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Szeremeta A, Jura-Półtorak A, Zoń-Giebel A, Olczyk K, Komosińska-Vassev K. Plasma Sclerostin Levels in Rheumatoid Arthritis Women on TNF-α Inhibitor Therapy. Pharmaceuticals (Basel) 2024; 17:666. [PMID: 38931334 PMCID: PMC11206420 DOI: 10.3390/ph17060666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
Rheumatoid arthritis (RA) is associated with significant systemic and local bone loss. The aim of this study was to assess whether or not 15-month tumor necrosis factor α inhibitor (TNFαI) therapy in combination with methotrexate (MTX) affects circulating levels of sclerostin (SOST) in female RA patients. Plasma levels of SOST were measured using immunoassays kits. Baseline SOST levels showed no significant differences between RA patients and control participants. Postmenopausal women with RA tended to have higher sclerostin levels than premenopausal woman with RA. After 15 months of treatment with TNFαI, plasma levels of SOST were decreased. Before starting biological therapy, circulating levels of SOST significantly correlated with the patient's age (p < 0.05) and the marker of inflammation, such as ESR (p < 0.05). Multivariate regression analysis showed that age was the only significant predictor for baseline SOST levels in women with RA (β = 0.008, p = 0.028, R2 model = 0.293). Moreover, a positive correlation between SOST levels and the 28 joint disease activity score value based on the erythrocyte sedimentation rate (DAS28-ESR) was found at baseline (p < 0.05), as well as after 15 months of biological therapy (p < 0.05). Thus, plasma SOST levels may be helpful for monitoring the efficacy of TNFαI treatment in RA patients. According to our results, TNFαI, in combination with MTX, has a beneficial effect on bone turnover with a significant reduction in bone metabolism marker SOST.
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Affiliation(s)
- Anna Szeremeta
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, Katowice, Jedności 8, 41-200 Sosnowiec, Poland; (A.J.-P.); (K.O.); (K.K.-V.)
| | - Agnieszka Jura-Półtorak
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, Katowice, Jedności 8, 41-200 Sosnowiec, Poland; (A.J.-P.); (K.O.); (K.K.-V.)
| | - Aleksandra Zoń-Giebel
- Department of Rheumatology and Rehabilitation, Specialty Hospital No. 1, Żeromskiego 7, 41-902 Bytom, Poland;
| | - Krystyna Olczyk
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, Katowice, Jedności 8, 41-200 Sosnowiec, Poland; (A.J.-P.); (K.O.); (K.K.-V.)
| | - Katarzyna Komosińska-Vassev
- Department of Clinical Chemistry and Laboratory Diagnostics, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, Katowice, Jedności 8, 41-200 Sosnowiec, Poland; (A.J.-P.); (K.O.); (K.K.-V.)
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2
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Zhao D, Wu L, Hong M, Zheng S, Wu X, Ye H, Chen F, Zhang D, Liu X, Meng X, Chen X, Chen S, Zhu J, Li J. DKK-1 and Its Influences on Bone Destruction: A Comparative Study in Collagen-Induced Arthritis Mice and Rheumatoid Arthritis Patients. Inflammation 2024; 47:129-144. [PMID: 37688661 DOI: 10.1007/s10753-023-01898-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/07/2023] [Accepted: 08/26/2023] [Indexed: 09/11/2023]
Abstract
Dickkopf-1 (DKK-1) has been considered a master regulator of bone remodeling. As precursors of osteoclasts (OCs), myeloid-derived suppressor cells (MDSCs) were previously shown to participate in the process of bone destruction in rheumatoid arthritis (RA). However, the role of DKK-1 and MDSCs in RA is not yet fully understood. We investigated the relevance between the level of DKK-1 and the expression of MDSCs in different tissues and joint destruction in RA patients and collagen-induced arthritis (CIA) mouse models. Furthermore, the CIA mice were administered recombinant DKK-1 protein. The arthritis scores, bone destruction, and the percentage of MDSCs in the peripheral blood and spleen were monitored. In vitro, the differentiation of MDSCs into OCs was intervened with recombinant protein and inhibitor of DKK-1. The number of OCs differentiated and the protein expression of the Wnt/β-catenin signaling pathway were explored. The level of DKK-1 positively correlates with the frequency of MDSCs and bone erosion in RA patients and CIA mice. Strikingly, recombinant DKK-1 intervention significantly exacerbated arthritis scores and bone destruction, increasing the percentage of MDSCs in the peripheral blood and spleen in CIA mice. In vitro experiments showed that recombinant DKK-1 promoted the differentiation of MDSCs into OCs, reducing the expression of β-catenin and TCF4 and increasing the expression of CyclinD1. In contrast, the DKK-1 inhibitor had the opposite effect. Our findings highlight that DKK-1 promoted MDSCs expansion in RA and enhanced the differentiation of MDSCs into OCs via targeting the Wnt/β-catenin pathway, aggravating the bone destruction in RA.
