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Buttgereit F, Palmowski A, Bond M, Adami G, Dejaco C. Osteoporosis and fracture risk are multifactorial in patients with inflammatory rheumatic diseases. Nat Rev Rheumatol 2024:10.1038/s41584-024-01120-w. [PMID: 38831028 DOI: 10.1038/s41584-024-01120-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Abstract
Patients with inflammatory rheumatic and musculoskeletal diseases (iRMDs) such as rheumatoid arthritis, connective tissue diseases, vasculitides and spondyloarthropathies are at a higher risk of osteoporosis and fractures than are individuals without iRMDs. Research and management recommendations for osteoporosis in iRMDs often focus on glucocorticoids as the most relevant risk factor, but they largely ignore disease-related and general risk factors. However, the aetiopathogenesis of osteoporosis in iRMDs has many facets, including the negative effects on bone health of local and systemic inflammation owing to disease activity, other iRMD-specific risk factors such as disability or malnutrition (for example, malabsorption in systemic sclerosis), and general risk factors such as older age and hormonal loss resulting from menopause. Moreover, factors that can reduce fracture risk, such as physical activity, healthy nutrition, vitamin D supplementation and adequate treatment of inflammation, are variably present in patients with iRMDs. Evidence relating to general and iRMD-specific protective and risk factors for osteoporosis indicate that the established and very often used term 'glucocorticoid-induced osteoporosis' oversimplifies the complex inter-relationships encountered in patients with iRMDs. Osteoporosis in these patients should instead be described as 'multifactorial'. Consequently, a multimodal approach to the management of osteoporosis is required. This approach should include optimal control of disease activity, minimization of glucocorticoids, anti-osteoporotic drug treatment, advice on physical activity and nutrition, and prevention of falls, as well as the management of other risk and protective factors, thereby improving the bone health of these patients.
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Affiliation(s)
- Frank Buttgereit
- Department of Rheumatology and Clinical Immunology at Charité - University Medicine Berlin, Berlin, Germany.
| | - Andriko Palmowski
- Department of Rheumatology and Clinical Immunology at Charité - University Medicine Berlin, Berlin, Germany
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
| | | | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Austria
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Nakamura A, Towheed T. Pathogenesis, assessment, and management of bone loss in axial spondyloarthritis. Semin Arthritis Rheum 2024; 64:152345. [PMID: 38103486 DOI: 10.1016/j.semarthrit.2023.152345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Axial spondyloarthritis (axSpA) presents a complex scenario where both new bone formation in entheseal tissues and significant trabecular bone loss coexist, emphasizing the intricate nature of bone dynamics in this context. METHODS A search of the literature was conducted to compose a narrative review exploring the pathogenesis, possible assessment methods, and potential management options for axSpA. RESULTS While chronic systemic and local inflammation contribute to bone loss, the mechanisms behind axSpA-associated bone loss exhibit distinct characteristics influenced by factors like mechanical stress and the gut microbiome. These factors directly or indirectly stimulate osteoclast differentiation and activation through the RANK-RANKL axis, while simultaneously impeding osteoblast differentiation via negative regulation of bone anabolic pathways, including the Wnt signaling pathway. This disruption in the balance between bone-resorbing osteoclasts and bone-forming osteoblasts contributes to overall bone loss in axSpA. Early evaluation at diagnosis is prudent for detecting bone changes. While traditional dual x-ray absorptiometry (DXA) has limitations due to potential overestimation from spinal new bone formation, alternative methods like trabecular bone score (TBS), quantitative CT (QCT), and quantitative ultrasound (QUS) show promise. However, their integration into routine clinical practice remains limited. In addition to approved anti-inflammatory drugs, lifestyle adjustments like regular exercise play a key role in preserving bone health. Tailoring interventions based on individual risk profiles holds potential for mitigating bone loss progression. CONCLUSION Recognizing the pivotal role of bone loss in axSpA underscores the importance of integrating regular assessments and effective management strategies into clinical practice. Given the multifaceted contributors to bone loss in axSpA, a multidisciplinary approach is essential.
