Bone mineral density and vertebral fractures in patients with systemic lupus erythematosus: A systematic review and meta-regression

Factors affecting bone mineral density in children and adolescents with systemic lupus erythematosus

PURPOSE

Patients with juvenile-onset systemic lupus erythematosus (JSLE) are at a high risk of entering adulthood with disease-related morbidities like reduced bone mass and osteoporosis. This study aimed to evaluate the clinical characteristics of JSLE and to analyze the factors associated with low bone mineral density (BMD) in these patients.

METHODS

Children and adolescents diagnosed with JSLE at a single institution in Korea were included. Demographic, clinical, and laboratory data as well as details about the use of glucocorticoids (GCs) and disease-modifying antirheumatic drugs were collected. The lumbar spine (LS) BMD z-score was measured using dual energy x-ray absorptiometry, and lateral thoracolumbar spine radiographs were collected.

RESULTS

A total of 29 patients with JSLE were included in this study. Of these patients, 7 had a BMD z-score of -2.0 or lower and were designated as the low BMD group. The differences in the clinical parameters and treatment variables between the low BMD and non-low BMD groups were compared. Higher cumulative GC dose, longer GC exposure, and higher cumulative hydroxychloroquine (HCQ) dose were all associated with low BMD; among them, the main factor was the duration of GC exposure. There was no significant correlation between BMD and clinical profile, disease activity, or bone-metabolism markers.

CONCLUSION

The duration of GC exposure, cumulative GC dose, and cumulative HCQ dose were risk factors for low BMD in patients with JSLE, with the main factor being the duration of GC exposure. Thus, patients with JSLE should be routinely monitored for low BMD and potential fracture risks, and GC-sparing treatment regimens should be considered.

The Relationship Between Systemic Lupus Erythematosus and Osteoporosis Based on Different Ethnic Groups: a Two-Sample Mendelian Randomization Analysis

The previous observational studies could not overcome the effects of confounding variables and reverse causality. We aimed to determine whether there is a causal relationship between systemic lupus erythematosus and osteoporosis in East Asian and European populations, respectively, by two-sample Mendelian Randomization analysis. We obtained and downloaded data from publicly available genome-wide association study databases and analyses for East Asian and European populations, including systemic lupus erythematosus (SLE), osteoporosis (OP), multisite bone mineral density (BMD), and OP with fracture. After screening for instrumental single-nucleotide polymorphisms (SNPs) significantly correlated to SLE, the inverse-variance weighted (IVW) method was used for calculating the ratio and 95% confidence interval, besides utilizing MR-Egger, weighted median, and weighted mode to assess the robustness of the primary outcome. Moreover, multiple analyses, including MR-PRESSO, MR-Egger intercept, Cochran's Q test, as well as "leave-one-out" sensitivity, were used for evaluating horizontal pleiotropy, heterogeneity, and stability. Finally, we exchanged exposure and outcome and performed a reverse MR analysis. IVW (OR = 1.05, 95% CI = 1.01-1.09, P = 0.009) indicated a significant positive correlation between genetically predicted SLE and OP in East Asians. Furthermore, neither heterogeneity nor horizontal pleiotropy was observed. In Europe, there was no significant genetically predicted causal relation between SLE and OP. Bi-directional MR analysis showed no reverse causality between SLE and OP. In the East Asian population, genetically predicted SLE may have had a positive causal relationship with OP. In Europe, there is insufficient evidence for a potential causal relation between SLE and OP or BMD and fracture, and the correlations currently observed may be attributed to a variety of confounder variables.

Systemic lupus erythematosus and damage: What has changed over the past 20 years?

