Disease activity as a major risk factor for osteonecrosis in early systemic lupus erythematosus

Screening for Asymptomatic Osteonecrosis of the Hip in Systemic Lupus Erythematous: A Systematic Review and Meta-Analysis of MRI-Based Prevalence

Objective. This paper aims to estimate asymptomatic hip osteonecrosis prevalence in SLE patients using MRI examination and to determine the prevalence among higher risk subpopulations. Materials and Methods. PubMed, Embase, Cochrane, and SCOPUS were searched from inception to May 9th, 2023. Studies on patients who were clinically diagnosed with systemic lupus erythematosus without reported symptoms attributable to hip osteonecrosis were included. Two independent reviewers extracted data and assessed the risk of bias. Data collected from each study include the study year, the number of hips screened, the number of hips with osteonecrosis, demographics, laboratory data, medications, follow-up time, radiological protocols, and MRI-based osteonecrosis detection and grading criteria. Results. Eleven eligible studies including 503 participants (15-35 years old; 74-100% female) with SLE were identified. Significant risk of bias was determined in one study. The overall prevalence of osteonecrosis of the hip was found to be 14% (184/1006 hip joints, 95% confidence interval: 7-22%, number needed to scan: 7.1). SLE patients who received corticosteroid treatment had a higher prevalence of asymptomatic hip osteonecrosis (18%) compared to non-corticosteroid users (0%, p-value < 0.01). Additionally, meta-regression results revealed that daily corticosteroid dose was associated with increased prevalence of asymptomatic osteonecrosis (0.5%/milligram, p-value < 0.01). Conclusions. The high prevalence of asymptomatic hip osteonecrosis in SLE patients raises concerns about the timeliness of interventions. The limitations of this study include a relatively low number of identified studies; and one study lacked full-text availability.

Impact of Belimumab on Organ Damage in Systemic Lupus Erythematosus

Organ damage is a key determinant of poor long-term prognosis and early death in patients with systemic lupus erythematosus (SLE). Prevention of damage is a key treatment goal of the 2019 update of the European Alliance of Associations for Rheumatology (EULAR) recommendations for SLE management. Belimumab is a monoclonal antibody that inhibits B lymphocyte stimulator (BLyS) and is the only therapy approved for both SLE and lupus nephritis. Here, we review the clinical trial and real-world data on the effects of belimumab on organ damage in adult patients with SLE. Across 4 phase III studies, belimumab in combination with background SLE therapy demonstrated consistent reductions in key drivers of organ damage including disease activity, risk of new severe flares, and glucocorticoid exposure compared to background therapy alone. Long-term belimumab use in SLE also reduced organ damage progression measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, as reported in open-label extension studies, and propensity score-matched comparative analyses to background therapy alone. Results from a clinical trial showed that in patients with active lupus nephritis, belimumab treatment improved renal response, reduced the risk of renal-related events, and impacted features related to kidney damage progression compared to background therapy alone. The decrease of organ damage accumulation observed with belimumab treatment in SLE, including lupus nephritis, suggest a disease-modifying effect.

Predictors of Osteonecrosis in Systemic Lupus Erythematosus: A Prospective Cohort Study

OBJECTIVE

We aimed at determining the predictors of osteonecrosis (ON) in a longitudinal lupus cohort.

METHODS

Data were reviewed from the initiation of the cohort in 1987 until October 2019. In total, 2,428 patients were included in the analysis based on 224,295 person-months of follow-up. We used pooled logistic regression to assess the relationship between risk factors and rates of ON events. After identifying a set of variables related to ON incidence, we fit a final multivariable model to identify the most important risk factors for incident ON.

RESULTS

In 18,691 person-years of follow-up after cohort entry, 122 incident ON events were observed (rate = 6.5/1,000 person-years). In the multivariable analysis, African American patients were at twice the risk for ON compared to White patients. Male patients and smokers had an increased risk for ON of ~80% and 50% compared to female patients and nonsmokers, respectively. For every 10-year increase in the age at diagnosis, there was a 20% reduced risk for ON. Patients diagnosed after the 1990s had a 50% reduced risk of ON compared to those diagnosed before the 1990s. A highest daily dosage of prednisone of 40 mg or higher, even when administered for a month or less, significantly increased the risk of ON. Use of pulse methylprednisolone or intramuscular triamcinolone was not associated with an increased risk of ON.

CONCLUSION

African American patients with systemic lupus erythematosus are at double the risk of experiencing ON compared to White patients. Oral prednisone at 20-39 mg for more than 1 month, or 40 mg daily for even 1 month, at any point in the disease course, remained the most important glucocorticoid predictor of ON.

Epidemiology and risk factors associated with avascular necrosis in patients with autoimmune diseases: a nationwide study

BACKGROUND/AIMS

Avascular necrosis (AVN) is a clinical condition characterized by the death of bone components due to interruption in the blood supply. This study aimed to investigate the epidemiology and determine the risk factors for AVN in patients with autoimmune diseases.

METHODS

We conducted a population-based retrospective cohort analysis using claims data from the Taiwan National Health Insurance Research Database. A total of 49,636 patients with autoimmune diseases between January 1, 2005 and December 31, 2013 were included. Cox regression analysis was used to identify associated risk factors for the development of AVN.

