Low bone density in systemic sclerosis. A systematic review

Prevalence and effects of Vitamin D receptor polymorphism on bone mineral density and metabolism in patients with systemic sclerosis: a preliminary study

Patients with systemic sclerosis (SSc) have a disproportionately high prevalence of reduced bone mineral density (BMD). Polymorphisms of the vitamin D receptor (VDR) gene have been associated with osteoporosis in patients with autoimmune diseases. The aim of this study was to investigate the prevalence and possible effects of VDR polymorphism on BMD and bone metabolism in patients with SSc. In patients with SSc measurement of BMD was performed using dual-energy X-ray absorptiometry. VDR polymorphisms (FokI, BsmI) were genotyped using restriction fragment length polymorphism analysis. Markers of bone metabolism (calcium, osteocalcin, β-crosslaps) were determined. Primary endpoint was the prevalence of VDR gene polymorphisms and the association with reduced BMD. Secondary endpoints included associations between bone metabolism and VDR gene polymorphism. 79 Caucasian patients with SSc were included. Overall, 83.5% had reduced BMD (51.9% osteopenia, 31.6% osteoporosis). The prevalence of VDR gene polymorphism (73% BsmI, 77% FokI) was comparable to studies in healthy and rheumatic populations. The homozygous presence of FokI polymorphism, but not BsmI, was significantly associated with reduced axial BMD. Fokl polymorphism was significantly associated with reduced CTX levels, although changes remained within the reference limits. VDR polymorphisms can frequently be found in patients with SSc in comparable prevalence to healthy and rheumatic populations. The homozygous presence of FokI polymorphism, but not BsmI, was significantly associated with reduced axial BMD. This could be a possible contributor for the high prevalence of reduced BMD in 83.5% of patients with SSc in this study.Trial registration. DRKS00032768, date: 05.10.2023, retrospectively registered.

Clinical Features Associated With Rate of Fractures in Patients With Systemic Sclerosis: A US Cohort Study

OBJECTIVE

Systemic sclerosis (SSc) is associated with several specific risk factors for fracture due to the complications of the disease and related medications. The present study was undertaken to examine the relationship between SSc-associated clinical features and fracture rate in a large US cohort.

METHODS

Participants with SSc in FORWARD, The National Databank for Rheumatic Diseases, were included (1998-2019). Age- and sex-matched individuals with osteoarthritis (OA) from the same database were included as comparators. The primary end point was self-reported major osteoporotic fracture. Cox proportional hazards models were used to study the associations between risk factors and fractures.

RESULTS

The study included 922 individuals (SSc patients, n = 154; OA patients, n = 768). Eighty-seven percent were female, with a mean age of 57.8 years. Fifty-one patients developed at least 1 fracture during a median of 4.2 years (0.5-22.0 years) of follow-up. Patients with SSc had more frequent fractures compared to OA comparators (hazard ratio [HR] 2.38 [95% confidence interval (95% CI) 1.47-3.83]). Among patients with SSc, a higher Rheumatic Disease Comorbidity Index score (HR 1.45 [95% CI 1.20-1.75]) and a higher Health Assessment Questionnaire disability index score (HR 3.83 [95% CI 2.12-6.93]) were associated with more fractures. Diabetes mellitus (HR 5.89 [95% CI 2.51-13.82]) and renal disease (HR 2.43 [95% CI 1.10-5.37]) were independently associated with fracture among SSc patients relative to SSc patients without these comorbidities.

CONCLUSION

Our findings highlight factors associated with fracture among patients with SSc. Disability as measured by the HAQ DI is a particularly strong indicator of fracture rate in SSc. Improving SSc patients' functional status, where possible, may lead to better long-term outcomes.

Multi-Organ System Screening, Care, and Patient Support in Systemic Sclerosis

Systemic sclerosis (SSc) is a heterogenous systemic autoimmune disease of complex multi-organ manifestations with a disease-specific mortality of >50%. The patient journey is fraught with severe, diverse, and diffuse physical impairment, psychological burden, and diminishing health-related quality of life. SSc remains unfamiliar to many clinicians. Delayed/misdiagnosis, inadequate screening, and attention for common complications with potentially preventable disability/death contribute to patients feeling isolated and unsupported. We present actionable standards including screening, anticipatory guidance, and counseling in patient-centered SSc-care emphasizing psycho-social health as the central goal, whereas robust vigilance and efforts to improve biophysical health and survival are imperatives that support this goal.

Preventative Care in Scleroderma: What Is the Best Approach to Bone Health and Cancer Screening?

Systemic sclerosis (SSc) is a rare multisystem autoimmune disease characterized by fibrosis, vasculopathy, and autoimmunity. Lesser known complications inherent to SSc, such as malignancies and osteoporosis, can lead to decreased quality of life and increased morbidity and mortality. Patients with SSc have a greater risk of developing malignancies than the general population. In addition, they are more likely to be vitamin D deficient and are at great risk of osteoporosis-related fractures. However, these complications can be addressed through preventative measures. The purpose of this review is to provide clinicians with an approach to bone health and cancer screening in SSc.

High prevalence and risk factors for osteoporosis in 1839 patients with systemic sclerosis: a systematic review and meta-analysis

OBJECTIVES

Osteoporosis is prevalent in patients with systemic sclerosis (SSc). Updated evidence is required to complement the previous systematic review on this topic to provide best practices. This systematic review and meta-analysis aimed to quantitatively synthesize data from studies concerning the prevalence and risk factors for osteoporosis among patients with SSc.

METHODS

We searched PubMed, EMBASE, Web of Science, and ScienceDirect databases for potential studies published from inception to May 31, 2022. Eligibility screening, data extraction, and quality assessment of the retrieved articles were conducted independently by two reviewers. Then meta-analyses were performed to determine osteoporosis prevalence and risk factors in patients with SSc. Meta-regression analysis was conducted to explore the sources of heterogeneity.

RESULTS

The pooled prevalence of osteoporosis in patients with SSc was 27% (95% CI, 24-31), with moderate heterogeneity (I² = 61.6%). Meta-regression revealed no significant difference among all variables. And the presence of SSc increased the likelihood of having osteoporosis (OR = 3.05, 95% CI, 2.32-4.01) compared to controls. These significant risk factors for osteoporosis in SSc patients were age > 50 years (OR = 2.94, 95% CI, 1.52-5.68), menopause (OR = 3.90; 95% CI, 1.94-7.84), aging (MD = 8.40; 95% CI,6.10-10.71) and longer disease duration (MD = 4.78; 95% CI,1.83-7.73). However, female (OR = 1.45; 95% CI, 0.75-2.77), pulmonary arterial hypertension (OR = 0.50; 95% CI, 0.17-1.54), and diffuse cutaneous SSc (OR = 1.05; 95% CI, 0.75-1.48) were not significant risk factors for osteoporosis in SSc patients.

