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

Areal bone mineral density, trabecular bone score and 3D-DXA analysis of proximal femur in psoriatic disease

Objectives

To evaluate bone mineral density (BMD) and bone quality, with assessment of the cortical and trabecular compartments, in patients with psoriasis (PsO) alone or with psoriatic arthritis (PsA).

Methods

Patients with PsA and patients with PsO alone were evaluated and compared to control subjects matched for age, sex and body mass index category. Areal BMD (aBMD) was determined for the lumbar spine, femoral neck, total hip and total body using dual-energy X-ray absorptiometry (DXA). Bone quality was evaluated by using trabecular bone score (TBS) at the lumbar spine, and by 3D DXA-based analysis (3D Shaper) for the proximal femur.

Results

One hundred ninety-six subjects including 52 patients with PsA and 52 patients with PsO and their respective paired controls were analyzed. Patients with PsA had comparable aBMD, TBS and 3D DXA analysis parameters compared to their paired controls. After adjustment for confounders, patients with PsO alone were characterized by a higher aBMD at the left femur and higher cortical 3D DXA derived parameters (total hip cortical surface BMD and total hip cortical thickness) than their paired controls. TBS was decreased in PsO compared to their controls.

Conclusion

Patients with PsA had normal bone mass and bone quality parameters. Patients with PsO were characterized by higher femoral neck bone density by DXA and cortical parameters by 3D DXA-based analysis, supporting no increased risk for hip fracture. Conversely, bone texture by TBS assessment was decreased in patients with PsO, which may be associated with impaired vertebral bone resistance.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan

We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures.

INTRODUCTION

The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors.

METHODS

A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible.

RESULTS

Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed.

CONCLUSIONS

These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

Preliminary image findings of lower limb stress fractures to aid ultrasonographic diagnoses: A systematic review and narrative synthesis

INTRODUCTION

This systematic review investigates which image appearances are most common when diagnosing lower limb stress fractures using ultrasound imaging, with the aim of outlining an image critique guideline for operators to support confident diagnoses.

METHOD

A comprehensive literature search of medical databases and handsearching was undertaken to identify relevant studies. All studies were critically examined for quality using the CASP critical appraisal tool. Results from eight studies were combined and interpreted using a narrative synthesis.

FINDINGS

A clear outline of common stress fracture appearances using ultrasound were identified in a combined total of 119 participants. Each finding was ranked according to its popularity. Periosteal thickening (78/119) and cortical disruption/irregularity (83/119) were noted in all eight studies. Hypervascularity of the periosteum visualised by colour Doppler imaging (66/119) was reported in six of the eight studies. Soft tissue hypervascularity (13/119), bony callus formation (5/119) and cortical break (22/119) were seen in three studies.

CONCLUSIONS

Based on the findings, we offer a guideline of the most significant preliminary image findings to be utilised by operators when examining athletes suspected of having lower limb stress fractures. The results show a gap in research for evaluating changes in appearance depending on the injury severity. Further research into distinguishing stress fractures from pathological involvement may in future reduce reliance on plain film radiography.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Osteoporosis in psoriatic arthritis: a cross-sectional study of an outpatient clinic population

Background

The risk of osteoporosis in patients with psoriatic arthritis (PsA) still remains unclear. The aim of this study was to investigate bone mineral density (BMD) at the hip and lumbar spine measured by dual-energy X-ray absorptiometry in patients with PsA.

Methods

From an outpatient clinic in southern Norway, 140 patients with PsA were consecutively recruited and assessed for osteoporosis as part of a prospective study from January 2013 to May 2014. An extensive data collection was performed including demographic data and measures reflecting disease activity and health status.

Results

Mean age was 52.4 years and 71 (50.7%) were women. Median disease duration was 7.8 years. The proportion of patients with low BMD (defined as Z score≤-1.0 SD) was comparable to the expected value of 16%, according to the normal distribution of the Z score in the population. Osteoporosis was only found in 6.4% (95% CI3% to 11%) of the patients. No significant associations were found between BMD and disease activity measures.

Conclusion

The prevalence of PsA patients with osteoporosis or low BMD was low and in the range seen in the reference population. This supports that patients with PsA are not at high risk for osteoporosis compared with the general population. Therefore, clinicians may follow the general population guidelines for monitoring of osteoporosis for patients with PsA.