RESULTS

A total of 490/49,636 patients (1.0%) developed symptomatic AVN. The systemic lupus erythematosus patients had a higher risk of AVN compared to other autoimmune diseases. AVN was positively correlated with male sex (p < 0.001), alcoholism (p < 0.001), mean daily prednisolone dosage 7.51 to 30 mg (p < 0.001) and > 30 mg (p < 0.001), and total cumulative prednisolone dose 0 g to 5 g (p = 0.002). However, AVN was inversely correlated with cumulative duration of hydroxychloroquine exposure > 0.6 years (p < 0.001).

CONCLUSION

Male sex, systemic lupus erythematosus, alcoholism, mean daily corticosteroid > 7.5 mg and a total cumulative dose of corticosteroid 0 to 5 g were independently associated with the development of AVN in autoimmune patients. While hydroxychloroquine use > 0.6 years conferred significant protection against the development of AVN. Clinicians should regularly assess patients with risk factors to enable the early diagnosis of AVN.

Anti-RNP Antibody: A Potential Novel Predictor for Osteonecrosis in Systemic Lupus Erythematosus

Objective

To explore risk factors for developing osteonecrosis in patients with systemic lupus erythematosus (SLE).

Methods

Twenty-six SLE patients with osteonecrosis from January 2018 to December 2019 were described. Fifty SLE patients without osteonecrosis were selected as controls from the SLE database (total 2,680) of our hospital during the same period. Clinical manifestations and laboratory tests were recorded and analyzed, especially antibodies. Univariate and multivariate analyses were used to evaluate possible associated risk factors.

Results

Twenty-six (3 male, 23 female) SLE patients with osteonecrosis were confirmed by X-ray and magnetic resonance imaging. The median course from SLE onset to osteonecrosis onset was 45 (range 2–302) months. Seven (27%) patients had a single joint involved and 19 (73%) patients had two or more joints involved. Besides, the incidence of femoral head osteonecrosis (FHON), knee ON, and humerus head ON were 85% (22/26), 27% (7/26), and 12%(3/26), respectively. The multivariate logistic regression analysis showed that the score of European Consensus Lupus Activity Measurement (ECLAM) at SLE onset [odds ratio (OR) 1.37; 95% confidence interval (CI) 1.07–1.75], a cumulative dose of prednisone above 10 g (OR 15.49; 95% CI 3.38–84.61), and positive of independent anti-RNP antibodies (OR 3.35; 95% CI 0.80–10.73) were significantly associated with osteonecrosis in SLE.

Conclusion

The score of ECLAM at SLE onset, a cumulative dose of prednisone above 10 g, and positive anti-RNP antibodies are associated with osteonecrosis in SLE. Herein, we reported for the first time that anti-RNP antibodies were associated with osteonecrosis in SLE patients and might be a novel predictor.

Conceptual framework for defining disease modification in systemic lupus erythematosus: a call for formal criteria

Disease modification has become a well-established concept in several therapeutic areas; however, no widely accepted definition of disease modification exists for SLE.

We reviewed established definitions of disease modification in other conditions and identified a meaningful effect on ‘disease manifestations’ (ie, signs, symptoms and patient-reported outcomes) and on ‘disease outcomes’ (eg, long-term remission or progression of damage) as the key principles of disease modification, indicating a positive effect on the natural course of the disease. Based on these findings and the treatment goals and outcome measures for SLE, including lupus nephritis, we suggest a definition of disease modification based on disease activity indices and organ damage outcomes, with the latter as a key anchor. A set of evaluation criteria is also suggested.

Establishing a definition of disease modification in SLE will clarify which treatments can be considered disease modifying, provide an opportunity to harmonise future clinical trial outcomes and enable comparison between therapies, all of which could ultimately help to improve patient outcomes. This publication seeks to catalyse further discussion and provide a framework to develop an accepted definition of disease modification in SLE.

Osteonecrosis in systemic lupus erythematosus: Systematic insight from the epidemiology, pathogenesis, diagnosis and management

Osteonecrosis (ON) is one of the serious and well recognized complicationscausing severe pain and disability in patients with systemic lupus erythematosus (SLE), and its manifestation and pathogenesis are only partially understood. This review provide an update of the recent progress in etiology, pathogenesis, diagnosis, and treatment of systemic lupus erythematosus related osteonecrosis (SLE-ON). Despite the concomitant use of corticosteroids, alcohol and obesity, the dysregulated immune micro-environment and the complex pathogenesis of SLE synergistically play important roles in the development of ON. Osteonecrosis of femoral head (ONFH) is the most often involved joint in SLE. The current classification and staging system of ONFH is based on imaging techniques, particularly relating to MRI and CT, for the identification and quantification of necrotic lesions. For SLE-ONFH patients, both SLE specific clinical symptoms and ONFH imaging findings should be comprehensively evaluated. Even though advances concerning bone grafting and arthroplasty procedures have resulted in improved clinical outcomes, early pharmacological treatment at the pre-collapse stage may prevent joint collapse and reduce the joint arthroplasty rate, and this needs to be accounted. Although some progress has been made, considerably more research is needed before we fully understand SLE-ONFH. Future treatments of SLE-ONFH may involve genetic or cell-based therapies that target potential biomarkers, and this will lead to effective measures for saving thefunction of hip joint and preventing osteonecrosis.