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Affiliation(s)
- Akihiro Nakamura
- Department of Medicine, Division of Rheumatology, Queen's University, Kingston, Ontario, Canada; Translational Institute of Medicine, School of Medicine, Queen's University, Ontario, Canada; Kingston Health Science Centre, Kingston, Ontario, Canada.
| | - Tanveer Towheed
- Department of Medicine, Division of Rheumatology, Queen's University, Kingston, Ontario, Canada; Translational Institute of Medicine, School of Medicine, Queen's University, Ontario, Canada; Kingston Health Science Centre, Kingston, Ontario, Canada.
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Tan S, Bagheri H, Lee D, Shafiei A, Keaveny TM, Yao L, Ward MM. Vertebral Bone Mineral Density, Vertebral Strength, and Syndesmophyte Growth in Ankylosing Spondylitis: The Importance of Bridging. Arthritis Rheumatol 2022; 74:1352-1362. [PMID: 35315248 PMCID: PMC9339458 DOI: 10.1002/art.42120] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/21/2022] [Accepted: 03/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To examine the relationship between vertebral trabecular bone mineral density (tBMD), vertebral strength, and syndesmophytes in patients with ankylosing spondylitis (AS) using quantitative computed tomography (QCT). METHODS We performed QCT of the spine to measure syndesmophytes and tBMD in 5 vertebrae (T11-L3) in 61 patients with AS. Finite element analysis was performed to measure vertebral strength in compressive overload, including in trabecular and cortical compartments. In cross-sectional analyses, we examined associations of syndesmophyte height with tBMD and vertebral strength in each vertebra. In 33 patients followed up for 2 years, we investigated whether baseline tBMD and vertebral strength predicted syndesmophyte growth in the same vertebra, and vice versa. RESULTS In the cross-sectional analyses, 126 vertebrae had bridging, 77 vertebrae had nonbridging syndesmophytes, and 83 vertebrae had no syndesmophytes. There were strong inverse associations between syndesmophyte height and tBMD, total strength, and trabecular strength only among bridged vertebrae. In the longitudinal analysis, nonbridged vertebrae with low tBMD (adjusted β = -0.01 [95% confidence interval (95% CI) -0.019, -0.0012]) and low strength (adjusted β = -0.0003 [95% CI -0.0004, -0.0002]) had more syndesmophyte growth over time. Similar associations were absent among bridged vertebrae. Conversely, vertebrae with bridging at baseline had a significant loss in percent tBMD over time (adjusted β = -0.001 [95% CI -0.0017, -0.0004]). CONCLUSION Associations between syndesmophytes and vertebral density and strength in AS differ between bridged and nonbridged vertebrae. Among nonbridged vertebrae, low tBMD and strength are associated with syndesmophyte growth. Bridging is associated with large subsequent losses in tBMD, possibly due to mechanical offloading.
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Affiliation(s)
- Sovira Tan
- Intramural Research Program, National Institute of
Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health,
Bethesda, MD
| | - Hadi Bagheri
- Radiology and Imaging Sciences, National Institutes of
Health Clinical Center, Bethesda, MD
| | | | - Ahmad Shafiei
- Radiology and Imaging Sciences, National Institutes of
Health Clinical Center, Bethesda, MD
| | - Tony M. Keaveny
- Departments of Mechanical Engineering and Bioengineering,
University of California, Berkeley, CA
| | - Lawrence Yao
- Radiology and Imaging Sciences, National Institutes of
Health Clinical Center, Bethesda, MD
| | - Michael M. Ward
- Intramural Research Program, National Institute of
Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health,
Bethesda, MD
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Wu X, Zhang L, Bian T, Man S, Li H, Liu W, Zhou Y. The correlation between volumetric bone mineral density and morphological parameters of the proximal femur and clinical outcomes in ankylosing spondylitis patients with hip involvement. BMC Musculoskelet Disord 2022; 23:24. [PMID: 34980053 PMCID: PMC8725399 DOI: 10.1186/s12891-021-04912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background To measure volumetric bone mineral density (vBMD) with quantitative computed tomography (QCT) in the proximal femur of ankylosing spondylitis (AS) patients with hip involvement and analyze their correlations with radiographic and clinical parameters. Methods Sixty-five AS inpatients were enrolled in this study. The bone mineral density was measured by QCT and dual-energy x-ray absorptiometry (DXA), respectively. The morphological parameters of the proximal femur were measured on digital anteroposterior (AP) radiographs of the pelvis. The correlations between them were analyzed by SPSS software. Results The average trabecular vBMD measured at the femoral neck was 136.38 ± 25.58 mg/cm3. According to the BASRI-Hip score, group A consisted of 39 hips (0–2 score) and group B consisted of 26 hips (3–4 score). There were significant differences regarding trabecular CTXA equivalent T-score between group A and B at the femoral neck (p = 0.004); intertrochanteric region (p < 0.001) and greater trochanter (p = 0.001). The trabecular CTXA equivalent T-score at femoral neck had a negative correlation with disease duration (r = − 0.311, p = 0.012) and with CBR (r = − 0.319, p = 0.010). Conclusions The low trabecular bone density at the site of the hip was associated with the duration of disease progression and degree of hip involvement. Meanwhile, it had a correlation with hip function status although we failed to confirm a significant relationship between hip vBMD and disease activity.