CONCLUSIONS

Osteoporosis was highly prevalent in patients with SSc, and the prevalence seemed to be high and similar in many countries. The age > 50 years, menopause, aging, and longer disease duration were identified as risk factors for osteoporosis in patients with SSc.

Symptomatic fractures in systemic sclerosis: A case-control study

This case-control study analyzed risk factors for symptomatic fractures in a group of 52 patients with systemic sclerosis compared with a group of 104 patients without fractures, matched for sex and age, who were attended at a single systemic sclerosis outpatient clinic from 2010 to 2020. Fractures affected predominantly vertebral (65.4%), rib (13.5%), and hip (7.7%) joints, while the mean age of fracture was 55.3 ± 9.5 years. Age at disease onset, age at diagnosis, disease duration, age at menarche, and age at menopause were similar in both groups, and 58.9% of the patients were menopausal at the time of the fracture. The presence of fractures had a significant association with densitometric osteoporosis (p < 0.001), lower weight (p = 0.032), and bone mineral index (p = 0.044), anti-RNA polymerase III (p = 0.040), use of corticosteroids (p = 0.019), and bisphosphonates (p < 0.001), as well as with densitometric T-scores of lumbar spine (p < 0.001), femoral neck (p = 0.025), and total hip (p = 0.013). Multivariate analysis showed that the variables significantly associated with fractures were high doses of corticosteroids (odds ratio = 4.10; 95% confidence interval = 1.290-13.090; p = 0.017), bisphosphonates (odds ratio = 3.91; 95% confidence interval = 1.699-8.984; p = 0.001), negative anti-Scl70 (OR = 0.34; 95% confidence interval = 0.124-0.943; p = 0.038), and lumbar T-score (odds ratio = 0.39; 95% confidence interval = 0.034-0.460; p = 0.010). In conclusion, symptomatic fractures were associated predominantly with lower bone mineral density of lumbar spine and use of high doses of corticosteroids and bisphosphonates in this cohort.

Trabecular bone score in rheumatic disease

Patients with rheumatic diseases (RD) are at high risk of osteoporosis (OP) and osteoporotic fractures. The Trabecular bone score (TBS) is a relatively novel method of assessing bone quality, which independently predicts fracture risk regardless of bone mineral density (BMD). A lower TBS in patients with RD compared to controls is shown in most studies concerning TBS and RD. The data obtained indicate that TBS predicts fractures better in RD, especially in patients receiving glucocorticoids, than BMD or the FRAX algorithm. TBS degradation has been associated with disease activity in ankylosing spondylitis, systemic sclerosis, and rheumatoid arthritis in a few studies. However, there is little data in the literature on the effect of rheumatic disease therapy and OP treatment in patients with RD on predictive ability of TBS for incident fracture.

Pathogenetic rationale for prescribing menopausal hormone therapy for systemic sclerosis

Systemic scleroderma (SS) is characterized by dysregulation of the innate and adaptive immune systems, vasculopathy, and generalized fibrosis. As with most autoimmune diseases, women predominate among patients, who get sick 3–14 times more often than men. It is assumed that gender differences and modulation of sex hormones are essential in the pathogenesis of SS. Estrogens are able to influence the immune response, have a vasodilating effect and stimulate the synthesis of collagen in the skin. The development of SS leads to a significant decrease in the quality of life, psychological disorders associated with changes in appearance, as well as the need for lifelong medication with the frequent development of side effects. Age-related estrogen deficiency associated with the onset of menopause is accompanied by a decrease in the quality of life and, in some cases, a change in the clinical manifestations of somatic diseases. This review considers the impact of menopause and menopausal hormone therapy (MHT) on the course and clinical manifestations of systemic scleroderma. It is noted that SS in some cases is accompanied by an early onset of menopause. The use of MHT is not associated with the progression of cutaneous fibrosis, and may also improve the vascular manifestations of SS.

Proton pump inhibitors in systemic sclerosis: a reappraisal to optimise treatment of gastro-oesophageal reflux disease

Gastroesophageal reflux disease (GERD) is associated with significant morbidity in patients with systemic sclerosis (SSc). Although the introduction of proton pump inhibitors (PPIs) into clinical care have represented a major achievement in the management of oesophago-gastric problems in SSc, PPIs are seldom fully effective in SSc patients, and the utilization of maximum PPI dosages is a very frequent clinical practice. However, currently there is little evidence currently to support the empiric use of PPIs in SSc which is especially relevant in regard to safety concerns of long-term exposure with have been raised in the general population. The purpose of this viewpoint is to highlight the significant beneficial impact of PPIs on GERD in SSc, while considering the potential adverse effects in this patient population. Furthermore, we highlight the unmet needs of SSc patients with GERD, and also propose an agenda for future research to optimise the safe and effective use of PPIs in SSc.

Relationship between ectopic calcifications and bone fragility depicted on computed tomography scan in 70 patients with systemic sclerosis

Background

A higher risk of osteoporotic fracture was described in systemic sclerosis patients than in healthy patients.

Objective

To evaluate the relation between osteoporotic fracture risk measured by the scanographic bone attenuation coefficient of the first lumbar vertebra (SBAC-L1) on computed tomography (CT) scan and the presence of ectopic calcifications: vascular, valvular and spinal.

Methods

This monocentric retrospective study was performed on patients followed between 2000 and 2014 at Nancy University Hospital. Systemic sclerosis patients, according to ACR/EULAR 2013 criteria, followed from 2000 to 2014 and who underwent, during their follow-up, a CT including the first lumbar vertebra were included. The SBAC-L1 was measured with a threshold set at 145 Hounsfield units (HU). Vascular and spinal calcifications were studied on CT. For vascular calcifications, the Agatston score was used. Valvular calcifications were studied on echocardiography.

Results

A total of 70 patients were included (mean age: 62.3 (±15.6) years, women 88.5%). The mean SBAC-L1 was 157.26 (±52.1) HU, and 35 patients (50%) presented an SBAC-L1 ⩽ 145 HU. The reproducibility of the calcification evaluation was good, with kappa coefficients varying between 0.63 and 1. In univariate analysis, spinal and vascular calcifications were associated with an SBAC-L1 ⩽ 145 HU, with ORs of 13.6 (1.6-113.3) and 8 (95%CI: 2.5-25.5), respectively. In multivariate analysis, the SBAC-L1 was not associated with the presence of any ectopic calcifications. The SBAC-L1 decreased with age (p = 0.0001).

Conclusion

Patients with systemic sclerosis with an SBAC-L1 ⩽ 145 HU were older, but they did not have more ectopic calcification.