Glucocorticoid-induced osteonecrosis in systemic lupus erythematosus patients

Osteonecrosis (ON) is a complex and multifactorial complication of systemic lupus erythematosus (SLE). ON is a devastating condition that causes severe pain and compromises the quality of life. The prevalence of ON in SLE patients is variable, ranging from 1.7% to 52%. However, the pathophysiology and risk factors for ON in patients with SLE have not yet been fully determined. Several mechanisms for SLE patients' propensity to develop ON have been proposed. Glucocorticoid is a widely used therapeutic option for SLE patients and high-dose glucocorticoid therapy in SLE patients is strongly associated with the development of ON. Although the hips and knees are the most commonly affected areas, it may be present at multiple anatomical locations. Clinically, ON often remains undetected until patients feel discomfort and pain at specific sites at which point the process of bone death is already advanced. However, strategies for prevention and options for treatment are limited. Here, we review the epidemiology, risk factors, diagnosis, and treatment options for glucocorticoid-induced ON, with a specific focus on patients with SLE.

Antiphospholipid antibodies and osteonecrosis in systemic lupus erythematosus: a meta-analysis

Objectives: The present meta-analysis aimed to assess the relationship between antiphospholipid antibodies (aPLs) or antiphospholipid antibody syndrome (APS) and the incidence of osteonecrosis (ON) in systemic lupus erythematosus (SLE) patients.Methods: MEDLINE/Pubmed, EMBASE, Web of science, the Chinese Biomedical Literature Database (CBM), the Wan-Fang Database, and the China National Knowledge Infrastructure (CNKI) were searched from their inception up until 26 December 2020. Studies in English were included. Case-control studies and cohort studies were included. Studies pertaining to the link between aPLs or APS and ON patients were slated for inclusion in the current analysis.Results: Twenty-two studies involving a total of 3054 SLE patients were included. The positivities of anticardiolipin antibody (ACL), IgG ACL, IgM ACL, LA and APS in SLE is not associated with ON. One study showed that IgG or IgM β2GP1 had no association with ON. No publication bias was detected. The quality of this evidence was low because of the high risk of bias across studies, and therefore robust inferences cannot be made.Conclusion: SLE patients demonstrated a weak association between aPLs and ON. The nature of the association between aPLs and ON in SLE needs to be investigated in-depth in future research.

[Atypical arthritis of the hands : Collagenosis-part 1]

BACKGROUND

Systemic lupus erythematosus (SLE) is a gynecotropic autoimmune vasculitis with manifestations in various organ systems including the skin, internal organs, and joints.

OBJECTIVE

Presentation of the atypical arthritis patterns of the hands in SLE as the most common autoimmunologic rheumatologic disease from the group of collagenoses in the context of clinical and serological findings and considering the classification criteria of the American College of Rheumatology compared to rheumatoid arthritis (RA) and psoriatic arthritis (PsA).

MATERIALS AND METHODS

Narrative review based on the current literature on the subject from a radiological and rheumatological point of view.

RESULTS

In 80-90% of all SLE cases, hand joint manifestations can be detected, mostly in the form of non-erosive oligo- or polyarthralgias with the picture of so-called luxation arthropathies and with the pattern of a so-called Jaccoud's or Lupus' syndrome, which are accompanied by "carpal instability" in 15% of cases. In association with an antiphospholipid antibody syndrome, ischemic osteonecrosis may occur in 5-50% of SLE, predominantly in weight-bearing areas of the skeleton, and less frequently in the carpal bones or metacarpal heads. The rare rhupus syndrome comprises patients with overlap of RA and SLE features.

CONCLUSIONS

Due to the heterogeneity of the symptoms and the often individually very different courses, the diagnosis of SLE can be difficult. Since new drug therapy concepts have significantly increased the 5‑year survival rates of SLE from 0% in the 1950s to 70-90% in recent decades, a timely and definite diagnosis is necessary, to which radiologists can also contribute by correctly classifying the image morphological SLE arthritis patterns in the hands.

Risk factors for symptomatic Avascular Necrosis (AVN) in a multi-ethnic Systemic Lupus Erythematosus (SLE) cohort

Avascular necrosis of bone (AVN) is increasingly being recognized as a complication of SLE and causes significant disability due to pain and mobility limitations. We studied the prevalence and factors associated with avascular necrosis (AVN) in a multiethnic SLE cohort. SLE patients who visited the outpatient clinic from October 2017 to April 2019 were considered eligible. Their medical records were reviewed to identify patients who developed symptomatic AVN, as confirmed by either magnetic resonance imaging or plain radiography. Subsequently, their SLE disease characteristics and treatment were compared with the characteristics of patients who did not have AVN. Multivariable logistic regression analyses were performed to determine the independent factors associated with AVN among the multiethnic SLE cohort. A total of 390 patients were recruited, and the majority of them were females (92.6%); the patients were predominantly of Malay ethnicity (59.5%), followed by Chinese (35.9%) and Indian (4.6%). The prevalence of symptomatic AVN was 14.1%, and the mean age of AVN diagnosis was 37.6 ± 14.4 years. Both univariate and multivariable logistic regression analyses revealed that a longer disease duration, high LDL-C (low density lipoprotein cholesterol), positive anti-cardiolipin (aCL) IgG and anti-dsDNA results, a history of an oral prednisolone dose of more than 30 mg daily for at least 4 weeks and osteoporotic fractures were significantly associated with AVN. On the other hand, hydroxychloroquin (HCQ), mycophenolate mofetil (MMF) and bisphosphonate use were associated with a lower risk of AVN. No associations with ethnicity were found. In conclusion, several modifiable risk factors were found to be associated with AVN, and these factors may be used to identify patients who are at high risk of developing such complications. The potential protective effects of HCQ, MMF and bisphosphonates warrant additional studies.