The young age of onset and chronic/relapsing nature of systemic lupus erythematosus (SLE) make SLE patients prone to develop and accrue organ damage as a result of long-standing disease activity and side effects of treatment. There is a growing interest in objectifying damage and identifying its risk factors. Still, the lack of therapeutic alternatives has led to difficulties in avoiding immunosuppressives particularly corticosteroids, which have been implicated in a large spectrum of organ damage in SLE patients. Moreover, it continues to be very challenging to determine what actually causes damage in different organ-systems. Cardiovascular disease continues to be one of the leading types of damage in patients with SLE, reported as early as 1976. Since then, many researchers have focused on identifying SLE or treatment-related and traditional risk factors. The same considerations are valid for other conditions, such as the occurrence of metabolic syndrome, osteoporosis, avascular necrosis, susceptibility to infections, etc. On the other hand, diverse risk factors contribute to the development of chronic kidney disease (CKD) in SLE. Most evidence suggests that high initial levels of serum creatinine, hypocomplementemia, nephrotic range proteinuria, concomitant uncontrolled hypertension, Black and Hispanic ancestry, non-adherence to treatment, and biopsy findings such as diffuse proliferative lupus nephritis (LN), a high chronicity index, tubular atrophy, and tubulointerstitial inflammation are risk factors for progression to end stage renal disease (ESRD) in LN. While cardiovascular disease, CKD and infections are leading causes of mortality in patients with SLE, hospitalizations are caused mostly by SLE disease flares and infections. Cognitive impairment and mood disorders are common in SLE but continue to impose a challenge on how to measure, manage and decipher the underlying pathogenesis. Nevertheless, they have a great impact on SLE patients' health-related quality of life (HRQoL) and social functioning. Also, skin manifestations, such as alopecia and scaring, cataracts, and sicca symptoms result in a significant decrease in HRQoL. In light of recent developments in SLE treatment, we can expect to enter a period of new-age targeted therapies that will enable us to reduce disease activity and glucocorticoid usage further and positively alter the trajectory of damage development and accrual in SLE.

Low disease activity state associated with fewer incident vertebral fractures in Mestizo women with systemic lupus erythematosus

BACKGROUND

Low disease activity state (LDAS) has been linked to a significant reduction in flares and damage accrual in patients with systemic lupus erythematosus (SLE); however, the effect of LDAS on the risk of vertebral fractures (VFs) in subjects with SLE is unknown, considering that low bone mineral density (BMD) and VF are frequent in SLE.

OBJECTIVE

to evaluate whether achieving LDAS ≥50% of the observation time prevents new VF and BMD changes in Mestizo women.

METHODS

We carried out a longitudinal, observational, and retrospective study. Mestizo women with SLE were included for a median of an 8-year follow-up. LDAS was described as Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score ≤4, prednisone ≤7.5 mg/day, and stable immunosuppressive therapies. BMD measurements and lateral thoracic and lumbar radiographs for a semiquantitative analysis for VF were assessed at baseline and during the follow-up. Uni- and multivariable interval-censored survival regression models were carried out.

RESULTS

We included 110 patients: 35 (31.8%) had new VF. A total of 56 patients (50.1%) achieved LDAS ≥50% of the time during the follow-up and achieved a significantly lesser risk of incident VF (HR = 0.16; 95% CI, 0.06-0.49). After adjusting by age, BMI, menopause, prevalent VF, baseline BMD, cumulative glucocorticoid use, and anti-osteoporotic therapy, LDAS-50 was significantly related to a decrease in the risk of a new VF (HR = 0.39; 95% CI, 0.16-0.98). There was no association between LDAS and BMD measurement changes. When only patients on LDAS but not in remission (n = 43) were evaluated for the risk of incident VF, both uni- and multivariate analyses were significant (HR = 0.12; 95 CI, 0.04-47; p = 0.001, and HR = 0.26; 95% CI, 0.7-0.88; p = 0.03).

CONCLUSIONS

LDAS ≥50% of the time was significantly associated with a diminished risk of new VF in Mestizo women with SLE, even in patients not in remission. However, LDAS did not help modify BMD changes over time.

Di-(2-ethylhexyl) phthalate exposure links to inflammation and low bone mass in premenopausal and postmenopausal females: Evidence from ovariectomized mice and humans

OBJECTIVE

Phthalates induce inflammation and are ubiquitously used in daily life. We aim to study the impact of di-(2-ethylhexyl) phthalate (DEHP) exposure on inflammation and osteoporosis in premenopausal and postmenopausal females.