Trial registration

The ethics committee of Nancy Hospital agreed with this study (referral file number 166). This study was designed in accordance with the general ethical principles outlined in the Declaration of Helsinki.

Management of calcinosis cutis in rheumatic diseases

Calcinosis (hydroxyapatite and calcium phosphate crystal deposition) within the extracellular matrix of the dermis and subcutaneous tissue is a frequent manifestation of adult and pediatric systemic autoimmune rheumatic diseases, specifically systemic sclerosis, dermatomyositis, mixed connective tissue disease and systemic lupus erythematosus. In this article, we review classification of calcinosis, highlight mechanisms that may contribute to the pathogenesis of calcinosis and summarize the evidence evaluating non-pharmacologic and pharmacologic interventions for the treatment of calcinosis.

Subcutaneous calcinosis: Is it different between systemic sclerosis and dermatomyositis?

Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It is a manifestation of several autoimmune connective tissue diseases, most frequently with systemic sclerosis and juvenile dermatomyositis, followed by adult dermatomyositis. Autoimmune connective tissue disease-associated calcinosis is of the dystrophic subtype, which occurs at sites of damaged tissue in the setting of normal serum calcium and phosphate levels. In juvenile dermatomyositis, calcinosis is considered a marker of ongoing disease activity and possibly inadequate treatment, while in adult dermatomyositis, it is a hallmark of skin damage due to chronic rather than active disease. Calcinosis is associated with long disease duration in systemic sclerosis and dermatomyositis, anti-polymyositis/sclerosis autoantibodies in systemic sclerosis and NXP-2 and melanoma differentiation-associated gene 5 in dermatomyositis. Calcinosis in systemic sclerosis occurs most frequently in the hands, particularly the fingers, whereas in dermatomyositis, it affects mainly the trunk and extremities. The primary mineral component of calcinosis is hydroxyapatite in systemic sclerosis and carbonate apatite in dermatomyositis. Calcinosis in dermatomyositis and systemic sclerosis share some pathogenic mechanisms, but vascular hypoxia seems to play a more important role in systemic sclerosis, whereas the release of calcium from mitochondria in muscle cells damaged by myopathy may be a primary mechanism contributing to dermatomyositis-related calcinosis. Multiple treatment strategies for dermatomyositis and systemic sclerosis-related calcinosis have been used with variable results. Early aggressive treatment of underlying myositis in patients with dermatomyositis may improve long-term outcomes of calcinosis. A better understanding of the pathogenesis of calcinosis is needed to improve treatment options.

Vitamin D Deficiency, Osteoporosis and Effect on Autoimmune Diseases and Hematopoiesis: A Review

Vitamin D (VD) is essential for bone homeostasis, but it is also involved in pleiotropic effects on various organs and tissues. In adults, VD deficiency can cause or exacerbate osteoporosis and induce osteomalacia. However, every tissue and cell in the body has a VD receptor, including the brain, heart, stomach, pancreas, skin, gonads, and immune cells, and a deficiency may modify the function of these organs. Thus, the wide-ranging actions of VD help to explain why a reduction in VD amount has been correlated with numerous chronic diseases. In fact, VD deficiency increases the risk of osteoporosis and several other diseases and complications characterized by impaired bone metabolisms, such as autoimmune diseases, inflammatory bowel diseases, allergy, endocrinological diseases, hematological malignancies, and bone marrow transplantation. This review aims to investigate the link between VD deficiency, osteoporosis, and its concomitant diseases. Further epidemiological and mechanistic studies are necessary in order to ascertain the real role of hypovitaminosis in causing the reported diseases; however, adequate vitamin supplementation and restoration of metabolic normality could be useful for better management of these pathologies.

A fixed reconstruction of partially edentulous patient with systemic scleroderma: A 4.8-year follow-up case report

INTRODUCTION

Systemic scleroderma (SSc) is a progressive autoimmune multisystem disease affecting several organs. In the oral cavity, its manifestations include enlarged periodontal ligament, xerostomia, microsomia, alveolar bone loss, and premature teeth loss. A removable prosthesis would not be a treatment option due to loss of hand dexterity, reduced chewing capacity, microsomia, and xerostomia in these patients. Alternatively, implant-supported fixed restorations are a plausible treatment for these patients. However, there is very limited literature showing implant survival rate in patients with SSc for a long follow-up.

CASE PRESENTATION

A 57-year-old female patient with SSc presented to our clinic. She was diagnosed with SSc 25 years ago. Initial clinical and radiological examination revealed that she showed slight to moderate chronic periodontitis, tooth cavities, remaining tooth tips, and a partial edentulism in the posterior areas. A total of seven implants were placed at different time points. The remaining upper teeth were crowned. At 4.8 years follow-up, the placed implants showed no sign of peri-implant disease.

CONCLUSION

This case report indicated that 4.8 years of follow-up revealed good oral hygiene and clinically or radiologically no sign of peri-implant disease around the implants in a patient with SSc. Implant-supported fixed restoration could be a viable treatment approach in these patients.

Body composition and bone status in relation to microvascular damage in systemic sclerosis patients

AIM

To evaluate, in Systemic sclerosis (SSc) patients, the body composition and the bone status according to the peripheral microcirculatory condition, assessed and scored by nailfold videocapillaroscopy (NVC, "Early", "Active", "Late" patterns).

METHODS

Body composition and bone mineral density (BMD) were assessed by Dual X-ray absorptiometry and dedicated software (GE Lunar USA) in 37 female SSc patients classified according to the 2013 EULAR/ACR criteria and 40 sex-matched healthy subjects. Clinical, laboratory, body composition and bone parameters were analyzed according to the different NVC patterns. Means were compared by the Student's t test or one-way analysis of variance; medians were compared by the Kruskal-Wallis test; and frequencies by the chi-square test.

RESULTS

Higher prevalence of vertebral (21% vs 7%) and femoral (35% vs 7%) osteoporosis (OP) was found in SSc. Particularly SSc patients with "Late" NVC pattern showed a significantly higher prevalence of vertebral (p = 0.018) and femoral OP (p = 0.016). Regional assessment of bone mass (BM) in seven different body areas showed a significantly lower BMD only at the total spine (p = 0.008) and femoral neck (p = 0.027) in advanced microvascular damage. Patients with "Late" NVC pattern showed a lower whole-body lean mass (LM) compared to "Early" and "Active" NVC patterns, particularly at upper limbs. To note, in all body sites, BMD correlates with LM and BMC according to NVC pattern severity.

CONCLUSIONS

SSc patients with most severe microvascular damage show a significantly altered body composition and bone status suggesting a strong link between microvascular failure and associated muscle/bone sufferance.

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.