Juvenile-onset multifocal osteonecrosis in systemic lupus erythematosus: A case report

RATIONALE

Osteonecrosis (ON) is a devastating illness that leads to bone ischemia and potential joint destruction. Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease, with multi-system involvement which is closely associated with occurrence of ON. Multifocal ON, with an estimated morbidity of 3% in SLE patients, is extremely rare in juvenile subjects.

PATIENT CONCERNS

A 13.3-year-old female SLE patient was admitted to hospital 20 months following the SLE diagnosis because of a sudden aggravation of sore knees. She suffered from double knee joint pain and her left knee joint showed typical signs of inflammation including redness, swelling, heat, and pain.

DIAGNOSES

The SLE patient was diagnosed with multifocal ON of her knee joint based on magnetic resonance imaging findings of bone destruction and osteoproliferation at the bilateral distal femur and proximal tibia.

INTERVENTIONS

The patient received high-dose methylprednisolone and intravenous cyclophosphamide pulse therapies for controlling active lupus and nephritis. Oral calcitriol and dipyridamole were administered to alleviate knee pain and inhibit thrombi formation, thereby suppressing ON progress.

OUTCOMES

Three weeks following the treatment, the swelling in patient's left knee subsided. Her self-reporting pain score decreased from 9 to 4 and walking time increased from 45minutes to 90minutes per day. Nearly 5 weeks later, the pain in bilateral knee joints disappeared and the patient could walk without difficulties.

LESSONS

This patient is the youngest SLE patient who developed multifocal ON based on the reported literature. It suggests that ON can occur in young SLE patients. A combination of internal and external risk factors can promote the development of ON. The balanced approach to the application of corticosteroids and immunosuppressors in the treatment of SLE and prevention of ON is a challenging problem that deserves further exploration.

Epidemiology and risk factors for avascular necrosis in childhood systemic lupus erythematosus in a Taiwanese population

Childhood-onset systemic lupus erythematosus (SLE) is associated with greater disease activity, more aggressive course, and high rates of organ damage. The prolonged use of corticosteroids in childhood SLE contributes to increased morbidity, including avascular necrosis (AVN). We conducted this retrospective study using claims data from the Taiwan National Health Insurance Research Database, enrolling 1,472 children with newly-diagnosed SLE between 2005 and 2013. The mean age at the diagnosis of SLE was 15.5 ± 3.3 years, and the female to male ratio was 6.2:1. Thirty-nine patients (2.6%) developed symptomatic AVN during a mean follow-up of 4.6 ± 2.5 years. In multivariate analysis, the risk of AVN was higher in the patients with a daily prednisolone dose between 7.5 mg and 30 mg (HR 7.435, 95% CI 2.882–19.178, p < 0.001) and over 30 mg (HR 9.366, 95% CI 2.225–39.418, p = 0.002) than in those with a dose ≤ 7.5 mg/day. In addition, AVN was inversely correlated with the use of hydroxychloroquine > 627 days (HR 0.335, 95% CI 0.162–0.694, p = 0.003). In conclusion, high daily doses of prednisolone were associated with a significant risk of AVN, whereas the use of hydroxychloroquine > 627 days conferred an advantage. We suggest that the judicious use of corticosteroids combined with hydroxychloroquine might be a promising preventive strategy for AVN.

Clinical profile of osteonecrosis in systemic lupus erythematosus - Experience from a tertiary care centre in South India

Introduction:

Osteonecrosis or Avascular necrosis of bone (AVN) is a well recognized complication of systemic lupus erythematosus (SLE) leading to significant morbidity.

Methods:

We did a cross sectional descriptive study in cohort of SLE patients, on regular follow-up at our Rheumatology OPD over a period of 5 years from 2012 to 2017.

Results:

Of the total 415 SLE, 5.1% (n = 21) patients were diagnosed to have osteonecrosis. The mean age was 32.8 ± 7.6 years. Male: female were 1:4.2. Mean time interval between the onset of SLE and diagnosis of osteonecrosis was 4.1 ± 2.7 years. Pain (100%) was the most common presenting symptom followed by limping gait (42.8%). Most common site affected by osteonecrosis was femoral head (80.9%) (n = 17). 14.3% (n = 3) had multifocal involvement. The most common systemic involvement was musculoskeletal system (80.9%). In total 28.5% had secondary antiphospholipid syndrome. Mean SLEDAI-2K at the time of diagnosis of osteonecrosis was 5.3 ± 2.9. Hypertension 19%, hypothyroidism 9.5%, osteoporosis 24%, and chronic HCV infection 4.7% were the associated comorbidities. The most common stage by imaging at diagnosis was stage IV (38%), followed by 24% stage V, 19% stage III and 9.5% stage II and 9.5% stage VI. Medical management include bisphosphonates (100%), statins (90.4%) and anticoagulant therapy (28.5%), while 9.5% received core decompression surgery and 14.3% underwent total hip replacement. The mean daily dose of prednisolone at diagnosis of osteonecrosis was 8.5mg (range 5–20mg).

Conclusion:

This study described the prevalence and epidemiology of osteonecrosis in our cohort of SLE patients.

Monitoring of Osteonecrosis in Systemic Lupus Erythematosus: A Systematic Review and Metaanalysis

Objective.

