in RA throughout the study (P = 0.043). Changes in periarticular bone density over 12 months differed between PsA and RA (P = 0.001). Hand bone loss at 3 months was associated with elevated BMI [odds ratio (OR) = 3.59, P = 0.041] and heavier alcohol intake (OR = 1.13, P = 0.035). Diagnosis of RA (OR = 57.48, P = 0.008), heavier alcohol intake (OR = 1.27, P = 0.012) and higher swollen joint count (SJC28) (OR = 1.5, P = 0.036) were independent predictors for hand bone loss in the first year.

CONCLUSION

Following treatment, we found ongoing hand bone loss in RA and unchanged periarticular bone density in PsA, supporting the hypothesis that different pathomechanisms are involved in hand bone remodelling in PsA. Presence of RA, heavier alcohol intake and higher SJC were identified as independent predictors for hand bone loss over 1 year.

Quantitative and Qualitative Changes of Bone in Psoriasis and Psoriatic Arthritis Patients

Psoriatic arthritis (PsA) is a chronic inflammatory disease characterized by periarticular bone loss and new bone formation. Current data regarding systemic bone loss and bone mineral density (BMD) in PsA are conflicting. The aim of this study was to evaluate bone microstructure and volumetric BMD (vBMD) in patients with PsA and psoriasis. We performed HR-pQCT scans at the ultradistal and periarticular radius in 50 PsA patients, 30 psoriasis patients, and 70 healthy, age- and sex-related controls assessing trabecular bone volume (BV/TV), trabecular number (Tb.N), inhomogeneity of the trabecular network, cortical thickness (Ct.Th), and cortical porosity (Ct.Po), as well as vBMD. Trabecular BMD (Tb.BMD, p = 0.021, 12.0%), BV/TV (p = 0.020, -11.9%), and Tb.N (p = 0.035, 7.1%) were significantly decreased at the ultradistal radius and the periarticular radius in PsA patients compared to controls. In contrast, bone architecture of the ultradistal radius and periarticular radius was similar in patients with psoriasis and healthy controls. Duration of skin disease was associated with low BV/TV and Tb.N in patients with PsA. These data suggest that trabecular BMD and bone microstructure are decreased in PsA patients. The observation that duration of skin disease determines bone loss in PsA supports the concept of subclinical musculoskeletal disease in psoriasis patients.

Total Saponin from Anemone flaccida Fr. Schmidt Prevents Bone Destruction in Experimental Rheumatoid Arthritis via Inhibiting Osteoclastogenesis

Anemone flaccida Fr. Schmidt is used in the clinical compound prescription for the treatment of rheumatoid arthritis (RA) in China and has the traditional use of draining dampness, diminishing swelling, and relieving pain. Total saponins (TS) are the characteristic components and also the main active ingredients of A. flaccida. Previous reports indicated that TS possess anti-inflammatory and immunoregulatory properties; however, the effects of TS on bone destruction of RA have not been evaluated. In this study, our data first showed the therapeutic effects of TS on severity of arthritis and arthritis progression in collagen-induced arthritis (CIA) rats. Then, by microfocal computed tomography (CT) quantification, TS significantly increased bone mineral density, bone volume fraction, and trabecular thickness and decreased trabecular separation of inflamed joints both at peri-articular and extra-articular locations. TS also diminished the level of the bone resorption marker CTX-I and simultaneously increased the bone formation marker osteocalcin in sera of CIA rats. Interestingly, TS prevented bone destruction by reducing the number of osteoclasts in inflamed joints, reducing the expression of receptor activator of nuclear factor-κF (RANK) ligand (RANKL) and RANK, increasing the expression of osteoprotegerin (OPG), at both mRNA and protein levels, and decreasing the ratio of RANKL to OPG in inflamed joints and sera of CIA rats. This was further confirmed in the co-culture system of human fibroblast-like synovial and peripheral blood mononuclear cells. In addition, TS inhibited the levels of pro-inflammatory cytokines implicated in bone resorption, such as interleukin-1β (IL-1β), tumor necrosis factor-α (TNFα), IL-6, IL-17, and IL-23 in sera and joints. These findings offer convincing evidence that TS attenuate RA partially by preventing both focal bone destruction and systemic bone loss. This anti-erosive effect results in part from inhibiting osteoclastogenesis by regulating the RANKL/RANK/OPG signaling pathway. The suppression of systemic and local pro-osteoclastogenic cytokines by TS was also highly effective.