Prevalence and clinical associations with premature ovarian insufficiency, early menopause, and low ovarian reserve in systemic sclerosis

The low prevalence of pregnancy in women with systemic sclerosis (SSc) is due to multi-factorial causes, including premature ovarian insufficiency (POI). The study aimed to determine the prevalence of POI, early menopausal status, and any clinical associations of these among Thai female SSc patients. An analytical cross-sectional study was conducted among female SSc patients between 18 and 45 years of age. The eligible patients underwent blood testing for follicle stimulating hormone and anti-mullerian hormone levels, gynecologic examination, and transvaginal ultrasound for antral follicle count. We excluded patients having surgical amenorrhea, previous radiation, and history of hormonal contraception < 12 weeks and pregnancy. A total of 31 patients were included. The majority (67.7%) had diffuse cutaneous systemic sclerosis. Three patients were POI with a prevalence of 9.7%. The factors associated with POI were a high cumulative dose of cyclophosphamide (CYC) (p = 0.02) and the long duration of CYC used (p = 0.02). After excluding POI, early menopause was detected in 10 patients with a prevalence of 35.7%. The factors associated with early menopause were long disease duration (p = 0.02), high cumulative dose of CYC (p = 0.03), and high cumulative dose of prednisolone (p = 0.02). Low ovarian reserve according to POSEIDON definition was found in 28 patients with the prevalence of 90.3%. POI in Thai SSc was uncommon, whereas early menopause and low ovarian reserve were frequently revealed. A high cumulative dose of CYC was associated with both POI and early menopause. Physicians should be aware of reproductive outcomes and advise patients at risk. Key Points • POI is revealed in patients with SSc particularly in who received high cumulative dose of cyclophosphamide, while early menopause and low ovarian reserve were major reproductive problem among SSc. • Prescriptions for CYC for female SSc-both for young patients of reproductive age and premenopausal middle-aged women-should be concerned of the long-term effects on gonadal function.

Few fragility fracture patients perceive that their bone health is affected by their comorbidities and medications

We examined fragility fracture patients' perceptions of associations between bone health and other chronic conditions and medications. Awareness of the associations between bone health and these conditions and medications was low. Providers should increase patients' awareness of these associations in order to minimize the risk of future fracture.

INTRODUCTION

Among patients with a fragility fracture presenting with at least one other chronic health condition, we examined (1) perceptions of the association between bone health and their other health conditions, and (2) perceptions of the association between bone health and prescribed medications taken for other health conditions.

METHODS

We identified fragility fracture patients presenting to a Canadian urban fracture clinic with at least one self-reported chronic health condition (in addition to bone fragility). In-depth interviews, 60-90 min in duration, were conducted. Our qualitative methodology was informed by saliency analysis.

RESULTS

We interviewed 26 patients (21 females, 5 males) aged 45 to 84 years old. Participants were taking 1-13 medications each and presented with a variety of comorbidities (range 1-7). All participants described at least one condition or medication they were currently taking for which there existed evidence of a negative effect on bone health (increased risk of fracture, bone loss, falling). Two participants perceived a correct association between their other health conditions and compromised bone health, and four participants perceived a correct association between their medications and compromised bone health.

CONCLUSION

All patients reported a chronic health condition and/or were taking at least one medication that potentially compromised their bone health. Patient awareness of the association between bone health and other health conditions and prescribed medications was low. Health care providers should increase patients' awareness of the bone health significance of their chronic conditions and medications in order to minimize the risk of future fracture.

Prevalence and risk factors for bone loss in Southern Chinese with rheumatic diseases

BACKGROUD

This study is to explore the prevalence of different stages of bone loss and the potential risk factors in rheumatic patients.

METHOD

A cross-sectional study recruits 1398 rheumatic patients and 302 healthy subjects. Demographic data, blood, and bone mineral density (BMD) tests are collected. Risk factors for bone loss in rheumatic patients are analyzed by logistic regression.

RESULTS

(1) Rheumatic patients are consisted of 40.0% rheumatoid arthritis (RA), 14.7% systemic lupus erythematosus (SLE), 14.2% osteoarthritis (OA), 9.2% ankylosing spondylosis (AS), 7.9% gout, 7.0% primary Sjogren syndrome (pSS), 3.8% systemic sclerosis (SSc), and 3.2% mixed connective tissue disease (MCTD). (2) In male patients aged under 50 and premenopausal female patients, the bone mineral density score of AS (53.9%, P < 0.001) and SLE (39.6%, P = 0.034) patients is lower than the healthy controls (18.2%). (3) Osteopenia and osteoporosis are more prevailing in male patients aged or older than 50 and postmenopausal female patients with RA (P < 0.001), OA (P = 0.02) and SLE (P = 0.011) than healthy counterparts. (4) Those with SLE, RA and AS gain the highest odd ratio of 'score below the expected range for age', osteopenia and osteoporosis, respectively. (5) Age, female, low BMI and hypovitaminosis D are found negatively associated with bone loss. Dyslipidemia and hyperuricemia could be protective factors.

CONCLUSION

Young patients with AS and SLE have a significant higher occurrence of bone loss, and older patients with RA, OA and SLE had higher prevalence than healthy counterparts. SLE, RA, SSc and AS were founded significant higher risks to develop into bone loss after adjustment. Age, BMI and gender were commonly-associated with bone loss in all age-stratified rheumatic patients. These findings were not markedly different from those of previous studies.

Calcinosis is associated with ischemic manifestations and increased disability in patients with systemic sclerosis

OBJECTIVE

Calcinosis is a debilitating complication of systemic sclerosis (SSc) with no effective treatments. We sought to identify clinical correlations and to characterize complications and disability associated with calcinosis in a multi-center, international cohort of SSc patients.

METHODS

We established a cohort of 568 consecutive SSc patients who fulfill 2013 revised ACR/EULAR criteria at 10 centers within North America, Australia, and Mexico. Calcinosis was defined as subcutaneous calcium deposition by imaging and/or physical examination, or a clear history of extruded calcium. All patients completed the Scleroderma Health Assessment Questionnaire Disability Index and Cochin Hand Functional Scale.

RESULTS

215 (38%) patients had calcinosis. In multivariable analysis, disease duration (OR=1.24, p = 0.029), digital ischemia (OR=1.8, p = 0.002) and Acro-osteolysis (OR=2.97, p = 0.008) were significantly associated with calcinosis. In the subset of patients with bone densitometry (n = 68), patients with calcinosis had significantly lower median T-scores than patients without (-2.2 vs. -1.7, p = 0.004). The most common location of calcinosis lesions was the hands (70%), particularly the thumbs (19%) with decreasing frequency moving to the fifth fingers (8%). The most common complications were tenderness (29% of patients) and spontaneous extrusion of calcinosis through the skin (20%), while infection was rare (2%). Disability and hand function were worse in patients with calcinosis, particularly if locations in addition to the fingers/thumbs were involved.

