Evaluation of risk factors of vertebral fracture in Japanese female patients with glucocorticoid-induced osteoporosis

Multiple thoracolumbar compression fractures induced by glucocorticoid-induced osteoporosis and cachexia in a young adult female patient with systemic lupus erythematosus: a case report with a 5-year follow-up

BACKGROUND

High doses of glucocorticoids and severe weight loss can cause osteoporosis. We present a case of glucocorticoid-induced osteoporosis and cachexia in an 18-year-old woman who experienced severe appetite loss leading to weight loss, amenorrhea, and multiple thoracolumbar compression fractures.

CASE PRESENTATION

The patient had been receiving high-dose glucocorticoid treatment for systemic lupus erythematosus since the age of 13 and developed unexplained appetite loss since the age of 16. She subsequently developed thoracolumbar compression fractures, which necessitated repeated hospitalization. Gradual glucocorticoid tapering using belimumab and weight regain were achieved through high-calorie nutrition administration via the central vein, which helped the patient overcome her cachexic state. Romosozumab administration increased bone mineral density.

CONCLUSION

Long-term administration of glucocorticoids may lead to osteoporosis and cachexia, resulting in amenorrhea, especially in young adults. Approaches that taper glucocorticoids and promote weight regain may be helpful in the management of such patients.

Drug-induced osteoporosis and mechanisms of bone tissue regeneration through trace elements

Osteoporosis is associated with an imbalance in bone formation, with certain drugs used in disease treatment being implicated in its development. Supplementation with trace elements may contribute to bone regeneration, offering an alternative approach by enhancing bone mineral density (BMD) and thereby thwarting the onset of osteoporosis. This review aims to assess the mechanisms through which trace elements such as copper (Cu), iron (Fe), selenium (Se), manganese (Mn), and zinc (Zn) are linked to increased bone mass, thus mitigating the effects of pharmaceuticals. Our findings underscore that the use of drugs such as aromatase inhibitors (AIs), proton pump inhibitors (PPIs), antiretrovirals, glucocorticoids, opioids, or anticonvulsants can result in decreased BMD, a primary contributor to osteoporosis. Research indicates that essential elements like Cu, Fe, Se, Mn, and Zn, through various mechanisms, can bolster BMD and forestall the onset of the disease, owing to their protective effects. Consequently, our study recommends a minimum daily intake of these essential minerals for patients undergoing treatment with the aforementioned drugs, as the diverse mechanisms governing the effects of trace elements Cu, Fe, Mn, Se, and Zn facilitate bone remodeling.

Pyoderma gangrenosum after surgery for forefoot deformity in a patient with rheumatoid arthritis: A case report

Pyoderma gangrenosum (PG) is a rare inflammatory skin disease characterised by skin ulcers that are associated with autoimmune diseases. Although the effectiveness of immunosuppression with glucocorticoids and tumour necrosis factor inhibitors in treating PG has been reported, the utility of negative-pressure wound therapy (NPWT) for severe ulcerative lesions in patients with PG remains controversial. Herein, we report the case of a 76-year-old woman with rheumatoid arthritis who developed PG after undergoing surgery for a forefoot deformity. The patient showed improvement in deep ulcer lesions through NPWT while receiving treatment with abatacept and systemic glucocorticoids. Subsequent topical glucocorticoid therapy led to the remission of the PG. This case suggests that NPWT, when used under immunosuppressive conditions, does not exacerbate the pathergy and may be beneficial for treating severe ulcerative PG.

Increasing baseline aortic valve peak flow velocity is associated with progression of aortic valve stenosis in osteoporosis patients-a possible link to low vitamin D status

PURPOSE

The purpose of this study was to investigate the morphological characteristics of the aortic valve and identify factors associated with the progression of aortic valve stenosis (AS) in osteoporosis patients.

METHODS

In this single-center prospective cohort study, we recruited 10 patients (mean age: 75 ± 7 years, 90% female) who were taking anti-resorptive medicines at the outpatient clinic of University of Miyazaki Hospital, Japan. Baseline assessments, including transthoracic echocardiogram, blood sampling, and dual energy X-ray absorptiometry, were performed. Follow-up assessments were conducted at 6, 12, 18, and 24 months.