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.

Risk factors and predictors of psoriatic arthritis in patients with psoriasis

Given the potential consequences of joint damage for patients with psoriatic arthritis, we believe that the optimization of screening methods and the investigation of arthritis in patients with psoriasis are a medical priority. It is very useful to identify predictors of arthritis in patients with psoriasis. In fact, there is a consensus among doctors that the large gap between the diagnosis of psoriasis and that of psoriatic arthritis should be narrowed. In order to better manage patients with psoriasis, the authors review and discuss recent publications on the evidence of current predictors of arthritis in patients with psoriasis.

Disease Activity and Bone Mineral Density of MCP Joints in Patients with Rheumatoid and Psoriatic Arthritis: Is There a Correlation?-A Study in Patients Treated with Methotrexate and an Anti-TNF α Agent

Background. Bone damage in rheumatoid arthritis (RA) and in psoriatic arthritis (PsA) includes an accelerated bone mineral density (BMD) reduction. The objective was to evaluate BMD variations of the metacarpophalangeal joints (MCPs) in patients starting treatment with methotrexate (MTX) or etanercept. Methods. Patients affected by RA or PsA with hand joints involvement and with moderate or high disease activity, were enrolled in this study. All patients underwent clinical examination, laboratory exams, and a DXA scan of the most affected hand, as assessed with an ultrasound examination at the baseline, at the time of enrolment and after 1, 3, 6, and 12 months. Patients non-responders to MTX received combination therapy, while patients with no previous treatment initiated MTX. Results. 22 patients were enrolled. In both RA and PsA groups, BMD increased independently of the treatment. However, in the patients affected by RA, a slight BMD decrease was observed at the last checkup. Globally, the BMD variations of the MCPs were strongly correlated with the disease activity. At the reduction of DAS28, the scores corresponded an increase of BMD. Conclusions. MCPs BMD is inversely correlated to disease activity. BMD increase seems to be correlated with the response to treatment and not with the drug itself.

Is hand bone mineral density a marker for hand function in patients with established rheumatoid arthritis? The correlation among bone mineral density of the hand, radiological findings and hand function

The objective of this study is to assess the role of hand bone mineral density (BMD) as a prospective marker for hand function and the correlation of hand BMD with X-ray findings and hand functioning in patients with established rheumatoid arthritis (RA). Eighty-three female patients diagnosed with RA were enrolled. All BMD measurements were performed on both hands. The radiological evaluation was conducted according to the van der Heijde modification of the Sharp method (Sharp/van der Heijde). Duruöz Hand Index (DHI) was used to establish the disability in the hands. Furthermore, handgrip strength (HGS), pinch strength (PS), lateral pinch (LP), tip-to-tip pinch (TTP) and three-fingered pinch (TFP) on both the dominant and the non-dominant hands was measured. A significant positive correlation between hand BMD and HGS as well as all PSs with p < 0.05 was observed, while no statistically significant relation was observed between BMD and DHI (p > 0.05). The hand BMD and the Sharp/van der Heijde scores were significantly in reverse correlation (p < 0.05). As for other DHI-related variants, HGS and PS and the total DHI scores were reversely correlated, while there was a positive significant association with radiological scores (p < 0.05). HGS and TTP were found significant (p < 0.05) as a result of a multivariant linear stepwise regression analysis among the sub-groups of DHI, HGS, LP, TTP, TFP and radiographic total scores. Our study demonstrated that a one-off hand BMD measurement failed to adequately indicate a loss in hand function as measured by DHI. Ultimately, HGS and TTP were shown to be the most effective indicators for measuring hand functions.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory joint disease which develops in patients with psoriasis. It is characteristic that the rheumatoid factor in serum is absent. Etiology of the disease is still unclear but a number of genetic associations have been identified. Inheritance of the disease is multilevel and the role of environmental factors is emphasized. Immunology of PsA is also complex. Inflammation is caused by immunological reactions leading to release of kinins. Destructive changes in bones usually appear after a few months from the onset of clinical symptoms. Typically PsA involves joints of the axial skeleton with an asymmetrical pattern. The spectrum of symptoms include inflammatory changes in attachments of articular capsules, tendons, and ligaments to bone surface. The disease can have divers clinical course but usually manifests as oligoarthritis. Imaging plays an important role in the diagnosis of PsA. Classical radiography has been used for this purpose for over a hundred years. It allows to identify late stages of the disease, when bone tissue is affected. In the last 20 years many new imaging modalities, such as ultrasonography (US), computed tomography (CT) and magnetic resonance (MR), have been developed and became important diagnostic tools for evaluation of rheumatoid diseases. They enable the assessment and monitoring of early inflammatory changes. As a result, patients have earlier access to modern treatment and thus formation of destructive changes in joints can be markedly delayed or even avoided.