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Affiliation(s)
- Xinfeng Wu
- Department of Spine Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Liang Zhang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Tao Bian
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Siliang Man
- Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Hongchao Li
- Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Wei Liu
- Department of Rheumatology and Immunology, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China
| | - Yixin Zhou
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College of Peking University, No. 31 Xinjiekou East Street, Xicheng District, Beijing, 100035, China.
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Juhász B, Gulyás K, Horváth Á, Végh E, Pusztai A, Szentpétery Á, Pethő Z, Bodnár N, Hamar A, Bodoki L, Bhattoa HP, Szekanecz É, Hodosi K, Domján A, Szamosi S, Horváth C, Szántó S, Szűcs G, Raterman HG, Lems WF, FitzGerald O, Szekanecz Z. Peripheral quantitative computed tomography in the assessment of bone mineral density in anti-TNF-treated rheumatoid arthritis and ankylosing spondylitis patients. BMC Musculoskelet Disord 2021; 22:817. [PMID: 34556105 PMCID: PMC8461899 DOI: 10.1186/s12891-021-04708-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/11/2021] [Indexed: 01/01/2023] Open
Abstract
Abstract Introduction Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with osteoporosis. There have not been many peripheral quantitative computed tomography (QCT) studies in patients receiving biologics. We assessed volumetric and areal bone mineral density (BMD) by forearm QCT and dual-energy X-ray absorptiometry (DXA), respectively in addition to laboratory biomarkers in these arthritides. Methods Forty RA and AS patients treated with either etanercept (ETN) or certolizumab pegol (CZP) were undergoing follow-ups for one year. Volumetric and areal BMD, as well as parathyroid hormone (PTH), osteocalcin, RANKL, 25-hydroxyvitamin D (VITD), P1NP, CTX, sclerostin (SOST), Dickkopf 1 (DKK-1) and cathepsin K (CATHK) were determined. Results We did not observe any further bone loss during the 12-month treatment period. Volumetric and areal BMD showed significant correlations with each other (p<0.017 after Bonferroni’s correction). Trabecular QCT BMD at baseline (p=0.015) and cortical QCT BMD after 12 months (p=0.005) were inversely determined by disease activity at baseline in the full cohort. Trabecular QCT BMD at baseline also correlated with CTX (p=0.011). In RA, CRP negatively (p=0.014), while SOST positively (p=0.013) correlated with different QCT parameters. In AS, RANKL at baseline (p=0.014) and after 12 months (p=0.007) correlated with cortical QCT BMD. In the full cohort, 12-month change in QTRABBMD was related to TNF inhibition together with elevated VITD-0 levels (p=0.031). Treatment and lower CATHK correlated with QCORTBMD changes (p=0.006). In RA, TNF inhibition together with VITD-0 (p<0.01) or CATHK-0 (p=0.002), while in AS, treatment and RANKL-0 (p<0.05) determined one-year changes in QCT BMD. Conclusions BMD as determined by QCT did not change over one year of anti-TNF treatment. Disease activity, CATHK, RANKL and VITD may be associated with the effects of anti-TNF treatment on QCT BMD changes. RA and AS may differ in this respect. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04708-5.