METHODS

Female 8-week-old C57BL/6JNarl mice received an ovariectomy (OVX) or a sham operation and were fed with DEHP or vehicle by oral gavage for 4 or 8 weeks. Their femurs were isolated for micro-computed tomography, and their serum was collected for inflammatory cytokine assays. Correlations between urinary phthalate metabolites and the lumbar spine bone mineral density (BMD) in premenopausal and postmenopausal volunteers were performed.

RESULTS

Among the OVX mice treated for 4 weeks, significant lower bone volume, bone volume/tissue volume, and trabecular number but significant higher trabecular bone pattern factor and structure model index were identified in the mice treated with DEHP than with vehicle. The OVX mice treated with DEHP for 4 weeks had significantly higher serum interleukin (IL)-1β, IL-10, IL-17A, interferon (IFN)-γ, tumor necrosis factor (TNF)-α, and Dickkopf-1 levels than those treated with vehicle. The sham mice treated with DEHP for 8 weeks showed an impaired femur trabecular microstructure and had significantly higher serum IL-1β, IL-6, IL-10, IL-17A, IFN-γ, and TNF-α than those treated with vehicle. DEHP metabolites were inversely correlated with the BMD of premenopausal women and the T-score of postmenopausal women.

CONCLUSION

DEHP treatment in OVX and sham mice results in osteoporosis and impairs the microstructure of the femur trabecula through inflammation. Phthalate exposure negatively affects the bone mass in both premenopausal and postmenopausal women. Thus, long-term avoidance is suggested.

Bone Involvement in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by a wide variability of clinical manifestations due to the potential involvement of several tissues and internal organs, with a relapsing and remitting course. Dysregulation of innate and adaptive immune systems, due to genetic, hormonal and environmental factors, may be responsible for a broad spectrum of clinical manifestations, affecting quality of life, morbidity and mortality. Bone involvement represents one of the most common cause of morbidity and disability in SLE. Particularly, an increased incidence of osteoporosis, avascular necrosis of bone and osteomyelitis has been observed in SLE patients compared to the general population. Moreover, due to the improvement in diagnosis and therapy, the survival of SLE patient has improved, increasing long-term morbidities, including osteoporosis and related fractures. This review aims to highlight bone manifestations in SLE patients, deepening underlying etiopathogenetic mechanisms, diagnostic tools and available treatment.

Dilemmas in the Management of Osteoporosis in Younger Adults

Osteoporosis in premenopausal women and men younger than 50 years is challenging to diagnose and treat. There are many barriers to optimal management of osteoporosis in younger adults, further enhanced by a limited research focus on this cohort. Herein we describe dilemmas commonly encountered in diagnosis, investigation, and management of osteoporosis in younger adults. We also provide a suggested framework, based on the limited available evidence and supported by clinical experience, for the diagnosis, assessment, and management of osteoporosis in this cohort. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Choroidal Thickness in Relation to Bone Mineral Density with Swept-Source Optical Coherence Tomography

Purpose

To assess whether bone mineral density, indicated by the lumbar X-ray scan, is related to changes in choroid thickness in normal subjects.

Methods

This study included 355 patients with decreased bone mineral density and 355 age- and sex-matched healthy subjects. Lumbar BMD was measured by dual-energy X-ray absorptiometry (DXA). Choroidal thickness was measured using swept-source optical coherence tomography (SS-OCT). Blood pressure (BP), cholesterol, triglyceride (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) were recorded on the same day.

Results

There was a significant difference in average choroidal thickness between low BMD subjects and normal subjects (p=0.003). The BP, cholesterol, triglyceride, HDL, and LDL showed no significant difference between the two groups. The correlations showed that average choroidal thicknesses were associated with BMD in the entire population (r = 0.125, p=0.001).

Conclusion

The choroidal thickness is thinner in low BMD populations compared with normal individuals. There is a strong positive correlation of choroidal thickness with BMD, regardless of age, sex, and other demographic and clinical factors.