Periarticular bone gain at proximal interphalangeal joints and changes in bone turnover markers in response to tumor necrosis factor inhibitors in rheumatoid and psoriatic arthritis

OBJECTIVE

Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are characterized by periarticular bone erosion; periarticular bone formation is a feature in PsA. The effect of anti-tumor necrosis factor-α (TNF-α) on periarticular bone remodeling is unclear in both diseases. Our aim was to assess the response of bone turnover markers (BTM) and hand bone mineral density (BMD) to anti-TNF over 3 years in RA and PsA.

METHODS

We measured serum bone-specific alkaline phosphatase (bone ALP), procollagen type-I N-propeptide (PINP), intact osteocalcin, C-terminal cross-linking telopeptides (CTX-I), urinary N-terminal cross-linking telopeptide of type-I collagen (NTX-I), and free deoxypyridinoline crosslinks (fDPD) at baseline, 1, 12, and 36 months. BMD measurements (hands/spine/hip) were obtained at 3 timepoints.

RESULTS

We recruited 62 patients (RA 35; PsA 27). BTM correlated significantly with hand BMD but not with central BMD. Low hand BMD was associated with RA and increased BTM. Following anti-TNF therapy, hip BMD declined while spine and hand BMD were unchanged. Periarticular BMD at proximal interphalangeal (PIP) joints increased while it decreased at metacarpophalangeal joints. Bone ALP increased steadily and was always higher in PsA. PINP and intact osteocalcin increased to a lesser extent, but resorption markers did not change.

CONCLUSION

At baseline, hand BMD was inversely associated with BTM. Bone formation rather than resorption markers better showed the bone response to anti-TNF. Despite a lack of effect on central BMD, the modest effect of anti-TNF on PIP BMD may provide evidence that BTM reflect specifically bone remodeling activity at periarticular sites of inflammation in RA and PsA.

Prospective assessment of bone texture parameters at the hand in rheumatoid arthritis

OBJECTIVE

Fractal bone analysis (Hmean) is a texture parameter reflecting bone microarchitecture. The BMA device (D3A™ Medical Systems, Orléans, France) is a high-resolution X-ray device that allows assessment of bone texture analysis. We aimed to measure Hmean in rheumatoid arthritis patients at the second and third metacarpal bones, at baseline and after 1 year of follow-up, and to assess the relationship of Hmean and rheumatoid arthritis disease parameters.

METHODS

Patients with rheumatoid arthritis according to ACR criteria were included. They were assessed over 1 year, in the context of a prospective study conducted in Maastricht. For this substudy, activity of the disease was assessed by erythrocyte sedimentation rate, C-reactive protein and Disease Activity Score 28 performed at each visit. Radiographic bone damage was assessed using hand and feet radiographs at baseline and on a 1-year basis. The bone texture parameters were evaluated on the second and third metacarpal heads of the left hand using BMA device.

RESULTS

One hundred and sixty-five rheumatoid arthritis patients were included in this study. At baseline, Hmean was negatively correlated with age [r=-0.22 (P=0.013)] and erythrocyte sedimentation rate [r=-0.16 (P=0.039)]. No significant correlation was found between Hmean and Disease Activity Score, disease activity Visual Analog Scale, daily corticosteroid dose and C-reactive protein. There was a significant increase in Hmean of second and third metacarpal bones over 1 year (1.6% and 1.3%, P<0.01) except in patients with local second and third metacarpal bones erosion.