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Affiliation(s)
- Balázs Juhász
- Department of Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Gulyás
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Ágnes Horváth
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Edit Végh
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Anita Pusztai
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Ágnes Szentpétery
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary.,Department of Rheumatology, Uppsala University Hospital, Uppsala, Sweden.,Conway Institute for Biomolecular Research, University College Dublin, Dublin, Ireland
| | - Zsófia Pethő
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Nóra Bodnár
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Attila Hamar
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Levente Bodoki
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Harjit Pal Bhattoa
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Éva Szekanecz
- Department of Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Hodosi
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Andrea Domján
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Szilvia Szamosi
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Csaba Horváth
- First Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Sándor Szántó
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary.,Department of Sports Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gabriella Szűcs
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary
| | - Hennie G Raterman
- Department of Rheumatology, Northwest Clinics, Alkmaar, The Netherlands
| | - Willem F Lems
- Amsterdam Rheumatology and Immunology Centre, Amsterdam, The Netherlands
| | - Oliver FitzGerald
- Conway Institute for Biomolecular Research, University College Dublin, Dublin, Ireland
| | - Zoltán Szekanecz
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Nagyerdei str. 98, Debrecen, 4032, Hungary.
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Lim MJ, Kang KY. A Contemporary View of the Diagnosis of Osteoporosis in Patients With Axial Spondyloarthritis. Front Med (Lausanne) 2020; 7:569449. [PMID: 33363182 PMCID: PMC7759657 DOI: 10.3389/fmed.2020.569449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/13/2020] [Indexed: 01/31/2023] Open
Abstract
Axial spondyloarthritis (axSpA) is a chronic inflammatory disease that primarily affects the axial joints. Altered bone metabolism associated with chronic inflammation leads to both new bone formation in the spine and increased bone loss. It is known that patients with axSpA have a high prevalence of osteoporosis and fractures. However, there is no consensus on which imaging modality is the most appropriate for diagnosing osteoporosis in axSpA. Bone mineral density measurement using dual-energy X-ray absorptiometry is the primary diagnostic method for osteoporosis, but it has notable limitations in patients with axSpA. This method may lead to the overestimation of bone density in patients with axSpA because they often exhibit abnormal calcification of spinal ligaments or syndesmophytes. Therefore, the method may not provide adequate information about bone microarchitecture. These limitations result in the underdiagnosis of osteoporosis. Recently, new imaging techniques, such as high-resolution peripheral quantitative computed tomography, and trabecular bone score have been introduced for the evaluation of osteoporosis risk in patients with axSpA. In this review, we summarize the current knowledge regarding imaging techniques for diagnosing osteoporosis in patients with axSpA.
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Affiliation(s)
- Mie Jin Lim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Inha University, Incheon, South Korea
| | - Kwi Young Kang
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Division of Rheumatology, Department of Internal Medicine, College of Medicine, Incheon Saint Mary's Hospital, The Catholic University of Korea, Incheon, South Korea
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Clunie G, Horwood N. Loss and gain of bone in spondyloarthritis: what drives these opposing clinical features? Ther Adv Musculoskelet Dis 2020; 12:1759720X20969260. [PMID: 33240403 PMCID: PMC7675871 DOI: 10.1177/1759720x20969260] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/05/2020] [Indexed: 12/13/2022] Open
Abstract
The breadth of bone lesion types seen in spondyloarthritis is unprecedented in
medicine and includes increased bone turnover, bone loss and fragility,
osteitis, osteolysis and erosion, osteosclerosis, osteoproliferation of soft
tissues adjacent to bone and spinal skeletal structure weakness. Remarkably,
these effects can be present simultaneously in the same patient. The search for
a potential unifying cause of effects on the skeleton necessarily focuses on
inflammation arising from the dysregulation of immune response to
microorganisms, particularly dysregulation of TH17 lymphocytes, and
the dysbiosis of established gut and other microbiota. The compelling notion
that a common antecedent pathological mechanism affects existing bone and
tissues with bone-forming potential (entheses), simultaneously with variable
effect in the former but bone-forming in the latter, drives basic research
forward and focuses our awareness on the effects on these bone mechanisms of the
increasing portfolio of targeted immunotherapies used in the clinic.