RESULTS

During the 2-year follow-up, three patients with aortic valve peak flow velocity (AV PFV) ≥2 m/s at baseline developed moderate AS, which is defined as AV PFV ≥3 m/s. However, seven patients with AV PFV <2 m/s did not exhibit any progression of AS. There were significant variations in terms of bone mineral density, T-score values, and biomarkers associated with bone turnover (i.e., bone alkaline phosphatase, tartrate-resistance acid phosphatase-5b) among the enrolled patients, but none of these factors were found to be associated with the progression of AS. All patients exhibited low vitamin D status, with a median level of 16.1 ng/mL (25th percentile, 9.7 ng/mL; 75th percentile, 23 ng/mL). The baseline levels of AV PFV values were negatively correlated with 25-hydroxyvitamin D levels, determined by univariate linear regression analysis (beta coefficient = -0.756, 95% confidence interval, -0.136 ̶ -0.023, p = 0.011).

CONCLUSION

Our data suggest that low vitamin D status might be a potential risk factor for the progression of AS in osteoporosis patients undergoing treatment with anti-resorptive medicines. Elderly patients with osteoporosis patients exhibited a subset of aortic valve stenosis. Our data suggest that the baseline aortic valve peak flow velocity predicts the progression of aortic valve stenosis, and there might be an association between the progression and the co-existing low vitamin D status in these patients.

[Analysis of cervical instability and clinical characteristics in treatment-naive rheumatoid arthritis patients]

OBJECTIVE

To study the proportion of cervical spine instability in treatment-naive rheumatoid arthritis (RA) patients, to investigate the associated neck symptoms, and to analyze the clinical characteristics in treatment-naive RA patients and treated RA patients.

METHODS

RA patients who underwent cervical spine X-ray imaging from the Department of Rheumatology and Immunology of Peking University Third Hospital and Peking University Shenzhen Hospital from August 2015 to October 2019 and had clinical records of medication administration were included. Clinical and laboratory data including cervical symptoms and X-ray imaging data of cervical spine were collected. The constituent ratio of cervical spine instability in treatment-naive RA patients was statistically analyzed. The clinical data and laboratory data were analyzed by t-test, u-test and chi square to explore the clinical characteristics of the treatment-naive RA patients with cervical instability.

RESULTS

Of the 408 RA patients, 105 patients were treatment-naive. Of the 105 treatment-naive patients, 82.9% (87/105) were female, with an average age of (52±14) years, the median duration of the disease was 24 months, the shortest history was 2 weeks, and the longest history was 30 years. 28.6% (30/105) of the treatment-naive RA patients showed cervical spine instability. The prevalence of cervical instability was 13.6% in the treatment-naive RA patients with disease duration less than 24 months. Among them, there were no significant differences in neck symptoms between cervical spine instability group and none cervical spine instability group. The patients with cervical spine instability had a longer duration of disease [60 (18, 180) months vs.16 (8, 51) months], a higher proportion of peripheral joint deformity (63.3%vs.21.3%), and a lower hemoglobin [(106.90±21.61) g/L vs. (115.77±14.69) g/L]. There was no significant difference in the occurrence of cervical instability in the treatment-naive RA patients compared with treated RA patients. Among the RA patients with cervical instability, there was no statistically significant difference in the composition of each type between the patients with treatment-naive RA and patients with treated RA, except for a shorter duration of disease [120.0 (72.0, 240.0) months vs. 60.0 (27.0, 167.5) months].

CONCLUSION

28.6% of treatment-naive RA patients showed cervical spine instability. Cervical instability was also common in RA patients with a duration less than 24 months. There was no significant correlation between cervical instability and neck symptoms. Patients with cervical spine instability had a long-term disease, a higher proportion of peripheral joint deformity and a lower hemoglobin. Controlling the condition of RA early may help to control the progression of cervical involvement in patients with RA.