Nontraumatic osteonecrosis (ON) is a well-recognized complication causing disability and affecting quality of life in patients with systemic lupus erythematosus (SLE). The aim of this study was to identify the risk factors for ON, and to identify the minimal investigation(s) needed to optimally monitor the risk of ON in patients with SLE.

Methods.

A systematic review was conducted using MEDLINE and EMBASE. These databases were searched up to January 2016 using the Medical Subject Heading (MeSH) terms “Osteonecrosis,” “Systemic lupus erythematosus,” and synonymous text words. Randomized controlled trials, case control, cohort, and cross-sectional studies were included. Risk factors for ON in patients with SLE were compiled. The quality of each study was assessed using the Newcastle-Ottawa scale for nonrandomized studies. The quality of evidence of each risk factor was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation method.

Results.

Of the 545 references yielded, 50 met inclusion criteria. Corticosteroid (CS) use may be strongly associated with ON in patients with SLE. Other clinical variables were moderately associated, including hypertension, serositis, renal disease, vasculitis, arthritis, and central nervous system disease. However, the evidence was low to very low in quality.

Conclusion.

Based on the best evidence available, CS use may be strongly associated with ON in patients with SLE. Results of this review were considered in the development of recommendations for the diagnosis and monitoring of patients with SLE in Canada and will guide clinicians in their assessment of these patients.

Association of common comorbidities with osteonecrosis: a nationwide population-based case-control study in Denmark

OBJECTIVE

To examine recent time trends in the incidence of osteonecrosis (ON) in Denmark and to investigate different common comorbidities association with ON in a population-based setting.

METHODS

Using Danish medical databases, we included all patients with a first-time hospital diagnosis of ON during 1995-2012. Each ON case was matched with 10 randomly selected population control subjects from general population. For all participants, we obtained a complete hospital history of comorbidities included in the CharlsonComorbidity Index 5 years preceding the inclusion date.

RESULTS

4107 ON cases and 41 063 controls were included. The incidence of ON increased from 3.9 in 1995 to 5.5 in 2012 per 100 000 inhabitants. Solid cancer was the most common comorbidity, associated with an adjusted OR (aOR) for ON of 2.0 (95% CI 1.7 to 2.2). For advanced metastatic cancer, leukaemia and lymphoma, aORs of ON were 3.4 (95% CI 2.5 to 4.5), 4.3 (95% CI 2.7 to 7.0) and 5.8 (95% CI 4.3 to 7.8), respectively. Among other chronic conditions, aORs were 3.5 (95% CI 3.0 to 4.1) for connective tissue diseases and 2.3 (95% CI 2.0 to 2.7) for chronic pulmonary diseases. aORs were also increased at 2.8 (95% CI 1.9 to 4.1) and 4.5 (95% CI 2.5 to 8.2) for mild and moderate-to-severe liver disease, respectively, and 4.2 (95% CI 3.4 to 5.2) for renal disease.

CONCLUSION

This large population-based study provides evidence for an increasing ON incidence in the general population and documents an association between several common comorbid conditions and risk of ON.

Systemic lupus erythematosus patients with high disease activity are associated with accelerated incidence of osteonecrosis: a systematic review and meta-analysis

Osteonecrosis (ON) is one of the serious complications for systemic lupus erythematosus (SLE); we aimed to study the risk relationship between disease activity and incidence of ON in SLE patients. The PubMed, Embase, and Cochrane library databases were searched for papers published up to May 2016 with English-language restriction; studies that compared disease activity between SLE patients with and without ON would be included, and eight studies involving a total of 1119 SLE patients were included. The incidence of ON in SLE was significantly associated with high patient's disease activity, including the degree (pool odds ratio 2.54, 95% confidence interval [CI] [1.33, 4.86], p = 0.005) and the scores (mean difference 2.33, 95% CI [0.86, 3.80], p = 0.002). Besides, immunosuppressive drug use was also a significant risk factor for ON (p = 0.00001), while antimalarial treatment played a protective role (p = 0.01). No evidence of publication bias was detected. In conclusion, disease activity is a significant and independent risk factor for ON, and higher disease activity score is associated with accelerated incidence of ON in SLE patients.

Increased risk of avascular necrosis in patients with psoriatic disease: A nationwide population-based matched cohort study

BACKGROUND

Avascular necrosis (AVN) and psoriasis have some pathogenic mechanisms and associated conditions in common.

OBJECTIVE

To examine the association between psoriasis and AVN.

METHODS

This study used data from the Taiwan National Health Insurance Research Database for the period 2004-2006 and identified 28,268 patients with psoriasis, who were then matched for age and sex with 113,072 controls without psoriasis from the Taiwan Longitudinal Health Insurance Database 2000. Multivariate Cox proportional hazards models were used for the analysis.

RESULTS

The unadjusted risk of AVN was significantly higher for patients with psoriasis than for controls (hazard ratio [HR] 2.29) and remained significant after adjustment for other risk factors (adjusted HR 1.96; 95% confidence interval 1.62-2.38). The risk for AVN increased in relation to psoriasis severity and was higher for patients with psoriasis and arthritis than for patients without arthritis. The adjusted HRs were higher for male patients than for female patients and for patients younger than 30 years compared with older patients.

LIMITATIONS

We lacked information on daily tobacco use, alcohol consumption, and physical activity.

CONCLUSION

The risk for AVN increased with the disease severity of psoriasis.