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Affiliation(s)
- Gavin Clunie
- Cambridge University Hospitals NHS Foundation Trust, Box, 204 Hills Rd, Cambridge CB2 0QQ, UK
| | - Nicole Horwood
- Norwich Medical School, University of East Anglia, Norwich, UK
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Chen Z, Yang P, Wu Y, Liu X, Yang Y, Song P, Chen YT, Lin C, Xu Q. Serum Uric Acid Shows Inverted "U" Type Correlation with Osteoporosis in Chinese Ankylosing Spondylitis Patients: A Retrospective Study. Med Sci Monit 2019; 25:9702-9711. [PMID: 31851643 PMCID: PMC6930702 DOI: 10.12659/msm.918766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study was to investigate the correlation between osteoporosis and serum uric acid in ankylosing spondylitis (AS) patients, and to further identify potential factors that might be associated with osteoporosis in AS patients. Material/Methods We included 182 AS patients, consisted of 143 male patients and 39 female patients, who visited our hospital from January 1, 2014 to December 31, 2018. We used dual-energy x-ray absorptiometry to measure bone mineral density (BMD) of orthotopic lumbar vertebrae in patients with AS. The gender, age, disease duration, BMD, T-score, Z-score, uric acid, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood platelet (PLT), and status of treatment with biologics of the patients were collected. Then, the Spearman correlation coefficient and multivariate liner regression analysis were applied to identify the relationship between the factors and BMD, T-score, and Z-score in AS patients. Results Male AS patients between the ages of 16 and 30 years old had a higher risk of osteoporosis (P<0.05). AS patients with uric acid value between 300–360 μmol/L had the highest BMD, T-score, and Z-score. The BMD had a positive correlation with age and disease duration (P<0.01) while had a negative correlation with PLT (P<0.05). BMD in AS patients with elevated ESR was significantly (P<0.05) lower than in AS patients with normal ESR. There were no significant differences in BMD between AS patients with elevated CRP and the patients with normal CRP and PLT. Treatment with TNFi (tumor necrosis factor alpha inhibitor) did not improve BMD in AS patients. Conclusions The relationship between uric acid and BMD in AS patients was observed as inverted “U”-type. Keeping uric acid within 300–360 μmol/L might be helpful in preventing AS patients from developing osteoporosis.
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Affiliation(s)
- Zhixin Chen
- Department of Rheumatology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland).,Department of Chinese Medicine, South China Agricultural University Hospital, Guangzhou, Guangdong, China (mainland)
| | - Peidan Yang
- Department of Rheumatology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Yuyun Wu
- Guangzhou Bai Yun Shan Chen Li Ji Pharmaceutical Factory Co., Ltd., Guangzhou, Guangdong, China (mainland)
| | - Xiaobao Liu
- Department of Rheumatology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland).,Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Yechun Yang
- Department of Rheumatology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland).,Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Pingfang Song
- Department of Rheumatology, Oregon Health and Science University, Portland, OR, USA
| | | | - Changsong Lin
- Department of Rheumatology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland).,Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Qiang Xu
- Department of Rheumatology, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland).,Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
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Fitzgerald GE, O'Shea FD. The Fascinating Paradox of Osteoporosis in Axial Spondyloarthropathy. J Rheumatol 2017; 44:1767-1776. [PMID: 28966207 DOI: 10.3899/jrheum.170051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2017] [Indexed: 12/21/2022]
Abstract
Low bone mineral density (BMD) is a recognized feature of axial spondyloarthropathy (axSpA). However, the osteoproliferation inherent in axSpA can make traditional dual-energy x-ray absorptiometry assessment inaccurate, particularly in structurally advanced disease. As a result, much about osteoporosis in axSpA is unknown. There is a wide variation in prevalence figures for low BMD in the literature. There is also no consensus regarding risk factors for developing low BMD in axSpA. It is accepted that there is an excess of vertebral fractures in patients with axSpA, but the role of low BMD in contributing to this risk is virtually unknown. This article provides a comprehensive review of the current knowledge regarding low BMD in axSpA. It highlights our current BMD measurement techniques along with their potential pitfalls, and discusses the significance of BMD in vertebral fractures. It also identifies gaps in our knowledge and makes recommendations for future research.