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Affiliation(s)
- Di Zhao
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Lisheng Wu
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Mukeng Hong
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Songyuan Zheng
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Xianghui Wu
- Laboratory Animal Research Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Haixin Ye
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Feilong Chen
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Dingding Zhang
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Xinhang Liu
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Xiangyun Meng
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Xiaoyun Chen
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Shixian Chen
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Junqing Zhu
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China
| | - Juan Li
- Department of Rheumatic & TCM Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, China.
- Department of Traditional Chinese Internal Medicine, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China.
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Abstract
Inflammation is among the major determinants of bone loss in chronic disease and aging. Bone metabolism is radically affected by inflammation with consequent bone loss and increased fracture risk. Various cytokines and mediators are involved in the pathogenesis of bone loss in inflammatory conditions. The present review has the aim of discussing the main pathways involved in the pathogenesis of bone loss in inflammatory diseases, focusing in particular on the Wnt system and its regulators. Literature review of studies published between inception to 2021 on osteoporosis and inflammation was conducted. I will discuss the epidemiology of osteoporosis and fractures in common inflammatory diseases. The molecular basis of bone loss related to inflammation will be discussed as well. Finally, the effects of various anti-inflammatory medications on bone metabolism will be reviewed.
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Affiliation(s)
- Giovanni Adami
- Rheumatology Unit, University of Verona, Pz Scuro 10, Verona, Italy.
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Vasiliadis ES, Evangelopoulos DS, Kaspiris A, Benetos IS, Vlachos C, Pneumaticos SG. The Role of Sclerostin in Bone Diseases. J Clin Med 2022; 11:jcm11030806. [PMID: 35160258 PMCID: PMC8836457 DOI: 10.3390/jcm11030806] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 12/26/2022] Open
Abstract
Sclerostin has been identified as an important regulator of bone homeostasis through inhibition of the canonical Wnt-signaling pathway, and it is involved in the pathogenesis of many different skeletal diseases. Many studies have been published in the last few years regarding sclerostin’s origin, regulation, and mechanism of action. The ongoing research emphasizes the potential therapeutic implications of sclerostin in many pathological conditions with or without skeletal involvement. Antisclerostin antibodies have recently been approved for the treatment of osteoporosis, and several animal studies and clinical trials are currently under way to evaluate the effectiveness of antisclerostin antibodies in the treatment of other than osteoporosis skeletal disorders and cancer with promising results. Understanding the exact role of sclerostin may lead to new therapeutic approaches for the treatment of skeletal disorders.
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Affiliation(s)
- Elias S. Vasiliadis
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, 16541 Athens, Greece; (D.-S.E.); (I.S.B.); (C.V.); (S.G.P.)
- Correspondence: ; Tel.: +30-21-3208-6000
| | - Dimitrios-Stergios Evangelopoulos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, 16541 Athens, Greece; (D.-S.E.); (I.S.B.); (C.V.); (S.G.P.)
| | - Angelos Kaspiris
- Laboratory of Molecular Pharmacology, Division for Orthopaedic Research, School of Health Sciences, University of Patras, 26504 Rion, Greece;
| | - Ioannis S. Benetos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, 16541 Athens, Greece; (D.-S.E.); (I.S.B.); (C.V.); (S.G.P.)
| | - Christos Vlachos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, 16541 Athens, Greece; (D.-S.E.); (I.S.B.); (C.V.); (S.G.P.)
| | - Spyros G. Pneumaticos
- 3rd Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, KAT Hospital, 16541 Athens, Greece; (D.-S.E.); (I.S.B.); (C.V.); (S.G.P.)
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Gharbia O, Hegazy A, Elhelaly R, ElGhaweet A. Serum sclerostin in rheumatoid-induced osteoporosis. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2020. [DOI: 10.1186/s43166-020-00015-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Rheumatoid arthritis (RA) is characterized by presence of localized and generalized osteoporosis. The mechanism of decreased bone mass is complex and multifactorial, a possible mechanism behind increased bone loss in RA is upregulation of sclerostin. The aim of this work was to evaluate serum sclerostin level in RA patients and its relation with bone mineral density (BMD) and disease activity.