A Retrospective Analysis of Longitudinal Changes in Bone Mineral Density in Women with Systemic Lupus Erythematosus

Most prospective studies of bone mineral density (BMD) in systemic lupus erythematosus (SLE) patients have been of relatively short duration, with a maximum of 6 years. To describe long-term changes in BMD in women with SLE and identify risk factors associated with BMD loss. We retrospectively evaluated 132 adult Mexican-Mestizo women with SLE who underwent dual X-ray absorptiometry (DXA). Demographic and clinical data were collected and BMD at the lumbar spine (L1-L4) and total hip were collected at baseline and during the follow up. At baseline, the mean age of participants was 43.4 ± 12.5 years, 50.8% had osteopenia and 11% osteoporosis. The median follow-up was 13 (IQR 10.2-14.0) years. During follow up, 79% of patients used glucocorticoid (GCT). The mean percentage of changes in BMD during follow up were: - 14.03 ± 11.25% (- 1.49%/year) at the lumbar spine, and - 15.77 ± 11.57% (- 1.78%/year) at the total hip, with significant changes (p < 0.001 for both comparisons). Multivariate analysis showed older age, GCT use at baseline, and transition to the menopause during the follow-up were significantly associated with greater reductions in BMD. This retrospective longitudinal study found significant BMD loss at the lumbar spine and hip. Older age, menopausal transition and GCT use were independently associated with BMD decline in women with SLE.

Factors associated with the use of complementary therapies in Taiwanese patients with systemic lupus erythematosus: a cross-sectional study

Background

This study aimed to investigate the prevalence of and the factors associated with the regular use of complementary therapies for Taiwanese patients with systemic lupus erythematosus (SLE).

Methods

In this cross-sectional study, 351 patients with SLE were consecutively recruited from a regional hospital in southern Taiwan from April to August 2019. Demographic and clinical information, including the use of different types of complementary therapies, was ascertained using a self-constructed questionnaire. Disease-specific quality of life was measured using the Lupus Quality of Life (LupusQoL) questionnaire. SLE disease activity was assessed using the rheumatologist-scored Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K). Factors associated with the regular use of complementary therapies were evaluated using multiple logistic regression analyses.

Results

Of the 351 patients with SLE, 90.3% were female, and 60.1% were ≥ 40 years of age. The prevalence of the regular use of any type of complementary therapy was 85.5%. The five most popular types of complementary therapy used were (1) fitness walking or strolling, (2) Buddhist prayer or attending temple, (3) vitamin consumption, (4) calcium supplementation, and (5) fish oil supplementation. Multiple logistic regression analyses revealed that the significant and independent factors associated with the regular use of complementary therapies in patients with SLE were age ≥ 40 years (adjusted odds ratio [aOR] 2.76, p = 0.013), nonoverweight or nonobesity (aOR 0.29, p = 0.004), engagement in vigorous exercise in the past year (aOR 4.62, p = 0.002), a lower SLEDAI-2 K score (aOR 0.90, p = 0.029), and a lower score in the physical health domain of the LupusQoL (aOR 0.57, p = 0.001).

Conclusions

A high prevalence of complementary therapy use in Taiwanese patients with SLE was observed. Rheumatologists should routinely ask patients about their use of supplements to minimize the risk of interaction with medical therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03416-w.

Psoriatic Arthritis and Risk of Vertebral Fracture: A Systematic Review and Meta-analysis

OBJECTIVE

This study was conducted in order to determine the association between psoriatic arthritis and risk of vertebral fracture by pooling the evidence from previous studies.

METHODS

Potentially eligible studies were identified from MEDLINE and EMBASE database from inception to March 2020 using search strategy that comprised of terms for "Psoriatic Arthritis" and "Vertebral Fracture". Studies were eligible for the meta-analysis if they were cohort studies that included psoriatic arthritis and individuals without psoriasis and followed them for incident vertebral fracture. Studies were also required to report standardized incidence ration, hazard risk ratio or relative risk with related 95% confidence intervals (CI) comparing the incidence of vertebral fracture between the two cohorts. The retrieved point estimates with standard errors from each study were pooled into the final result by the random-effect model, generic inverse variance method.