CONCLUSION

The bone texture parameter Hmean is influenced by age, inflammation and local erosions in rheumatoid arthritis.

Effects of anti-tumor necrosis factor α agents on bone

PURPOSE OF REVIEW

Tumor necrosis factor (TNF) inhibitors are effective for achieving disease control in several inflammatory diseases. Although anti-TNF agents can inhibit bone loss in vitro, their role in the prevention of clinically relevant outcomes such as osteoporosis and fractures has not been clearly established.

RECENT FINDINGS

There are many studies of the effects of TNF inhibitors on markers of bone turnover; however, few have measured bone mineral density (BMD) or fractures. Most of these studies have small sample sizes and a minority had a placebo control group. Overall these studies suggest that the antiresorptive effects of anti-TNF therapy are related to control of disease activity.

SUMMARY

The antiresorptive effects of TNF inhibitors are likely related to their anti-inflammatory properties. Studies to date have not demonstrated any advantages of TNF inhibitors over traditional nonbiologic therapies in the prevention of bone loss and fractures.

Quantification of periarticular demineralization and synovialitis of the hand in rheumatoid arthritis patients

The bone mineral density (BMD) measurement of the hand in rheumatoid arthritis (RA) patients is no standard measurement method as yet. The aim was to contribute to the standardization of the hand BMD measurement, especially of periarticular regions. As results, we found best precision values for the wrist and a significant correlation between hand and spine/femur BMD depending on disease activity and disease duration.

INTRODUCTION

This study was conducted to investigate (i) the precision of periarticular hand BMD measuring, (ii) the periarticular demineralization of the hand, (iii) the correlation between periarticular hand BMD and spine/femur BMD, and (iv) the correlation of hand BMD to hand synovitis.

METHODS

A number of 52 RA patients were examined by BMD measurement of the femoral neck, spine, whole hand, metacarpophalangeal (MCP) joints II-V, personal identity profile (PIP) joints II-V, and wrist using dual-energy X-ray absorptiometry (DXA). Synovitis of the hand was examined by ultrasonography and magnetic resonance imaging (MRI). Three subgroups were further analyzed: early RA, established RA with moderate and with high disease activity. Early RA and established RA patients with high disease activity were Followed up after 12 months.

RESULTS

We found (1) best precision of BMD measurement for the wrist, (2) BMD in RA significantly reduced if compared to normal controls, (3) a highly significant positive correlation between hand and spine/femur BMD and the power of correlation to depend on disease activity and disease duration (high correlation in RA with moderate disease activity and early RA, very high correlation in RA with high disease activity), (4) a negative correlation between hand BMD and hand synovitis in RA with high disease activity, and (5) a significant reduction of synovitis but no change in hand BMD after 12 months, respectively.

CONCLUSIONS

This study shows a highly significant correlation between hand BMD and spine/femur BMD in RA patients depending on disease activity and disease duration. We conclude to measure BMD at different sites including hands in order to quantify bone loss in RA patients most properly.

High frequency of vertebral fractures in early spondylarthropathies

We demonstrated that vertebral fractures (VF) are commonly found in early SpA. Patients with VF had lower lumbar BMD than patients without VF. VF remained frequently 'unrecognized' and untreated. VF have been associated with more back pain, reduced Qol, and increased risk of future fractures which stresses the importance of recognition also in early stage SpA.

INTRODUCTION

VF are a common complication of long-standing ankylosing spondylitis (AS). However, data of VF in early AS patients and in other spondylarthropathies (SpA) are scarce. Therefore we examined the prevalence of VF in early SpA patients and investigated the associations between VF and demographic and disease-related variables.

METHODS

SpA patients were included consecutively and radiographs of the spine were made. VF were assessed according to the method of Genant et al.: fractures were defined as reduction of ≥20% of the vertebrae. Descriptive statistics, t-tests and logistic regression analyses were used to study the relationship between VF and demographic and disease-related variables, radiographic damage and BMD.