Results
Serum sclerostin level in RA patients was significantly higher than the controls (p < 0.001). Osteopenia and osteoporosis were more prevalent in RA patients (22.5% and 7.5% respectively) compared to controls (15% and 2.5% respectively) (p = 0.006). Serum sclerostin level was significantly correlated with tender joint count (p = 0.014), swollen joint count (p = 0.036), erythrocytes sedimentation rate (p = 0.010), C reactive protein serum level (p = 0.025), disease activity score (DAS) 28-ESR (p = 0.018), DAS28-CRP (p = 0.005), and radiological modified Sharp erosion score (p = 0.049). The correlation of serum sclerostin level in RA patients with BMD and with T-score in all sites revealed an inverse relationship with p values insignificant.
Conclusion
Serum sclerostin is a major player in bone metabolism as a negative regulator of bone growth through inhibition of Wnt signaling that is largely influenced by the disease activity. Controlling the disease activity is a major factor for prevention of local as well as generalized osteoporosis and is essential for the reparative local and systemic bone health.
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Singh A, Gupta MK, Mishra SP. Study of correlation of level of expression of Wnt signaling pathway inhibitors sclerostin and dickkopf-1 with disease activity and severity in rheumatoid arthritis patients. Drug Discov Ther 2019; 13:22-27. [PMID: 30880318 DOI: 10.5582/ddt.2019.01011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study was done with aim to assess the serum sclerostin and dickkopf-1 (DKK-1) level in patients of rheumatoid arthritis (RA) and to correlate their level with disease activity and bone mineral density. Fifty patients of RA and equal age and sex matched healthy controls were included in the study. Patients were evaluated clinically and investigated with routine blood tests along with rheumatoid factor (RF), anti-citrullinated protein antibody (anti-CCP2), radiographs and bone mineral density (BMD). Serum sclerostin and DKK-1 levels of both cases and controls was assayed by using enzyme-linked immunosorbent assay (ELISA) assay [RayBio®, Georgia, USA with coefficient of variation percent (CV %), < 10%] and compared with disease activity and bone mineral density. Disease activity was measured by Disease Activity Score 28 (DAS28) along with Modified Health Assessment Questionnaire (MHAQ) score. Mean serum sclerostin and DKK-1 was significantly higher in study group as compared to control group. Serum sclerostin showed significant correlation with disease activity scores (DAS score and MHAQ score), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level. Serum sclerostin at level of 394 pg/mL was found to have diagnostic significance with sensitivity of 100% and specificity of 90%. DKK-1 level shows significantly positive correlation with larson score which denotes radiological progression (r value 0.468; p value 0.001). More studies with larger sample size of RA patients are needed for better determination of the role of sclerostin and DKK-1 in RA. Also, the correlation of these and other bone turn over markers will help decipher their role with disease progression in RA patients.
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Affiliation(s)
- Anup Singh
- Department of Geriatric Medicine, Institute of Medical Sciences, Banaras Hindu University
| | - Manish Kumar Gupta
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University
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7
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Gaudio A, Fiore V, Rapisarda R, Sidoti MH, Xourafa A, Catalano A, Tringali G, Zanoli L, Signorelli SS, Fiore CE. Sclerostin is a possible candidate marker of arterial stiffness: Results from a cohort study in Catania. Mol Med Rep 2017; 15:3420-3424. [PMID: 28339088 DOI: 10.3892/mmr.2017.6390] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 02/13/2017] [Indexed: 11/06/2022] Open
Abstract
Osteoporosis and cardiovascular disease are worldwide public health issues. Recent evidence indicates a possible role of the canonical Wnt/β-catenin signalling pathway as a common mediator between these two diseases. The aim of the present study was to investigate the relationship between serum concentrations of sclerostin and Dkk1, two extracellular inhibitors of Wnt/β-catenin signalling, with carotid intima-media thickness (CIMT) and with arterial stiffness, evaluated by measuring the pulse wave velocity (PWV) in an ambulatory population of adults. To this aim, 67 subjects were recruited in the 'Atherosclerosis and osteoporosis: identification of common pathogenetic factors' investigation. Serum sclerostin levels correlated positively with CIMT (r=0.314, p=0.03) and inversely with the augmentation index, a marker of arterial stiffness (r=-0.286, p<0.05), whereas Dkk1 did not. Moreover, in a multivariate linear regression model, sclerostin [β -0.1472; p=0.0023; standard error (SE)=0.04620] was an independent predictor of PWV in the study subjects. Our study shows that, following adjustment for confounders, sclerostin is an independent predictor of arterial stiffness in an ambulatory population, whereas Dkk1 is not.