RESULTS

A total of 26,090 articles were identified. After two rounds of independent review by three investigators, we included five cohort studies that met the eligibility criteria in the meta-analysis. PsA is significantly associated with VF the pooled odds ratio of 2.09 (95% CI, 1.11 - 3.96; I² 70%). The funnel plot was fairly asymmetric, thus, the publication bias in favor of studies may present.

CONCLUSIONS

This systematic review and meta-analysis indicates that psoriatic arthritis patients have a significantly elevated risk of developing vertebral fracture.

European Consensus Statement on the diagnosis and management of osteoporosis in chronic kidney disease stages G4-G5D

Controlling the excessive fracture burden in patients with chronic kidney disease (CKD) Stages G4-G5D remains an impressive challenge. The reasons are 2-fold. First, the pathophysiology of bone fragility in patients with CKD G4-G5D is complex and multifaceted, comprising a mixture of age-related (primary male/postmenopausal), drug-induced and CKD-related bone abnormalities. Second, our current armamentarium of osteoporosis medications has not been developed for, or adequately studied in patients with CKD G4-G5D, partly related to difficulties in diagnosing osteoporosis in this specific setting and fear of complications. Doubts about the optimal diagnostic and therapeutic approach fuel inertia in daily clinical practice. The scope of the present consensus paper is to review and update the assessment and diagnosis of osteoporosis in patients with CKD G4-G5D and to discuss the therapeutic interventions available and the manner in which these can be used to develop management strategies for the prevention of fragility fracture. As such, it aims to stimulate a cohesive approach to the management of osteoporosis in patients with CKD G4-G5D to replace current variations in care and treatment nihilism.

The changes in bone turnover markers of female systemic lupus erythematousus patients without glucocorticoid

OBJECTIVES

SLE is a chronic autoimmune disease, which can affect the level of bone metabolism and increase the risk of osteoporosis and fracture. The purpose of this research is to study the effect of SLE on bone turnover markers without the influence of glucocorticoids.

METHODS

A total of 865 female subjects were recruited from Zhejiang Provincial People's Hospital and the First Hospital of Jiaxing, including 391 SLE patients without the influence of glucocorticoids and 474 non-SLE people. We detected Bone turnover markers including amino-terminal propeptide of type 1 procollagen (P1NP), C-terminal turnover of β - I collagen (β-CTX), N-terminal midfragment of osteocalcin (NMID) and 25(OH)D, and analyzed the difference in Bone turnover markers between the SLE group and the control group, as well as the influence of age and season on bone metabolism in female SLE patients.

RESULTS

In the SLE group, the average age was 43.93±13.95 years old. In the control group, the average age was 44.84±11.42 years old. There was no difference between the two groups (t = 1.03, P = 0.30). P1NP, NMID and 25(OH)D in the SLE group were significantly lower than those in the control group (Z = 8.44, p < 0.001; Z = 14.41, p < 0.001; Z = 2.19, p = 0.029), and β-CTX in the SLE group was significantly higher than that in the control group (Z = 2.61, p = 0.009). In addition, the levers of β-CTX, NMID, P1NP and 25(OH)D in older SLE female patients were statistically significantly higher than those in younger (ρ = 0.104, p = 0.041; ρ = 0.223, p < 0.001; ρ = 0.105, p = 0.038; ρ = 0.289, p < 0.001). Moreover, β-CTX reached a high value in summer and PINP reached a low value in winter.

CONCLUSION

The bone formation markers of female SLE patients without glucocorticoid were lower than those of normal people and the bone resorption marker was higher than that of normal people. The 25 (OH) D of female SLE patients without glucocorticoid was lower than that of normal people. The risk of osteoporosis and fracture may be higher in elderly women with SLE. The bone resorption level of female SLE patients is high in summer and the bone formation level is low in winter.