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Affiliation(s)
- Gillian E Fitzgerald
- From the Department of Rheumatology, St. James's Hospital, Dublin, Ireland. .,G.E. Fitzgerald, MB, BCh, BAO, MRCPI, Rheumatology Specialist, Registrar, Department of Rheumatology, St. James's Hospital; F.D. O'Shea, MB, BCh, BAO, MRCPI, Consultant Rheumatologist and General Physician, Department of Rheumatology, St. James's Hospital.
| | - Finbar D O'Shea
- From the Department of Rheumatology, St. James's Hospital, Dublin, Ireland.,G.E. Fitzgerald, MB, BCh, BAO, MRCPI, Rheumatology Specialist, Registrar, Department of Rheumatology, St. James's Hospital; F.D. O'Shea, MB, BCh, BAO, MRCPI, Consultant Rheumatologist and General Physician, Department of Rheumatology, St. James's Hospital
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Hinze AM, Louie GH. Osteoporosis Management in Ankylosing Spondylitis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2016; 2:271-282. [PMID: 28620575 DOI: 10.1007/s40674-016-0055-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Low bone mineral density (BMD) is increasingly recognized as a common comorbid condition in ankylosing spondylitis (AS). As low BMD increases fracture risk, it is important to identify and treat low BMD in patients with AS who have been shown to be at increased risk for fractures above the population normal. Since low BMD occurs early in disease, we screen during the first year of diagnosis with dual energy x-ray absorptiometry (DXA). If patients are found to have osteoporosis by T-score of less than -2.5 or if their Z-score on DXA is more than two standard deviations below the mean, we initiate therapy with bisphosphonates in males and in females who are not planning any future pregnancies. While reduction in fracture risk with bisphosphonate therapy has not been clearly defined in patients with AS, reduction in vertebral and hip fractures has been well established in primary osteoporosis and thus it is our first line treatment. If there are contraindications to the use of bisphosphonates in the treatment of low BMD, we will consider the use of denosumab. If the patient is not receiving a TNF-alpha inhibitor (TNFi) and has active disease, we also favor early initiation of TNFi due to their positive effects on BMD though the outcome on reduction in vertebral fractures remains unclear. We counsel all patients regarding the importance of adequate intake of vitamin D and calcium per the Institute of Medicine guidelines. All patients should be encouraged to participate in weight-bearing activities with a focus on core strength and gait training.
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Affiliation(s)
- Alicia M Hinze
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL Building, Center Tower, Suite 4100, Baltimore, MD, 21224
| | - Grant H Louie
- Division of Rheumatology, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL Building, Center Tower, Suite 4100, Baltimore, MD, 21224
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Kilic E, Ozgocmen S. Bone mass in axial spondyloarthritis: A literature review. World J Orthop 2015; 6:298-310. [PMID: 25793171 PMCID: PMC4363813 DOI: 10.5312/wjo.v6.i2.298] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/14/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To review the published literature reporting bone loss in patients with axial spondyloarthritis (SpA) particularly those studies using dual X-ray absorptiometry (DXA) methods.
METHODS: This literature review examines the reported bone mass in patients with ax-SpA, particularly those using the DXA methods. The MEDLINE, Web of Science and Scopus databases were searched for relevant articles published between September 1992 and November 2013. Some of used search terms were ankylosing spondylitis (AS), SpA, spondyloarthropathy, bone loss, bone mass, osteopenia, bone mineral density, osteoporosis (OP), densitometry. Studies in which bone loss was investigated by using DXA in patients with SpA were eligible. Each article was reviewed and the key elements were noted.