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Affiliation(s)
- Agostino Gaudio
- Department of Clinical and Experimental Medicine, University of Catania, I-95123 Catania, Italy
| | - Valerio Fiore
- Department of Clinical and Experimental Medicine, University of Catania, I-95123 Catania, Italy
| | - Rosario Rapisarda
- Department of Clinical and Experimental Medicine, University of Catania, I-95123 Catania, Italy
| | - Maria Helga Sidoti
- Department of Clinical and Experimental Medicine, University of Catania, I-95123 Catania, Italy
| | - Anastasia Xourafa
- Department of Clinical and Experimental Medicine, University of Catania, I-95123 Catania, Italy
| | - Antonino Catalano
- Department of Clinical and Experimental Medicine, University of Messina, I-98125 Messina, Italy
| | - Giovanni Tringali
- Medical and Environmental Research Institute (IRMA), I-95024 Acireale, Italy
| | - Luca Zanoli
- Department of Clinical and Experimental Medicine, University of Catania, I-95123 Catania, Italy
| | | | - Carmelo Erio Fiore
- Department of Clinical and Experimental Medicine, University of Catania, I-95123 Catania, Italy
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Weivoda MM, Youssef SJ, Oursler MJ. Sclerostin expression and functions beyond the osteocyte. Bone 2017; 96:45-50. [PMID: 27888056 PMCID: PMC5328839 DOI: 10.1016/j.bone.2016.11.024] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 11/17/2016] [Accepted: 11/21/2016] [Indexed: 11/24/2022]
Abstract
Sclerostin, the product of the SOST gene, is a secreted inhibitor of Wnt signaling that is produced by osteocytes to regulate bone formation. While it is often considered an osteocyte-specific protein, SOST expression has been reported in numerous other cell types, including hypertrophic chondrocytes and cementocytes. Of interest, SOST/sclerostin expression is altered in certain pathogenic conditions, including osteoarthritis and rheumatic joint disease, and it is unclear whether sclerostin plays a protective role or whether sclerostin may mediate disease pathogenesis. Therefore, as anti-sclerostin antibodies are being developed for the treatment of osteoporosis, it is important to understand the functions of sclerostin beyond the regulation of bone formation.
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Affiliation(s)
- Megan M Weivoda
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Mayo Clinic, USA.
| | - Stephanie J Youssef
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Mayo Clinic, USA
| | - Merry Jo Oursler
- Division of Endocrinology, Metabolism, Nutrition & Diabetes, Mayo Clinic, USA
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El-Bakry S, Saber N, Zidan H, Samaha D. Sclerostin as an innovative insight towards understanding Rheumatoid Arthritis. EGYPTIAN RHEUMATOLOGIST 2016. [DOI: 10.1016/j.ejr.2015.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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Sclerostin serum levels in patients with systemic autoimmune diseases. BONEKEY REPORTS 2016; 5:775. [PMID: 26909149 DOI: 10.1038/bonekey.2016.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 12/16/2015] [Indexed: 12/19/2022]
Abstract
Systemic autoimmune diseases (SADs) are associated with lower bone mass and an increased risk of fractures. Sclerostin has a pivotal role in bone metabolism. Available data on circulating sclerostin levels in healthy subjects are limited, whereas those in SAD patients are absent. Our objective was to determine circulating sclerostin concentrations in systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and Crohn's disease (CD) patients, and to analyze the factors associated with sclerostin concentrations. In this cross-sectional case-control study, serum sclerostin levels were measured in 38 SLE patients, 20 CD patients, 8 SSc patients and 20 healthy controls using a sclerostin ELISA. The mean values of the sclerostin (95% confidence interval) were 35.36 pmol l(-1) (12-101) in patients and 33.92 pmol l(-1) (2.31-100) in control subjects. The mean sclerostin value was 36.4 pmol l(-1) (22.1-48.5) in SLE patients, 26.7 pmol l(-1) (17.3-36.3) in CD patients and 51.8 pmol l(-1) (26.5-77.1) in SSc patients (P=0.001). Serum sclerostin levels were positively correlated with age (P<0.001), body mass index (BMI) (P=0.01) and lumbar spine Z-score (P=0.001) and negatively with creatinine clearance (P=0.001). Glucocorticoid treatment did not affect sclerostin levels. Sclerostin levels seem to have a heterogeneous pattern in different autoimmune diseases. SLE and SSc patients did not differ from healthy controls regarding sclerostin levels. The CD group had significantly lower values compared with SSc patients. Factors associated with sclerostin levels in autoimmune diseases seem to be the same than in the general population.
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11
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Chapurlat RD, Confavreux CB. Novel biological markers of bone: from bone metabolism to bone physiology. Rheumatology (Oxford) 2016; 55:1714-25. [DOI: 10.1093/rheumatology/kev410] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Indexed: 12/14/2022] Open
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