Risk Factors for Symptomatic Avascular Necrosis in Childhood-onset Systemic Lupus Erythematosus

Objective.

To examine the frequency and risk factors for symptomatic avascular necrosis (AVN) in childhood-onset systemic lupus erythematosus (cSLE).

Methods.

A single-center, nested, matched, case-control design was used. There were 617 patients with cSLE followed at the Hospital for Sick Children (SickKids) Lupus Clinic between July 1982 and June 2013 included in the study. The AVN cohort consisted of 37 patients identified with clinical findings of symptomatic AVN and diagnosis was confirmed by 1 or more imaging modalities. Three controls were matched to each patient with AVN by date and age at diagnosis. Baseline clinical, laboratory, and treatment characteristics were compared between patients with AVN and controls by univariable analyses and if statistically significant, were included in a multivariable logistic regression model.

Results.

A total of 37/617 patients (6%) developed symptomatic AVN in 91 joints during followup at SickKids. The mean duration to disease was 2.3 years. The hip was the most commonly involved joint (26/37, 70%). Compared with the matched non-AVN cohort, patients with AVN had a higher incidence of central nervous system (CNS) involvement and nephritis, required greater cumulative prednisone (PRED) from cSLE diagnosis to AVN, received a greater maximal daily PRED dose, and had more frequent use of pulse methylprednisolone therapy. Multivariable regression analysis confirmed major organ involvement (CNS disease and/or nephritis) and maximal daily PRED dose as significant predictors of symptomatic AVN development.

Conclusion.

Patients with cSLE with severe organ involvement including nephritis and CNS disease and higher maximal daily dose of PRED are more likely to develop symptomatic AVN.

Osteonecrosis in systemic lupus erythematosus

OBJECTIVES

To define the proportion of osteonecrosis (ON) in our patient population with lupus and to identify factors associated with the development of ON in systemic lupus erythematosus, as well as to carry out a descriptive analysis of ON cases.

MATERIALS AND METHODS

Observational retrospective study of 158 patients with SLE (ACR 1982 criteria). Demographic and laboratory data, clinical manifestations, SLICC, SLEDAI, cytotoxic and steroid treatments were compared. In patients with ON, we analyzed time of disease progression and age at ON diagnosis, form of presentation, joints involved, diagnostic methods, Ficat-Arlet classification, and treatment. To compare the means, t-test or Mann-Whitney's test were employed and the cHi-2 test or Fisher's exact test, as appropriate, were used to measure the equality of proportions.

RESULTS

ON was present in 15 out 158 patients (9.5%), 13 women and 2 men, with a mean age of 30 (r: 16-66) at diagnosis and 35 months of evolution until diagnosis (r: 1-195). Among the 15 patients, 34 joints presented ON, 23 were symptomatic and 22 were diagnosed by magnetic resonance images. Twenty-six occurred in hips (24 bilateral), 4 in knees and 4 in shoulders. In 13 patients, ON involved 2 or more joints. At onset, 28 joints were in stage i-ii, one in stage iii and 5 had no data and; in the end, 14 were in stage iii-iv, 5 in stage i-ii and 15 had no data. Twenty-nine underwent conservative treatment with rest and 8 hips required joint replacement. ON progression was associated with Cushing's syndrome (P=0.014) OR 4.16 (95% CI 1.4-12.6) and 2nd year SLICC (P=0.042). No relation with clinical manifestations, lab results, cytotoxic treatment, steroid treatment (total accumulated dose, mean daily dose and duration) metilprednisolone pulses, nor activity was found. All patients with ON received antimalarials, in contrast to 77% of those without ON.

CONCLUSIONS

The proportion of ON was 9.5%, mainly in women, 76% in hips (26) and 92% bilaterally. They were associated significantly with Cushing's syndrome and accumulated damage at second year.

Prevalence, incidence, and associated factors of avascular necrosis in Korean patients with systemic lupus erythematosus: a nationwide epidemiologic study

Avascular necrosis (AVN) is one of the most frequent types of organ damage in systemic lupus erythematosus (SLE). However, little is currently known about the epidemiology of AVN in SLE patients. The aim of this study was to estimate the prevalence and incidence of AVN in Korean patients with SLE based on National Health Insurance (NHI) claims data and to determine the risk factors for AVN among SLE patients. This study was conducted using the 2006-2010 data of 25,358 SLE patients from the NHI program. AVN cases were defined as those with at least one diagnosis of AVN. The prevalence was calculated by dividing the number of AVN cases by the number of SLE cases in the same year. The annual incidence was calculated by dividing the number of incident AVN cases by the number of SLE-prevalent cases not previously diagnosed with AVN. Patients who developed AVN in 2008-2010 were compared with SLE patients who did not develop AVN to identify any risk factors. The prevalence of AVN among SLE patients (2006-2010) was 31.5-34.2 per 1,000 persons and was similar in all the years studied. The incidence per 1,000 persons of AVN among SLE patients was 8.6 [95 % confidence interval (95 % CI) 6.9-10.3] in 2008, 9.8 (95 % CI 8.0-11.6) in 2009, and 8.4 (95 % CI 6.8-10.0) in 2010. Regression analysis indicated that taking an oral corticosteroid [odds ratio (OR) 2.12, 95 % CI 1.39-3.23] or an intravenous corticosteroid (OR 1.5, 95 % CI 1.2-1.89) was significantly associated with AVN. In addition, AVN was associated with use of immunosuppressive agents (OR 2.12, 95 % CI 1.66-2.72), hydroxychloroquine (OR 1.4, 95 % CI 1.09-1.81), and lipid-lowering agents (OR 1.78, 95 % CI 1.24-2.57) among the prescribed medications, and with hypertension (OR 1.39, 95 % CI 1.08-1.79) among the comorbidities. The prevalence and incidence of AVN among SLE patients, which were 31.5-34.2 and 8.4-9.8 per 1,000 persons, respectively, may be representative of the entire population of symptomatic AVN patients with SLE in Korea. AVN is associated with the use of corticosteroids, immunosuppressants, hydroxychloroquine, lipid-lowering agents, and with hypertension. Studies of large, prospective cohorts are needed to confirm these results.