High Comorbidity Burden in Patients with SLE: Data from the Community-Based Lupus Registry of Crete

Comorbidities and multimorbidity, often complicating the disease course of patients with chronic inflammatory rheumatic diseases, may be influenced by disease-intrinsic and extrinsic determinants including regional and social factors. We analyzed the frequency and co-segregation of self-reported comorbid diseases in a community-based Mediterranean registry of patients (n = 399) with systemic lupus erythematosus (SLE). Predictors for multimorbidity were identified by multivariable logistic regression, strongly-associated pairs of comorbidities by the Cramer's V-statistic, and comorbidities clusters by hierarchical agglomerative clustering. Among the most prevalent comorbidities were thyroid (45.6%) and metabolic disorders (hypertension: 24.6%, dyslipidemia: 33.3%, obesity: 35.3%), followed by osteoporosis (22.3%), cardiovascular (20.8%), and allergic (20.6%) disorders. Mental comorbidities were also common, particularly depression (26.7%) and generalized anxiety disorder (10.7%). Notably, 51.0% of patients had ≥3 physical and 33.1% had ≥2 mental comorbidities, with a large fraction (n = 86) displaying multimorbidity from both domains. Sociodemographic (education level, marital status) and clinical (disease severity, neurological involvement) were independently associated with physical or mental comorbidity. Patients were grouped into five distinct clusters of variably prevalent comorbid diseases from different organs and domains, which correlated with SLE severity patterns. Conclusively, our results suggest a high multimorbidity burden in patients with SLE at the community, advocating for integrated care to optimize outcomes.

Bone mineral density, osteopenia, osteoporosis, and fracture risk in patients with atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

The relationship between atopic dermatitis (AD) and abnormal bone metabolism remains unclear. We performed a systematic review and meta-analysis to determine whether patients with AD were associated with increased risks of low bone mineral density (BMD), osteopenia, osteoporosis, and related fractures.

METHODS

We searched PubMed, Embase, and the Cochrane Library through December 2019 to identify studies that investigated the association between AD and abnormal bone metabolism (including BMD, osteopenia, osteoporosis, and related fractures). The predefined primary outcome was related fractures; secondary outcomes included osteoporosis, osteopenia, and BMD. We calculated the summary odds ratios (ORs) and 95% confidence intervals (CIs) using a random-effects model.

RESULTS

Ten studies were included in this systematic review. In children and adolescents, four studies investigated the association between AD and BMD; three studies indicated that children and adolescents with AD were associated with an increased risk of low BMD; one study found similar BMD between AD and control groups. In adults, three studies assessed the risk of fracture and were included in the meta-analysis, comprising 562,405 AD patients among 3,171,268 participants. Adults with AD were associated with an increased risk of fracture (OR 1.13; 95% CI, 1.05-1.22; P=0.001). Three studies investigated the association between AD and osteoporosis, which suggested that patients with AD were associated with an increased risk of osteoporosis (OR 1.95; 95% CI, 1.18-3.23; P=0.009). Further, patients with AD were associated with increased risks of osteopenia (OR 1.90; 95% CI, 1.51-2.38; P<0.001) and low BMD at the femur and spine.

CONCLUSIONS

Patients with AD were associated with increased risks of low BMD, osteopenia, osteoporosis, and related fractures. Both clinical studies and basic research are needed to clarify the mechanisms of association between AD and abnormal bone metabolism.

Low prevalence of bone mineral density testing in patients with systemic lupus erythematosus and glucocorticoid exposure

SummaryPatients with systemic lupus erythematosus (SLE) have an increased risk of developing osteoporosis and fractures due to systemic inflammation and glucocorticoids (GCs). Professional organizations recommend bone mineral density (BMD) testing in SLE patients on GCs, especially within 6 months of initiation. Using a validated algorithm, we identified SLE patients in an electronic health record cohort with long-term GC exposure (≥90 days). Our primary outcome was ever BMD testing. We assessed the impact of patient and provider factors on testing. We identified 693 SLE cases with long-term GC exposure, 41% of whom had BMD testing performed. Only 18% of patients had BMD testing within 6 months of GC initiation. In a logistic regression model for BMD testing, male sex (OR = 0.49, 95% CI 0.27 - 0.87, p = 0.01) was associated with being less likely to have BMD testing after adjusting for race and ethnicity. In contrast, older age (OR = 1.04, p < 0.001) and nephritis (OR = 1.83, p = 0.003) were associated with being more likely to have BMD testing after adjusting for race and ethnicity. Bone health in SLE patients remains an area in need of improvement with attention to patients who are younger and male.