RESULTS

A total of 113 early SpA patients were included with a disease duration of 7 months, a mean age of 37 years. Seventeen patients (15%) had at least one VF. Fourteen patients had one VF, three patients had two VF. Most VF were located at Th6-Th8. In patients with VF, bone mineral density (BMD) of lumbar spine was lower than BMD of patients without VF (t-test: p = 0.043). Axial Psoriatic Arthritis (PsA) was significantly associated with a higher risk for VF (odds ratio [OR]: 4.62, 95% confidence interval [CI] 1.15-18.58, p = 0.031). No significant associations were found with disease activity variables nor with radiographic severity.

CONCLUSION

In a group of 113 early, young SpA patients, 15% already had at least one VF. Most VF were asymptomatic, undetected by routine diagnostic procedures and located at the mid-thoracic spine. The VF were associated with low BMD of the lumbar spine and with axial PsA.

Osteoporosis in psoriatic arthritis: is there any?

AIMS

Although considered as a feature of inflammatory rheumatic diseases, there is a lot of controversy around low bone mass in patients with psoriatic arthritis. The aim of this cross-sectional study was to analyze bone mineral density in patients with psoriatic arthritis, as well as to investigate its possible association with some measures of disease activity and functional capacity.

SUBJECTS AND METHODS

Sixty-nine patients with established psoriatic arthritis (mean age 56.20 ± 12.23 years) and who have not been treated with specific antiosteoporotic drugs were recruited from the out-patient clinic database. Bone mineral density was measured by dual-energy X-ray absorptiometry at the lumbar spine and at the left hip. Disease activity measures included: duration of morning stiffness, tender and swollen joint count, patient's and physician's global assessment, presence of dactylitis and enthesitis, ESR, CRP and Disease Activity Score 28. Health Assessment Questionnaire was used to assess functional status.

RESULTS

According to WHO definition, spinal osteoporosis was found in 7.2% of patients, total hip osteoporosis in 1.4% of patients and femoral neck osteoporosis in 2.9% of patients. There was no significant association of any of the measures of disease activity with BMD at any site. Higher HAQ scores were associated with lower total hip BMD.

CONCLUSIONS

In our sample of patients with psoriatic arthritis we did not find increased prevalence of osteoporosis. There was no association of BMD with indices of disease activity, while negative correlation was found between HAQ and total hip BMD.

Periarticular osteoporosis: a useful feature in the diagnosis of early rheumatoid arthritis? Reliability and validity in a cross-sectional diagnostic study using dual-energy X-ray absorptiometry

OBJECTIVES

To identify regions of interest (ROIs) relevant to periarticular osteoporosis in RA with low precision error and sufficient inter-rater reliability and to test diagnostic validity for RA.

METHODS

Periarticular BMD was measured using dual-energy X-ray absorptiometry (DXA). Five ROIs were defined around MCP and/or PIP joints II-V, II-IV and mid-metacarpal to mid-phalangeal. They were evaluated for precision using the root mean square coefficient of variation (RMS-CV) and the intra-class correlation coefficient (ICC) for inter-reader reliability. To test validity, established RA patients (n = 25) and early arthritis patients (n = 25) were compared with healthy controls (n  = 37) matched on sex, age and menopausal status using paired t-tests, ROC curves and scatterplots.

RESULTS

The RMS-CV was 0.45-1.07%. The ICC was 0.99. Mean BMDs of the five ROIs ranged from 0.321 to 0.372 g/cm(2) in established RA, from 0.321 to 0.382 g/cm(2) in early arthritis and from 0.342 to 0.401 g/cm(2) in healthy controls. Mean differences ranged from 0.012 to 0.032 g/cm(2) for established RA and from 0.023 to 0.033 g/cm(2) for early arthritis patients compared with matched controls, with P < 0.05 for ROIs 1-5 in early arthritis and the whole hand in established RA. ROC curves indicated low discriminative power, with an area under the curve (AUC) of 0.61-0.64, and scatterplots showed great overlap between BMD values of patients and controls.

CONCLUSIONS

Periarticular BMD measured with DXA seems not to be a useful diagnostic feature due to strong overlap of BMD values between healthy controls, established RA patients and early arthritis patients.

Assessment of osteoporosis in psoriasis with and without arthritis: correlation with disease severity

BACKGROUND

The most frequent extracutaneous association with psoriasis is arthritis. Because proinflammatory cytokines are increased in psoriasis, patients with this disease may be more prone to osteoporosis than the healthy individuals.