Multifocal osteonecrosis in systemic lupus erythematosus: case report and review of the literature

Osteonecrosis is a relatively common comorbidity in systemic lupus erythematosus (SLE), but avascular necrosis in multiple sites is unusual. Multifocal osteonecrosis is defined as osteonecrotic lesions affecting three or more separate anatomic sites. We report a case of a 24-year-old woman diagnosed with SLE when she presented with mucocutaneous, haematological and mild renal manifestations. Initially, she was treated with prednisone and hydroxychloroquine and her condition remained stable. Two years later, she developed severe bilateral pretibial ulcers intractable to immunosuppressive therapy and broad-spectrum antibiotics. MRI of both legs disclosed osteonecrosis of the distal tibia, proximal tibia, distal fibula and talus bilaterally. She had elevated anticardiolipin antibodies for which she was treated with chronic anticoagulation resulting in complete healing of the leg ulcers and no further episodes of osteonecrosis. In addition to this case, we review the demographic, clinical and pharmacological features of 14 cases reported in the literature.

Osteonecrosis in systemic lupus erythematosus: an early, frequent, and not always symptomatic complication

Osteonecrosis may complicate the course of systemic lupus erythematosus and may contemporaneously affect multiple joints. The major risk factor associated with the development of osteonecrosis is the use of glucocorticoid at high doses. Recent studies using serial MRI, which represents the “gold standard” for the early detection of osteonecrosis, yielded some interesting findings about the natural history of this clinical entity. Osteonecrosis in the majority of the cases is asymptomatic and occurs early in the course of the disease. Its later occurrence is associated with lupus flare that requires the increase of corticosteroid dose. The optimal treatment of osteonecrosis is controversial. In case of silent osteonecrosis involving a small area conservative strategy is usually adequate. When lesions are symptomatic surgical treatment as core decompression or free vascularized fibular grafting is required; extracorporeal shockwave treatment may represent an alternative therapeutic approach. When the lesion has a medium-large dimension or involves a weight-bearing area bone collapse is a common complication requiring total joint replacement. Coadministration of bisphosphonate or warfarin with high doses of corticosteroid might be a promising preventive strategy of osteonecrosis.

The use of joint-specific and whole-body MRI in osteonecrosis: a study in patients with juvenile systemic lupus erythematosus

OBJECTIVE

This study aimed to estimate the prevalence of osteonecrosis (ON) in juvenile systemic lupus erythematosus (SLE) patients using joint-specific and whole-body MRI; to explore risk factors that are associated with the development of ON; and to evaluate prospectively patients 1 year after initial imaging.

METHOD

Within a 2 year period, we studied 40 juvenile SLE patients (aged 8-18 years) with a history of steroid use of more than 3 months duration. Risk factors including disease activity, corticosteroid use, vasculitis, Raynaud's phenomenon and lipid profile were evaluated. All patients underwent MRI of the hips, knees and ankles using joint-specific MRI. Whole-body STIR (short tau inversion recovery) MRI was performed in all patients with ON lesions.

RESULTS

Osteonecrosis was identified in 7 patients (17.5 %) upon joint-specific MRI. Whole-body STIR MRI detected ON in 6 of these 7 patients. There was no significant difference between the ON and non-ON groups in the risk factors studied. One patient had pre-existing symptomatic ON. At 1 year follow-up, the ON lesions had resolved in one patient, remained stable in four and decreased in size in two. No asymptomatic patients with ON developed clinical manifestations.

CONCLUSION

Whole-body STIR MRI may be useful in detecting ON lesions in juvenile SLE patients but larger studies are needed to define its role.

Factors associated with osteonecrosis in Thai lupus patients: a case control study

OBJECTIVE

To identify associated factors for the development of osteonecrosis of a femoral head (ON) in patients with systemic lupus erythematosus (SLE).

METHODS

We conducted a retrospective nested case-control study from SLE patients who attended the Rheumatology Clinic at Phramongkutklao Hospital from 1992-2008. Cases were defined as SLE patients, who had clinically apparent ON (confirmed by plain radiographs or magnetic resonance imaging). For each case, a control was selected and matched to the case by age and disease duration. The main outcome measure was the odds ratio (OR) of ON among SLE patients. The clinical and laboratory variables thought to be risk factors of ON variables were compared between patients who did and did not develop ON. Significant and clinically relevant variables were then examined by a stepwise logistic regression model.