What Role Does Trabecular Bone Score Play in Chronic Inflammatory Rheumatic Diseases?

Patients suffering from rheumatic inflammatory diseases, e.g., systemic sclerosis, rheumatoid arthritis, and ankylosing spondylitis, are at risk of low bone mass. Dual-energy X-ray Absorptiometry (DXA) is the traditional radiological measurement technique for bone mineral density (BMD). The recently developed trabecular bone score (TBS) enhances the skeletal information provided by standard BMD. It re-analyzes the spatial dynamics of pixel intensity changes in lumbar spine DXA images, defining a quantitative index, characterizing trabecular bone microarchitecture. It has been demonstrated that low TBS values are associated with an increased incidence of fractures in patients with rheumatic diseases. These methods used together for bone damage evaluation can be of value to identify individuals who will potentially fracture. The main scientific literature on the clinical aspects of osteoporosis, including the use of TBS in evaluating this pathology, are herein reported aimed at shedding light on the role trabecular bone score plays in chronic inflammatory rheumatic diseases.

Autoimmunological serum parameters and bone mass density in premature ovarian insufficiency: a retrospective cohort study

Purpose

It is still not clear whether to screen women with primary premature ovarian insufficiency for autoimmunity. Moreover, a possible association of autoimmunity with decreased bone mass density in premature ovarian insufficiency patients has not been evaluated. Thus, the objectives of this study were to review our experience with the use of an autoimmune screening panel in premature ovarian insufficiency women and to focus on bone mass density.

Methods

In a retrospective cohort study, 76 chromosomally normal women with primary premature ovarian insufficiency were included. The main outcome parameters were the results of an autoimmune screening panel and of dual-energy X-ray absorptiometry.

Results

Median age was 33 years. Sixty percent of premature ovarian insufficiency patients revealed abnormal dual-energy X-ray absorptiometry results (minimal T-score < −1.0). Any signs of autoimmunity were found in 21 women (36.2%). The most frequent abnormal results were increased thyroperoxidase antibodies (24.1%) and thyroglobulin antibodies (20.7%). A longer duration of amenorrhea (β = −0.015; p = 0.007), any abnormality during autoimmune screening (β = −0.940; p = 0.010), and a lower body mass index (β = −0.057; p = 0.036) were associated with a lower minimal T-score.

Conclusion

In chromosomally normal women with primary premature ovarian insufficiency, the prevalence of autoimmunity and decreased bone mass density seem high. Our data highlight the association between autoimmune abnormalities and decreased dual-energy X-ray absorptiometry results.

Trabecular Bone Score and Bone Quality in Systemic Lupus Erythematosus Patients

Background: Systemic lupus erythematosus (SLE) patients run a higher risk of having low bone mass due to multifactorial events that include physical inactivity, persistent inflammation, low vitamin D levels, and glucocorticoid treatment. This study aimed at obtaining a comparison between bone involvement in SLE patients and healthy matched subjects (HS).

Methods: A total of 40 SLE females (average age 54.1 ± 16.3 years) and 40 age–gender matched HS (average age 54.2 ± 15.9 years) were enrolled after having obtained informed written consent. Bone mineral density (BMD, g/cm²) of the lumbar spine (L1–L4) was analyzed by a dual-energy X-ray absorptiometry (DXA) scan (GE, Lunar Prodigy). The lumbar spine trabecular bone score (TBS) was derived for each spine DXA examination by the TBS index (TBS iNsight Medimaps).

Results: The lumbar spine TBS score was statistically significantly lower in SLE patients than in HS (0.797 ± 0.825 vs. 1.398 ± 0.207, p < 0.001, as was BMD (p < 0.001) in all areas examined.

Conclusions: SLE is associated with significant low bone mass as evidenced by DXA and TBS. This study emphasizes the importance of using DXA and TBS in the evaluation of the different aspects of bone architecture.