CONCLUSIONS

We confirmed a strong association between calcinosis and digital ischemia. Calcinosis in SSc patients most commonly affects the hands and is associated with a high burden of disability and hand dysfunction.

Pharmacological treatment for managing bone health in axial spondyloarthropathy: systematic review and meta-analysis

Axial spondyloarthropathy (axSpA) is associated with an increased prevalence of osteoporosis, but no recommendations exist to guide management. This systematic review and meta-analysis aim to assess the efficacy of pharmacological and non-pharmacological interventions on bone mineral density (BMD) in axSpA. Electronic databases were searched from inception to June 2019 for randomised controlled trials (RCTs) and quasi (q)-RCTs with pharmacological and non-pharmacological interventions. Independent reviewers undertook screening, and risk of bias and quality assessments. Primary outcomes of interest were BMD at spine and hip. Eight studies (two RCTs and six qRCTs) were included (602 participants). Moderate level evidence favoured alendronate over placebo at femoral neck [mean difference (MD) 2.01, 95% CI 0.67 to 3.35], but there was low-level evidence showing no effect at the spine. There was moderate level evidence showing no effect of tumour necrosis factor inhibitors (TNFi) on BMD at total hip (MD - 0.01, 95% CI - 0.06 to 0.04). Very low-level evidence demonstrated no effect of TNFi on spine or femoral neck. Moderate level evidence favoured neridronate over infliximab at the spine (MD 3.26, 95% CI 1.14 to 5.38), but low-level evidence showed no effect at the total hip (MD 2.75, 95% CI - 0.21 to 5.71). There were no eligible studies investigating the efficacy of non-pharmacological interventions. We conditionally recommend alendronate for management of low BMD in axSpA. The balance of evidence does not recommend the use of TNF-inhibitors for treating low BMD. There is a lack of high-quality evidence guiding clinicians treating osteoporosis in axSpA.

Nutritional Status and Bone Microarchitecture in a Cohort of Systemic Sclerosis Patients

Systemic sclerosis (SSc) is a connective tissue disease characterized by initial microvascular damage, immune system activation and progressive fibrosis with insufficiency of internal organs. Gastrointestinal (GI) involvement is characterized by atrophy of the smooth muscle and small bowel hypomotility, mainly resulting from an autonomic nerve dysfunction. These modifications significantly affect gut transit and nutrient absorption, thus leading to malnutrition deficit induced by malabsorption. Nutritional deficit induced by malabsorption might also lead to bone alterations. This study aims to evaluate the relationship between malnutrition and bone status. Thirty-six postmenopausal female patients fulfilling the ACR 2013 criteria for SSc underwent dual-energy X-ray absorptiometry scan (DXA) to detect quantitative lumbar spine bone mineral density (BMD) and trabecular bone score (TBS) analysis to detect bone quality. Data from DXA also allow to assess body composition and provide several quantitative parameters, including free fat mass index (FFMI) that identifies the patient with malnutrition (values <15 kg/m² in women and 17 kg/m² in men), according to the ESPEN criteria. Body mass index (BMI) was calculated for all SSc patients and every patient completed a diary reporting GI symptoms. Two groups of SSc patients with or without diagnosed malnutrition according to FFMI parameter were identified. Malnourished SSc patients showed significantly lower weight (p = 0.01) and BMI (p = 0.001), as well as lower serum levels of hemoglobin (p = 0.009), albumin (p = 0.002), PTH (p = 0.02) and 25OH-vitamin D (p = 0.008). DXA analysis showed significantly lower lumbar L1-L4 T-score (p = 0.009) and BMD values (p = 0.029) in malnourished SSc patients. Consistently, TBS values were significantly lower in malnourished patients (p = 0.008) and correlated with BMD (at any site) and serum albumin levels (p = 0.02). In addition, FFMI positively correlated with bone parameters as well as with symptoms of intestinal impairment in malnourished SSc patients. Finally, GI symptoms significantly correlated with BMD but not with TBS. This pilot study shows that in malnourished SSc patients (2015 ESPEN criteria: FFMI<15 kg/m²), an altered bone status significantly correlates with GI involvement, in terms of symptoms being mainly due to intestinal involvement together with the presence of selected serum biomarkers of malnutrition.

A meta-analysis of fracture risk and bone mineral density in patients with systemic sclerosis

INTRODUCTION

Osteoporosis and fractures are important public health issues that impose serious burdens on patients. Patients with systemic sclerosis (SSc) have low bone mineral density (BMD) and increased risk for fracture. We aimed to explore the association between SSc and BMD and fracture risk.

METHODS

For this meta-analysis, we analyzed data from articles that reported mean differences in BMD or fracture risk between patients with SSc and controls. We undertook a systematic literature search of the PubMed, Web of Science, and Cochrane Library databases. The pooled weighted mean difference (WMD) was used to estimate the mean difference in BMD between patients with SSc and controls. Pooled odds ratios (ORs; with 95% confidence intervals [95% CIs]) were used to assess the association between SSc and fracture risk.

RESULTS

Analysis of the results from 18 studies showed that patients with SSc had significantly lower BMD than controls in the following categories: whole body (WMD - 0.07, 95% CI - 0.1 to - 0.04, p < 0.00001), lumbar spine (WMD - 0.08, 95% CI - 0.11 to - 0.05, p < 0.00001), femoral neck (WMD: -0.28, 95% CI: -0.46 to -0.10, p=0.002), total hip (WMD - 0.10, 95% CI - 0.14 to - 0.06, p < 0.00001), and femoral trochanter (WMD - 0.06, 95% CI - 0.09 to - 0.03, p < 0.0001). Moreover, patients with SSc had an increased risk of vertebral fracture (OR 10.38, 95% CI 1.19 to 90.58, p = 0.03). We did not find a significant difference in the risk of osteoporotic fracture between patients with SSc and controls (OR = 2.24, 95% CI 0.58 to 8.59, p = 0.24).

CONCLUSION

Patients with SSc have a significant reduction in bone mass, and these patients have an increased risk of vertebral fracture. The early monitoring of BMD in patients with SSc is recommended for the prevention of osteoporosis and fracture.Key points• SSc patients have a significant low BMD• SSc patients also have an increased risk of vertebral fracture.

Complex assessment of bone mineral density, fracture risk, vitamin D status, and bone metabolism in Hungarian systemic sclerosis patients

Objective

We wished to determine bone alterations in systemic sclerosis (SSc) patients by conventional densitometry (DXA), peripheral quantitative computed tomography (pQCT), and bone biomarkers.