METHODS

We evaluated 50 patients with psoriasis, with or without psoriatic arthritis (PsA), for the presence and degree of osteoporosis by performing dual energy x-ray absorptiometry (DEXA) and obtaining serum osteoprotegrin (OPG) levels. In addition, we correlated these results with the extent of skin and joint disease. Psoriasis area and severity index (PASI) was determined in all 50 patients with psoriasis, and total joint score (TJS) was recorded in the 16 patients who also had PsA. Results of DEXA and serum OPG were also obtained for 20 healthy individuals who served as controls.

RESULTS

Osteoprotegrin level was significantly increased in psoriasis patients (with or without PsA) vs. controls. However, DEXA revealed that PsA patients had a higher degree of osteoporosis in the femur neck and wrist. In PsA patients, TJS correlated positively with both disease duration and PASI but correlated negatively with Z score of the femur.

CONCLUSION

Psoriasis patients with or without arthritis may suffer from osteoporosis as evidenced by significantly increased serum OPG. Prolonged and extensive cutaneous disease is an important risk factor for the development and severity of PsA. Patients with a greater number of affected joints are at higher risk of osteoporosis.

Chronic inflammation in FMF: markers, risk factors, outcomes and therapy

Familial Mediterranean fever (FMF) is the most common of the hereditary periodic fever syndromes. Although the typical clinical course of FMF is characterized by bouts of painful inflammation, this presentation represents only the tip of the iceberg. In many patients inflammation can persist in attack-free periods, as shown by high levels of acute-phase proteins, cytokines and inflammation-induced proteins. This subclinical inflammation puts patients at risk of developing complications such as anemia, splenomegaly, decreased bone mineral density, heart disease and life-threatening amyloid A amyloidosis, among others. In this article, we review the published data on markers and other factors involved in the persistence of inflammation in patients with FMF during attack-free periods, examine the risk factors for the development of this subclinical inflammation, summarize the complications of chronic inflammation in FMF and propose a new strategy for treatment, based on these data.

Managing comorbid disease in patients with psoriatic arthritis

Psoriatic arthritis (PsA) is a unique type of inflammatory arthritis that is associated with skin psoriasis. The concept that PsA is simply a skin and joint disease has been challenged by large epidemiologic studies that link PsA with substantial comorbidity. Important comorbidities related to PsA include premature cardiovascular disease, infectious complications, malignancy risk, osteoporosis, and reduced quality of life. This review focuses on the prevalent comorbid diseases in patients with PsA and highlights how the presence of these associated comorbidities can affect the management of these patients.

Comparative analysis of disease activity measures, use of biologic agents, body mass index, radiographic features, and bone density in psoriatic arthritis and rheumatoid arthritis patients followed in a large U.S. disease registry

OBJECTIVE

To compare disease activity, radiographic features, and bone density in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) matched cohorts.

METHODS

Disease activity and radiographic data in the Consortium of Rheumatology Researchers of North America database from 2001 to 2008 were compared for 2481 patients with PsA and 17,107 patients with RA subsequently matched for age, gender, and disease duration. Radiographic outcomes included presence of erosions, and joint deformity. In addition, bone mineral density (BMD) scores for lumbar spine (L-spine) and femoral neck were compared using the same matching criteria plus weight and smoking status.

RESULTS

Tender (4.5 vs 3.4, p < 0.001) and swollen (4.4 vs 2.9, p < 0.012) joint counts, and modified Health Assessment Questionnaire scores were significantly higher (0.4 vs 0.3, p < 0.001) in patients with RA compared with patients with PsA. Patient general health and pain scores were also higher in patients with RA vs patients with PsA. Joint erosions (47.4% vs 37.6%, p = 0.020) and deformity (25.2% vs 21.6%, p = 0.021) were more prevalent in RA than PsA. In multivariate analysis, a reduced prevalence of erosions in PsA vs RA was noted (OR 0.609, p < 0.001). After matching, T-scores for L-spine (-0.54 vs -0.36, p = 0.077) and femoral neck (-0.88 vs -0.93, p = 0.643) were similar in patients with RA and patients with PsA, although body weight was a major confounder.