Prevalent vertebral fractures incur high risk of future fractures in inflammatory myositis

OBJECTIVE

To assess accrual of new vertebral fractures (VF) in patients with idiopathic inflammatory myositis (IIM) over a period of time.

METHODS

Hundred patients who were previously enrolled for a cross-sectional study on prevalence of asymptomatic VF were telephonically requested to review with repeat spinal radiographs and dual-energy X-ray absorptiometry (DEXA) after 3 years. Radiographs were scored using Genant's semi-quantitative technique. Disease activity and damage were assessed by myositis damage index (MDI) extent of damage and modified MDI for which the osteoporotic fracture item in MDI was removed. VF progressors were compared with non-progressors.

RESULTS

Of 31 patients reviewed, 11 had dermatomyositis, 8 polymyositis, and 6 each overlap and anti-synthetase syndrome. Eighteen patients underwent DEXA scan. Seventeen had VF at baseline. At 91.62 patient years of follow-up, total number of VF increased from 27 to 51. Patients who had previous VF had higher risk of developing a new VF when compared with those with no VF (76.5% vs. 14.28%, RR: 5.35). Patients with old VF accrue fractures at a rate of 26.2 per 100 patient years. The number of fractures correlated significantly with age, T scores at the L4 level, and lower third of radius on DEXA, MDI, and modified MDI. Neither conventional nor disease-related variables differed between progressors and non-progressors.

CONCLUSION

Patients with IIM with a prior VF incurred a five times risk of subsequent VF irrespective of disease activity and glucocorticoids. Key Points • Patients with inflammatory myositis are at a high risk of asymptomatic vertebral fractures. • Patients with baseline vertebral fractures incur a high risk of future fractures on follow-up. • Number of fractures is negatively correlated with age, BMD values at lower end of radius, L4, and damage.

Views on glucocorticoid therapy in rheumatology: the age of convergence

After decades of sometimes fierce debate about the advantages and disadvantages of glucocorticoids, an age of convergence has been reached. Current recommendations for the management of diseases such as rheumatoid arthritis (RA), polymyalgia rheumatica and large vessel vasculitis reflect the current consensus that as much glucocorticoid as necessary, but as little as possible, should be used. Over the past few years, a range of glucocorticoid-sparing strategies have been developed, as have tools to improve the management of this therapy. A comprehensive view of glucocorticoid-induced osteoporosis has also emerged that recognizes that bone fragility is not solely determined by the dose and duration of glucocorticoid treatment. Nevertheless, open questions remain around whether long-term use of very low doses of glucocorticoids is a realistic option for patients with RA and whether the search for innovative glucocorticoids or glucocorticoid receptor ligands with improved benefit-to-risk ratios will ultimately be successful.

Osteoporosis in Rheumatic Diseases

Osteoporosis is a chronic disease characterized by an increased risk of fragility fracture. Patients affected by rheumatic diseases are at greater risk of developing osteoporosis. The purpose of the present review is to discuss the pathogenesis, epidemiology, and treatment of osteoporosis in patients affected by rheumatic diseases with special focus for rheumatoid arthritis, psoriatic arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, vasculitides, Sjogren syndrome, and crystal-induced arthritis.

Systemic lupus erythematosus and menopause

Estrogen has been known for a long time to be a trigger on auto-immunity and may influence the course of lupus. Women experiencing systemic lupus are at high risk for premature ovarian insufficiency if using cyclophosphamide, of osteoporosis, arterial ischemic diseases and venous thrombosis at young age. In about 30% of them, an antiphospholipid/anticoagulant antibody can occur which is associated with very high risk of thrombosis. However, the severity of the disease may vary and some women with lupus could benefit from a menopausal hormone therapy (MHT). As a consequence, management of menopause symptoms needs to evaluate carefully the condition of the patient, her lupus history and cardiovascular risk. We will describe the effect of lupus on menopause, of menopause on lupus and report in detail the literature available on MHT and the risk of lupus or the risk of flares in women with lupus. Some other options than MHT for the management of climacteric symptoms will be discussed.