Methods

We included 44 SSc patients and 33 age-matched healthy controls. Lumbar spine and femoral neck bone mineral density (BMD) was assessed by DXA. Volumetric BMD was measured by pQCT at the radius. FRAX, 25-hydroxyvitamin-D₃ (25-OH-D₃), parathyroid hormone, osteocalcin, C-terminal collagen telopeptide, and procollagen type I amino-terminal propeptide were also assessed.

Results

SSc patients had lower L2–4 BMD (0.880 ± 0.108 vs. 0.996 ± 0.181 g/cm²; p = 0.019) and femoral neck (FN) BMD (0.786 ± 0.134 vs. 0.910 ± 0.090 g/cm²; p = 0.007) by DXA. In SSc vs. controls, pQCT indicated lower mean cortical (328.03 ± 103.32 vs. 487.06 ± 42.45 mg/cm³; p < 0.001) and trabecular density (150.93 ± 61.91 vs. 184.76 ± 33.03 mg/cm³; p = 0.037). Vitamin D₃ deficiency was more common in SSc vs. controls (60.0% vs. 39.3%; p = 0.003). L2–4 (p = 0.002) and FN BMD (p = 0.015) positively correlated with BMI. pQCT assessments confirmed an inverse correlation between pulmonary manifestation and total (p = 0.024), trabecular (p = 0.035), and cortical density (p = 0.015). Anti-Scl70 positivity inversely correlated with pQCT total density (p = 0.015) and the presence of digital ulcers with cortical density (p = 0.001). We also found that vertebral and FN BMD as determined by DXA significantly correlated with pQCT total, trabecular, and cortical density (p < 0.05).

Conclusion

The results of our study suggest that bone loss in SSc patients may be associated with lower BMI, anti-Scl70 positivity, and the presence of pulmonary manifestations and digital ulcers. Both DXA and pQCT are appropriate tools to evaluate the bone alterations in SSc patients.

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.

Calcinosis in scleroderma

PURPOSE OF REVIEW

To provide an update on the available literature regarding the epidemiology, pathophysiology, diagnosis, and treatment of calcinosis cutis in patients with systemic sclerosis (SSc).

RECENT FINDINGS

We identified observational studies that describe the frequency of calcinosis in SSc and associated clinical features; molecular studies exploring potential pathogenic mechanisms; and case reports and case series describing new diagnostic approaches and treatments.

SUMMARY

Calcinosis cutis is the deposition of insoluble calcium in the skin and subcutaneous tissues. It represents a major clinical problem in patients with SSc affecting at least one quarter of patients. It is associated with longer disease duration, digital ulcers, acro-osteolysis, positive anticentromere antibody, and positive anti-PM/Scl antibody. Although pathogenesis is unknown, there is evidence supporting local trauma, chronic inflammation, vascular hypoxia, and dysregulation of bone matrix proteins as potential mechanisms. Diagnosis can be made clinically or with plain radiography. Several pharmacologic therapies have been tried for calcinosis with variable and modest results, but surgical excision of calcium deposits remains the mainstay of treatment.

Distal radius and tibia bone microarchitecture impairment in female patients with diffuse systemic sclerosis

Radius and tibia bone microarchitecture, analyzed through a high-resolution peripheral quantitative computed tomography, were significantly impaired in female patients with diffuse systemic sclerosis compared with healthy controls. Acroosteolysis, quality of life-grip strength, hand disability, and disease duration were significantly associated with this bone deterioration.

INTRODUCTION

The effect of diffuse systemic sclerosis (dSSc) on the bone is not completely understood. The objective of this study was to analyze the volumetric bone mineral density (vBMD), microarchitecture, and biomechanical parameters at the distal radius and tibia using high-resolution peripheral quantitative computed tomography (HR-pQCT, XtremeCT) in female patients with dSSc and identify clinical and laboratory variables associated with these parameters.

METHODS

Thirty-eight women with dSSc and 76 healthy controls were submitted to HR-pQCT at the distal radius and tibia. Clinical and laboratory findings, bone mineral density(BMD), nailfold capillaroscopy (NC), total passive range of motion(ROM), and quality of life (health assessment questionnaire-HAQ) were associated with HR-pQCT (Scanco Medical AG, Brüttisellen, Switzerland) parameters. Multiple linear regression models adjusted for clinical and laboratory variables, ROM and HAQ, were performed.

RESULTS

Density, microarchitecture, and biomechanical parameters at the distal radius and tibia were significantly impaired in dSSc patients compared with healthy controls (p < 0.001). Multiple linear regression models showed that lower trabecular density (Tb.vBMD) (radius R² = 0.561, p = 0.002; and tibia R² = 0.533, p = 0.005), and lower trabecular number (Tb.N) (tibia R² = 0.533, p = 0.005) were significantly associated with acroosteolysis. Higher trabecular separation (Tb.Sp) was associated with disease duration and higher HAQ-grip strength (radius R² = 0.489, p = 0.013), while cortical density (Ct.vBMD) was associated with ROM (radius R² = 0.294, p = 0.002).

CONCLUSION

Bone microarchitecture in patients with dSSc, analyzed through HR-pQCT, showed impairment of trabecular and cortical bone at distal radius and tibia. Variables associated with hand involvement (acroosteolysis, quality of life-grip strength, and ROM) and disease duration may be considered prognostic factors of this bone impairment.

Overview of osteo-articular involvement in systemic sclerosis: Specific risk factors, clinico-sonographic evaluation, and comparison with healthy women from the French OFELY cohort

Osteoarticular involvement in systemic sclerosis (SSc) is frequent and varied. Data are scarce on the prevalence and risk factors of osteoporosis (OP). We aimed to assess clinical parameters, radiological parameters, US articular involvements, and the frequency of OP and evaluate SSc-specific risk factors. In a prospective cohort of 54 patients with SSc, data of OP risk factors, SSc organ involvements, tender and swollen joint counts, DAS28-CRP, hand US sonographies, X-ray hand views, and bone mineral density (BMD) were assessed. BMD values were compared to those from a healthy female population (OFELY cohort). Nineteen patients (40%) had OP. SSc was a risk factor of lower BMD in the patient group than in the control group. OP was associated with SSc-related risk factors and not with conventional OP risk factors. Nine patients had clinical synovitis (16%), and 23 (68%) patients had at least one US synovitis. No correlation was found with articular destruction, disease severity, autoantibody profile, or other organ impairment.

Bone mineral density and microarchitecture linkages with micro- and macro-vascular impairments at the hand in systemic sclerosis: an HRpQCT study

Objective

To investigate the link between bone alteration and micro- and macro-vascular disease in patients with systemic sclerosis (SSc).