CONCLUSION

The level of disease activity and radiographic damage was significantly higher for RA vs PsA subjects, although the magnitude of differences was relatively small. BMD levels were comparable between cohorts. Outcomes in patients with PsA and patients with RA may be more similar than previously reported.

Using hand bone mass measurements to assess progression of rheumatoid arthritis

In rheumatoid arthritis (RA) bone involvement presents as joint erosions in addition to generalized and periarticular osteoporosis. Joint erosions on radiographs of the hands and feet are considered to be the gold standard to evaluate progression of bone and joint damage in RA, even though erosions on radiographs are not used as a marker of early bone involvement. Periarticular bone loss seen on radiographs may be the first sign of bone involvement in RA. Over the last decade there has been an increased awareness of the importance of early aggressive treatment in RA, leading to a need for methods which can identify bone involvement in the early stages of RA. As inflammatory bone loss, especially at the hand, has been shown to occur early in RA, quantitative measures of hand bone loss have been proposed as an outcome measure for the detection of bone involvement. In this review article we present data supporting the hypothesis that both erosions and osteoporosis in RA occur as a result of the same pathophysiological mechanisms activating the osteoclast. Furthermore the role of hand bone loss as an early marker of inflammatory bone involvement, a predictor of subsequent radiographic joint damage and a response variable to anti-inflammatory treatment is discussed.

Antibodies to human tissue transglutaminase and alterations of vitamin D metabolism in ankylosing spondylitis and psoriatic arthritis

Both in ankylosing spondylitis (ASP) and psoriatic arthritis (PsA), osteopenia is present in one-third of women and men, whereas osteoporosis mainly affects men, even in their 30 s. Subclinical gut inflammation has been described in patients with AS or PsA. Joint involvement also occurs with other gastrointestinal diseases such as celiac disease. We tested the hypothesis, whether elevated serum levels of human anti-tissue-transglutaminase-IgA (htTG) are associated with changes in disease activity, vitamin D metabolism and bone mineral density (BMD) in patients with ASP and PsA. In a cross-sectional study, we evaluated both biochemical markers of bone turnover, BMD and htTG in 76 patients with ASP and 120 patients with PsA. A reduction of BMD in lumbar spine was determined both in ASP (42.7%) and in PsA (57.3%). Furthermore, a significantly higher prevalence of htTG was detected only in ASP (14/76). ASP patients with negative htTG status have significant higher 25-vitamin D3 levels. ASP patients with positive htTG status are younger. A positive htTG status entails the risk of a bad vitamin D supply, which should be considered in young patients since this constellation favors a reduction in bone density. The coincidence of ASP along with detection of htTG and clinically asymptomatic celiac disease as an accessory source of inflammation with a negative influence on the bone metabolism is also conceivable. Clinicians need to be aware of patients younger than 45 years with ASP, which have important implications for the correct treatment and vitamin D supplementation.

The diagnosis and treatment of early psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory musculoskeletal disorder associated with a heterogeneous disease presentation, varied disease expression and an unpredictable but often chronically destructive clinical course. Joint damage can occur early in the disease; indeed, several imaging modalities have demonstrated subclinical joint involvement in psoriasis patients without musculoskeletal signs or symptoms. Efforts are underway to validate questionnaires that will enable dermatologists to screen patients with psoriasis for the presence of musculoskeletal disease. To date, the use of therapies in patients with early PsA has not been reported in randomized controlled trials. Moreover, conventional agents are partially effective in established PsA but, in general, trials with DMARDS have not included validated outcome measures for the different manifestations of PsA. Tumor necrosis factor antagonists can alleviate the signs and symptoms of established psoriatic arthritis and inhibit radiographic progression, but the therapeutic impact of early intervention with these agents requires further study. The extent of disease and the presence of comorbidities should be used to guide treatment decisions and to minimize adverse events.