RESULTS

Of 186 SLE patients, we identified 41 patients who developed ON during the course of follow-up. Twenty patients were available for data analysis. From the univariate analysis, incidence of renal involvement and the use of steroids (recorded as evidenced by maximum and mean daily prednisolone dose) were significantly higher in the ON group than in controls. The use of antimalarials was significantly lower in patients with ON than in controls. No difference in disease activity, lipid profiles or anticardiolipin antibody was found between groups. In the logistic regression, the presence of renal involvement remained as a positive associated factor for ON (OR = 7.80, CI = 1.249-48.748, P = 0.028) and the use of antimalarial drugs was a negative associated factor for ON (OR = 0.09, CI = 0.009-0.961, P = 0.046).

CONCLUSION

The presence of renal involvement was associated with ON and the antimalarial use may have a protective effect for ON in Thai patients with SLE. The findings from this study further support the use of antimalarial drugs in SLE patients.

Extracorporeal shockwave for hip necrosis in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) frequently received corticosteroid therapy, resulting in osteonecrosis of the femoral head (ONFH). Prior studies demonstrated the effectiveness of extracorporeal shockwave treatment (ESWT) for ONFH.. This study evaluated the effectiveness of ESWT for ONFH in patients with SLE. We studied 39 patients, including 15 patients with SLE (26 hips) and 24 controls (29 hips). To each affected hip we applied ESWT (6000 impulses at 28 kV in a single session). Patients were ambulated with partial weight bearing for 4-6 weeks. The primary endpoint was the need for hip replacement. The secondary endpoints were improvement in hip pain and function and image changes on X-ray and MRI. Patients received total hip replacement in 12% of patients with SLE and in 14% of controls (P = 0.802). There was no statistically significant difference in pain scores (0.86 vs. 0.89; P = 0.467) and function scores (89% vs. 91%; P = 0.194) between patients with SLE and controls. SLE response to ESWT for ONFH is comparable with ONFH in patients without SLE.

Lupus arthritis

Arthritis in systemic lupus erythematosus (SLE) is one of the most common disease manifestations. Nearly all joints can be affected by SLE, but hand and knee involvement are the most typical. Periarticular structures can be inflamed leading to tendonitis, tenosynovitis and tendon rupture. Avascular necrosis (AVN) also occurs causing joint pain and disability, typically in larger joints such as the hip and knee. This article addresses the clinical features of arthritis in lupus and an approach to the differential diagnosis. Treatment strategies include nonsteroidal anti-inflammatories, corticosteroids, anti-malarials and a variety of immunosuppressive medications.

Investigation of occurrence of osteonecrosis of the femoral head after increasing corticosteroids in patients with recurring systemic lupus erythematosus

Osteonecrosis (ON) of the femoral head is known to occur commonly in cases with systemic lupus erythematosus (SLE) that received corticosteroid (CS) treatment. However, there have been no detailed reports about the onset of ON in cases with recurrence of SLE. Using MRI, we followed up 17 patients who experienced recurrence of SLE for at least 1 year at our hospital and in whom the CS dose was increased from a maintenance dose to middle to high dose to see if ON would occur. We then compared the group that developed ON and the group that did not with respect to patient characteristics, blood test results, changes in serum lipid levels, and CS dose. ON occurred in five subjects (29.4%), revealing that osteonecrosis occurs not only when CS are first administered but also in cases which the CS dose is increased for recurrence of SLE. Especially, serum cholesterol levels and its rate of increase soared rapidly soon after increasing the CS dose in the ON group as compared with the non-ON group (P < 0.05). This suggests that increased serum lipid levels might be a contributing factor to onset of ON. Moreover, SLE disease activity index 2000 (SLEDAI-2K) scores when the CS dose was increased were significantly (P < 0.05) higher in the ON group, suggesting that SLE disease activity itself is a risk factor for onset of ON.

Notable difference between the development of vertebral fracture and osteonecrosis of the femoral head in patients treated with high-dose glucocorticoids for systemic rheumatic diseases

OBJECTIVE

Vertebral fracture (VF) and osteonecrosis of the femoral head (OFH) are serious concerns in patients with rheumatic diseases treated with high-dose glucocorticoids (GCs). We comparatively examined the risk factors of VF and OFH in patients who had recently received high-dose GC therapy.

PATIENTS AND METHODS

Patients with rheumatic diseases receiving GCs (> or =0.5 mg/kg/day for prednisolone equivalent) within the past 2 months were enrolled in this study, and treated with 200 mg/day of etidronate cyclically. The bone mineral density (BMD) of the lumbar spine (L2-4) was examined by QDR2000. OFH was evaluated by magnetic resonance imaging (MRI). [ClinicalTrials.gov identifier: NCT00679978].

RESULTS

Forty-four patients completed the 2-year study including annual X-rays and the BMD analysis. MRI evaluation at entry and 2 years was performed in 41 patients. The BMD values with anteroposterior (AP) and lateral views decreased by 6.4% and 9.7%, respectively, in the first year, but were stable in the second year. Eleven patients developed VF and 9 patients developed OFH. The risk factors for VF included previous VF and a low BMD value (T score<-1.5) of AP view at baseline with an odds ratio (OR) of 14.9 (95%CI 2.9-76.4), while the risk factor for OFH was a recent maximum GC dosage (>1.2 mg/kg/day versus< or =; OR=7.7, 95%CI 1.3-45.5) and a decrease in BMD value of lateral view (>15% versus< or =; OR=6.7, 95% CI 1.2-36.1) in the first year.

CONCLUSION

The development of VF relies on the predisposing factors, while that of OFH depends on the response to high-dose GC therapy.