Results

33 SSc patients were included. In univariate analysis, low values of cortical vBMD were significantly associated with a low DBI at the 2nd finger (p = 0.004) and at the 4th (p = 0.002) and with severe capillaroscopic score (p = 0.008). In multivariate analyses, low cortical vBMD was associated with a low DBI at the 4th finger, age and severe capillaroscopic score (adjusted R² = 0.58; p = < 0.001). Low cortical thickness was associated with a low DBI at the 4th finger, severe capillaroscopic score and age (adjusted R² = 0.49, p = < 0.001).

Conclusion

Our study findings showed an association between micro- and macro-vessel damage and altered microarchitectural indices at the radius in SSc.

Methods

We performed a pilot study in female patients with SSc. Microvascular disease was assessed by the capillaroscopic score of Cutolo. Macrovascular involvement was measured by digito-brachial pressure index (DBI) on laser-Doppler at the 2nd and 4th finger. Volumetric bone mineral density (vBMD) and bone microarchitecture involvement were analysed by High-Resolution peripheral Quantitative Computed Tomography (HRpQCT) at the distal radius.

Aerobic and resistance exercise in systemic sclerosis: State of the art

INTRODUCTION

Patients with systemic sclerosis (SSc) experience reduced exercise capacity and muscle strength compared with healthy subjects. There are also indications of reduced levels of physical activity.

OBJECTIVE

To present the current knowledge of physical exercise in SSc.

RESULTS

Most studies presently available [three case studies, one single subject experimental design, one study comparing patients with healthy controls, one quasi experimental design (pre-post), two clinical trials and two random controlled trials] have included small samples of patients, mostly composed of patients with and without pulmonary involvement. It seems that patients with SSc without pulmonary involvement are able to perform and benefit from aerobic exercises of at least moderate intensity. Exercise tolerance, aerobic capacity, walking distance, muscle strength and muscle function as well as health-related quality of life (HRQL) have been found to be improved after participation in programmes including aerobic exercise and aerobic exercise combined with resistance exercises. Improvements seem to be only partially retained at follow up. Patients with pulmonary involvement may also experience improved muscle strength, physical and aerobic capacity, as well as HRQL following exercise.

CONCLUSIONS

Patients with SSc without pulmonary involvement can be recommended to be as physically active as the general population. Patients with mild pulmonary involvement can be recommended to be physically active by engaging in exercises of moderate intensity and to participate in moderate-load resistance exercises. Health professionals should inform patients with SSc about the importance of physical activity and avoidance of a sedentary lifestyle.

Are there risk factors for scleroderma-related calcinosis?

OBJECTIVES

Pathogenesis and risk factors of scleroderma associated calcinosis is poorly understood and there is no effective treatment. This study was performed to better understand the prevalence and clinical features associated with calcinosis in a cohort of SSc outpatients.

METHODS

In this cross-sectional study, we compared clinical characteristics of SSc patients with (SSc-calcinosis) and without calcinosis (SSc-control) seen in the outpatient Rutgers-RWJ Scleroderma Program between 2012 and 2015. Our analysis included clinical characteristics, comorbidities (i.e. osteoporosis), autoantibodies and imaging results. We performed univariable and multivariable regression analyses to determine common factors associated with calcinosis.

RESULTS

There were 215 SSc patients, including 65 SSc-calcinosis (81.5% females) and 150 SSc-without calcinosis (controls, 77% females). SSc-calcinosis patients were older (p = .026) with significantly longer disease duration (20 ± 10.5 years versus 12 ± 8 years, p < .0001). Limited cutaneous scleroderma was more common (54%) in the calcinosis group. Longer disease duration from non-Raynaud symptoms (OR 3.77; 95%CI 1.26, 11.27) and osteoporosis (OR 3.43; 95%CI 1.15, 10.36) remained independently associated with calcinosis.

CONCLUSIONS

Calcinosis was common in both limited and diffuse systemic sclerosis; both longer disease duration and osteoporosis were independently associated with calcinosis. Prospective studies are needed to confirm our findings.

Mesenchymal stem cell transplantation in tight-skin mice identifies miR-151-5p as a therapeutic target for systemic sclerosis

Systemic sclerosis (SSc), an autoimmune disease, may cause significant osteopenia due to activation of the IL4Rα/mTOR pathway. Mesenchymal stem cell transplantation (MSCT) can ameliorate immune disorders in SSc via inducing immune tolerance. However, it is unknown whether MSCT rescues osteopenia phenotype in SSc. Here we show that MSCT can effectively ameliorate osteopenia in SSc mice by rescuing impaired lineage differentiation of the recipient bone marrow MSCs. Mechanistically, we show that donor MSCs transfer miR-151-5p to the recipient bone marrow MSCs in SSc mice to inhibit IL4Rα expression, thus downregulating mTOR pathway activation to enhance osteogenic differentiation and reduce adipogenic differentiation. Moreover, systemic delivery of miR-151-5p is capable of rescuing osteopenia, impaired bone marrow MSCs, tight skin, and immune disorders in SSc mice, suggesting that miR-151-5p may be a specific target for SSc treatment. Our finding identifies a previously unrecognized role of MSCT in transferring miRNAs to recipient stem cells to ameliorate osteopenia via rescuing a non-coding RNA pathway.

Imaging in osteoporosis in rheumatic diseases

Osteoporosis is a common comorbidity of all major rheumatic diseases, and manifests itself both systemically and locally. Systemic bone loss manifests because of several factors, primarily inflammation, immobility, and commonly used medical treatment for rheumatic diseases. Local bone loss manifests as periarticular demineralization and bone erosion due to local release of inflammatory agents and cytokines, which promote bone resorption. All these factors contribute to the phenomenon of arthritis-associated osteoporosis. This review summarized the currently available and used methods that play a role in the diagnosis and monitoring of osteoporosis and in the detection of osteoporotic fractures.

[Bone mineral density in patients with scleroderma systematica]

AIM

To study the frequency and magnitude of a reduction in bone mineral density (BMD) and its association with clinical parameters in patients with scleroderma systematica (SDS).

SUBJECTS AND METHODS

Fifty-six postmenopausal women aged 45-71 years (58.1±7.1 years) with a valid diagnosis of SDS and 44 age-matched healthy women were examined. Dual-energy X-ray absorptiometry (Hologic QDR 4500, Waltham, MA) was performed in all the included patients to measure BMD in the lumbar spine (L(I)-L(IV)), femoral neck, and proximal femur.