Interstitial Lung Disease in a Woman with Rheumatoid Arthritis Treated with Denosumab: A Case Report

The present report describes the case of an 84-year-old female Japanese patient with rheumatoid arthritis (RA) who experienced exacerbation of interstitial lung disease (ILD) after denosumab (Dmab) treatment. The onset of RA occurred in 2008, and the patient had been treated with intravenous or subcutaneous injection of tocilizumab (TCZ) since 2009. In July 2013, she experienced a lumbar vertebral fracture and began treatment with 60-mg Dmab injection every 6 months in January 2014. The patient had a history of mild ILD and was evaluated for ILD by chest computed tomography (CT) imaging prior to the start of Dmab use. The vertebral fracture did not recur after the initiation of Dmab treatment, and her osteoporosis was successfully treated. However, she expressed a concern of exacerbations of cough and respiratory discomfort that had occurred since September 2019. The chest CT image in November 2015 showed minor ILD progression, whereas the image in September 2019 showed severe exacerbation of ILD. To treat this exacerbation, 10 mg of methylprednisolone (mPSL) and 2.5 mg of tacrolimus (TAC) were administered, and Dmab was discontinued. The patient was subsequently switched to oral bisphosphonate. The patient's respiratory discomfort and the finding of interstitial lung lesion in CT imaging improved after Dmab discontinuation. This case showed that exacerbation of ILD may occur after Dmab treatment, and physicians should consider the risks of Dmab-related ILD in patients with RA complicated by ILD.

Effect of denosumab switched from bisphosphonates in preventing joint destruction in postmenopausal rheumatoid arthritis patients with anti-cyclic citrullinated peptide antibodies

INTRODUCTION

This study aimed to determine the effects of denosumab treatment on the joint destruction of Japanese females with rheumatoid arthritis (RA) and anti-cyclic citrullinated peptide (CCP) antibodies.

MATERIALS AND METHODS

This retrospective longitudinal study included 56 patients treated with denosumab and 50 patients treated with bisphosphonate. All participants were positive for anti-CCP antibodies. All patients also had a history of osteoporosis treatment with bisphosphonate, which was either continued or switched to 60 mg of subcutaneous denosumab injection every 6 months. To assess the progression of joint destruction, hand and foot radiographs were taken, and changes in modified total Sharp score (mTSS), erosion score (ERO), and joint space narrowing score (JSN) were evaluated at 12 months and 24 months. The changes in BMD of the lumbar spine and hip were also assessed at 12 months.

RESULTS

At 12 months, there were significant differences in the change of ERO (p = 0.015) and mTSS (p = 0.01). Similarly, there were significant differences in the change of ERO (p = 0.013) and mTSS (p = 0.003) at 24 months. In contrast, no significant difference was observed in the changes of JSN and clinical parameters. There were significant differences in the changes in BMD in the femoral neck (p = 0.011) and total hip (p = 0.012).

CONCLUSION

Denosumab treatment might be effective for the inhibition of bone erosion progression in the patients with RA, and it potentially contributes to the treatment of osteoporosis and prevention of destructive arthritis in patients with switching treatment from bisphosphonate.

The Effect of Teriparatide for the Treatment of Multiple Spontaneous Clinical Vertebral Fractures after Discontinuation of Denosumab in a Female Patient with Rheumatoid Arthritis: A Case Report

Discontinuation of denosumab is associated with the risk of rebound in bone turnover and rebound-associated spontaneous clinical vertebral fractures. This case report presents an 86-year-old woman with rheumatoid arthritis who experienced rebound-associated spontaneous clinical vertebral fractures at 9 months after denosumab discontinuation. Following 5-year bisphosphonate treatment, the patient had 9 injections of 60-mg denosumab every 6 months. Because of tooth extraction, denosumab treatment was discontinued, and raloxifene was administered. At 9 months after the last denosumab injection, the patient experienced severe low back pain. Magnetic resonance imaging (MRI) and radiograph demonstrated clinical fracture at the fourth lumbar vertebra. MRI performed at 3 months after first fracture showed two additional fractures at the second and third lumbar vertebrae. Teriparatide was administered for management of rebound-associated spontaneous clinical, multiple vertebral fractures. Teriparatide was effective for accelerating the fracture healing and suppressing the occurrence of new fractures. However, 2-year treatment of teriparatide did not have suppressive effect of rebound in bone turnover and general bone loss. This case suggested that teriparatide was effective for suppression of new rebound-associated spontaneous clinical vertebral fractures, but not effective in prevention of general bone loss after denosumab discontinuation.