Increased serum osteoprotegerin levels associated with decreased bone mineral density in familial Mediterranean fever

Familial Mediterranean fever (FMF) has episodic or subclinical inflammation that may lead to a decrease in bone mineral density (BMD). The aim of this study was to evaluate the effect of FMF on bone metabolism and to investigate the factors that can influence bone metabolism, such as body mass index (BMI), mutations in Mediterranean fever (MEFV) gene, osteoprotegerin (OPG), leptin and inflammatory cytokines, including interleukin (IL)-1beta, IL-6 and tumor necrosis factor-alpha (TNF-alpha). OPG, a soluble protein produced by osteoblasts, favors increased bone mass. Leptin may influence bone metabolism by acting on differentiated osteoblasts, having anabolic effects on bone. Thirty-one FMF patients in attack-free period (12 females and 19 males; mean age 31.4 +/- 9.3 years) and 18 healthy controls (11 females and 7 males; mean age 34.6 +/- 9.5 years) were compared according to the above parameters. BMD (g/cm(2)) and standard deviation scores (Z-score) were measured at the lumbar spine L(1)-L(4) (BMD-L(1-4)) and proximal femur by dual X-ray absorptiometry. Osteopenia is defined as a Z-score between -1 and -2.5 and osteoporosis is equal or below -2.5. FMF patients showed statistically significant reduction in BMD-L(1-4) and Z-score-L(1-4). Moreover, serum OPG concentration was significantly elevated in FMF patients. In contrast, MEFV gene mutations, leptin and the inflammatory cytokines did not differ between the patient and control groups. In conclusion, BMD was decreased and OPG was increased in our FMF patients. The high OPG levels may reflect a preventive mechanism against bone loss; namely, OPG might protect the FMF patients from excessive osteoporosis.

Serum levels of tissue inhibitor of metalloproteinase-1 and periarticular bone loss in early rheumatoid arthritis

We investigated the relationship between disease activity, serum biological mediators of joint damage, and periarticular bone loss in inflammatory arthritis. Patients with early inflammatory arthritis were recruited from a dedicated early arthritis clinic. At the time of recruitment, all had clinical evidence of synovitis. Patients were assessed at baseline and at 1-year follow-up. Periarticular and axial bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Serum levels of matrix metalloproteinase 1 and tissue inhibitor of metalloproteinases 1 (TIMP-1) were measured by enzyme-linked immunosorbent assay. A total 38 patients were included in the study. Twenty had rheumatoid arthritis (RA) and 18 had a seronegative spondylarthropathy (SpA). At baseline, periarticular hand BMD measurements were similar in RA and SpA. At 1 year, the mean periarticular hand BMD was significantly lower in RA (p < 0.05). Significant inverse correlations between both the Ritchie articular index and C-reactive protein levels and the change in periarticular hand BMD at 1 year were observed in RA (r = -0.792, p < 0.001 and r = -0.478, p = 0.045, respectively). Baseline TIMP-1 levels correlated with the change in periarticular hand BMD at 1 year in RA (r = 0.519, p = 0.02). At 1 year, radiographic measures of joint damage were highest in RA. Inverse correlations between the change in periarticular hand BMD and the changes in erosion score (r = -0.90, p = 0.04) were observed in patients demonstrating significant periarticular bone loss. Persistent disease activity was associated with increased periarticular bone loss in the hands in patients with RA, consistent with synovitis-mediated periarticular bone loss. The correlation between baseline TIMP-1 levels and periarticular bone loss over 1 year suggests that TIMP-1 may have utility as a biomarker of periarticular bone loss in early RA.

Associations with subregional BMD-measurements in patients with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) have bone loss to various degrees at different skeletal sites. The subregional bone mineral density (BMD) of the hand and the correlation of BMD to other regional bone losses, parameters of inflammation or bone resorption was evaluated in 421 patients with RA and controls. RA patients had significantly (P<0.01) lower BMD values in the carpus (0.405+/-0.004 g/cm2), metacarpal joint II (0.318+/-0.036 g/cm2) and metacarpal joint III (0.326+/-0.022 g/cm2) compared to controls. There was no difference in bone density at the lumbar spine or hip. Significant (P<0.001) correlations were found between BMD total of the hand, its subregions, the forearm and hip. Parameters of inflammation correlated significantly (P<0.001) with pyridinolines (r=0.378), desoxypyridinolines (r=0.183), forearm (r=-10, P<0.05), MCP II (r=-0.190, P<0.001), MCP III (r=0.204, P<0.001) and carpus (r=0.191, P<0.001).