RESULTS: There were 286 hits on MEDLINE, 200 on Web of Science and 476 on Scopus. After applying inclusion and exclusion criteria, we identified 55 articles in our systematic search. The sample size of the studies varied from 14 to 332 patients with SpA. The reported age range varied from 25 to 56 years in the reviewed studies. The symptom duration of patients with axSpA varied from 1.6 to 49 years. There were more males than females in these studies. Most of the recruited females were premenopausal women. Reported HLA-B27 positivity changed between 19% to 95%. The prevalence of OP and osteopenia in patients with SpA varied from 3%-47% to 5%-88%, respectively, in the included studies. In particular, the prevalence of OP and osteopenia ranged from 2.0%-47.0% and 5.0%-78.3%, respectively, in patients with AS. There are conflicting results regarding the relationship among disease activity, acute phase response and bone mass. Some studies suggest good correlation of bone mass with disease activity and acute phase reactants.
CONCLUSION: Bone loss may be determined in patients with axSpA at the lumbar spine or proximal femur even in the early phase of the disease and may be associated with inflammation (bone marrow edema) at the vertebral colon.
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Abstract
PURPOSE OF REVIEW To review the recent literature on the prevalence of osteoporosis, risk of vertebral fractures, and the recent advances in the treatment of osteoporosis in patients with ankylosing spondylitis (AS). RECENT FINDINGS Newer data suggest that the prevalence of osteoporosis is 25% and vertebral fractures is 10% in patients with AS. New advances in the field of osteoimmunology help explain the trabecular bone loss and generalized osteoporosis linked to increased expression of receptor activator of nuclear factor kappa B ligand (RANK-L) due to pro-inflammatory cytokines, and the simultaneous new bone formation (e.g. syndesmophytes) in areas of previous inflammation through suppressed Dickkopf-related protein 1 levels and increased WNT (wingless) signaling. SUMMARY Osteoporosis is a common problem for patients with AS. We recommend screening within 10 years of diagnosis. Suspecting and promptly recognizing vertebral fractures in patients with AS could prevent serious neurological complications. Although bisphosphonates and tumor necrosis factor-α inhibitors look promising, further prospective trials on the treatment of osteoporosis in AS are needed.
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High prevalence of low bone mineral density in patients within 10 years of onset of ankylosing spondylitis: a systematic review. Clin Rheumatol 2012; 31:1529-35. [PMID: 22706444 PMCID: PMC3483100 DOI: 10.1007/s10067-012-2018-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 05/28/2012] [Accepted: 05/30/2012] [Indexed: 02/07/2023]
Abstract
Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease. Decreased bone mineral density (BMD) is a common complication of AS, with a prevalence range of 19 to 62 %. Many studies have shown decreased BMD in AS with long disease duration, but only a few studies investigated BMD in early AS. The prevalence of decreased BMD in early disease stages of AS has not yet been clearly described, and for that reason, we reviewed the literature which describes the prevalence of decreased BMD in AS patients with a short disease duration (<10 years). In this review, we included articles which used the modified New York criteria for the diagnosis of AS, included patients with a disease duration of less than 10 years, and used the WHO criteria for osteopenia and osteoporosis. Decreased BMD was defined as a T score < −1.0, including both osteopenia and osteoporosis. For this review, only articles that acquired BMD data of lumbar spine and femoral neck by DXA were used. The literature search provided us 35 articles of which 7 matched all our criteria, and they will be further outlined in this review. The overall prevalence of decreased BMD of the articles reviewed is 54 % (n = 229/424) for lumbar spine and 51 % (n = 224/443) for femoral neck. The prevalence of osteopenia vs. osteoporosis for lumbar spine is 39 vs. 16 % and for femoral neck, 38 vs. 13 %. This review showed a high total prevalence of 51–54 % decreased BMD and 13–16 % osteoporosis in AS with a short disease duration. This high prevalence was not to be expected in a relatively young and predominantly male population. Further research is needed to determine the clinical relevance of this low BMD by investigating the relation between low BMD and vertebral and nonvertebral fractures at this early stage in AS.
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