RESULTS

The patients with SDS and the healthy women showed no differences in body mass index (BMI) (24.7±4.6 and 25.7±3.5 kg/m(2), respectively) and postmenopause duration (9.6±6.4 and 9.5±7.0 years, respectively); menopause occurred earlier in the patients with SDS than in the healthy women (46.9±3.6 and 49.7±3.0 years, respectively (p<0.001). The patients with SDS versus the controls had a significantly lower BMD in the lumbar spine (0.821±0.121 and 0.861±0.092 g/cm(2); р<0.05), femoral neck (0.620±0.129 and 0.736±0.112 g/cm(2); p<0.0001), and proximal femur (0.736±0.148 and 0.884±0.124 g/cm(2); р<0.0001). Osteoporosis (OP) was detected in 29 (52%) of the 56 patients and in only 5 (11%) of the 44 control women (р<0.0001). The patients with diffuse SDS displayed a much greater reduction in BMD in all the regions than those with circumscribed SDS. BMD was significantly lower in the patients treated with glucocorticosteroids (GCS) than in the untreated ones. In the control group, BMD was associated with age, duration of menopause, and BMI. In the patients with SDS, BMD was correlated with BMI and inversely correlated with duration of menopause, and the magnitude of a BMD reduction was closely related to disease duration. The patients also showed an inverse correlation of BMD with the daily dose of GCS.

CONCLUSION

The postmenopausal women with SDS were found to have a lower BMD in 80% of cases. In this category of women, the reduction in BMD was significantly commoner and more pronounced than in the age-matched healthy women. Low BMI, diffuse SDS, disease duration, and GCS use are risk factors for reduced BMD and OP.

Bone Metabolism in a Large Cohort of Patients with Systemic Sclerosis

The aim of this study was to evaluate in a large size cohort of SSc patients bone mineral density (BMD) and to analyze its possible determinants. 106 consecutive outpatients affected by SSc were enrolled and completely evaluated for bone metabolism and SSc characteristics. For the statistical analysis, we preferred Z score to BMD or T score since the population was composed of patients of different ages and of both sexes. Mean neck Z score was significantly lower than 0. No significant differences were found for other sites. Female patients were shown to have a total femur and neck Z score significantly lower than 0 (p = 0.028 and p < 0.001, respectively). 13 % of patients had at least one morphometric non-clinical vertebral fracture. In univariate analysis, total femur Z score was lower in female (p = 0.050) and positively correlates with BMI (p = 0.001), neck Z score positively correlates with age (p = 0.016), and whole body Z score positively correlates with BMI (p < 0.001). No correlations were found for lumbar Z score. The multivariate analysis confirmed the positive correlation between BMI and total femur and whole body Z score and between age and neck femur Z score (p = 0.005, p < 0.001 and p = 0.040, respectively). Lung involvement was shown to correlate with a lower whole body Z score in multivariate analysis (p = 0.037). We found a modest risk of low BMD in patients with SSc and the important protective role of BMI. Patients with lung involvement showed lower whole body Z score.

Calcinosis is associated with digital ulcers and osteoporosis in patients with systemic sclerosis: A Scleroderma Clinical Trials Consortium study

OBJECTIVES

We sought to identify the clinical factors associated with calcinosis in an international multicenter collaborative effort with the Scleroderma Clinical Trials Consortium (SCTC).

METHODS

This is a retrospective cohort study of 5218 patients with systemic sclerosis (SSc). Logistic regression was used to obtain odds ratios (OR) relating calcinosis to various clinical features in multivariate analyses.

RESULTS

A total of 1290 patients (24.7%) had calcinosis. In univariate analyses, patients with calcinosis were older than patients without calcinosis, more likely to be female, and had longer disease duration from the first non-Raynaud phenomenon symptom. Patients with calcinosis were more likely to have digital ulcers, telangiectasias, acro-osteolysis, cardiac disease, pulmonary hypertension, gastrointestinal involvement, arthritis, and osteoporosis, but less likely to have muscle disease. Anti-Scl-70, RNA-polymerase-III, and U1-RNP autoantibodies were significantly less common in patients with calcinosis, while anticentromere (ACA), anti-PM/Scl, and anticardiolipin antibodies were more frequent. In multivariate analysis, the strongest associations with calcinosis were digital ulcers (OR = 3.9; 95% CI: 2.7-5.5; p < 0.0001) and osteoporosis (OR = 4.2; 95% CI: 2.3-7.9; p < 0.0001).

CONCLUSION

One quarter of patients with SSc have calcinosis at some time during their illness. Our data confirm a strong association of calcinosis with digital ulcers, and support a novel association with osteoporosis.

Association of Acroosteolysis With Enhanced Osteoclastogenesis and Higher Blood Levels of Vascular Endothelial Growth Factor in Systemic Sclerosis

OBJECTIVE

Bone resorption of distal phalanges, or acroosteolysis (AO), can develop in patients with systemic sclerosis (SSc), causing pain and functional limitation. This study was undertaken to investigate whether AO may be associated with abnormal osteoclastogenesis in SSc patients and whether hypoxia may be involved in this process.

METHODS

Peripheral blood mononuclear cells (PBMCs) obtained from 26 SSc patients (11 with AO and 15 without AO) and 14 healthy controls were cultured in the presence of RANKL and macrophage colony-stimulating factor for 9 days. Tartrate-resistant acid phosphatase-positive multinucleated giant cells (MGCs) containing 3 or more nuclei were counted as osteoclasts. Plasma levels and effects of vascular endothelial growth factor (VEGF) on osteoclast formation were evaluated.

RESULTS

SSc patients with AO formed significantly more osteoclasts after 9 days than did patients without AO (mean ± SD 142.4 ± 67.0 versus 27.2 ± 17.6 MGCs/well; P < 0.001) or healthy controls (mean ± SD 18.7 ± 27.0 MGCs/well; P < 0.001). No significant difference in osteoclast formation was noted between the patients without AO and healthy controls. Plasma levels of VEGF were higher in SSc patients with AO compared to those without (mean ± SD 142.4 ± 69.6 pg/ml versus 88.1 ± 38.2 pg/ml; P < 0.005) or healthy controls (54.2 ± 24.6 pg/ml; P = 0.018). Priming with VEGF-A for 24 hours significantly increased osteoclast generation by 5.3 ± 1.9 fold (P = 0.0018). The radiographic extent of AO was associated with increased osteoclast formation (Spearman's ρ = 0.741, P = 0.01).

CONCLUSION

Our findings indicate that increased osteoclast formation and higher VEGF levels may contribute to AO in SSc patients. Further studies are needed to elucidate whether targeting osteoclastogenesis may provide a specific therapeutic option for SSc-associated AO.

Prevalence and predictive factors of osteoporosis in systemic sclerosis patients: a case-control study

Purpose

Investigate the prevalence of osteoporosis in patients with systemic sclerosis (SSc) and describe alterations of bone tissue with High-Resolution peripheral Quantitative Computed Tomography (HR-pQCT).

Methods

Thirty-three patients and 33 controls matched on age, body mass index (BMI) and menopause were included. Bone mineral density (BMD) was measured at the lumbar spine (LS), femoral neck (FN) and total hip (TH) by dual energy X-ray absorptiometry. Volumetric BMD (vBMD) and bone microarchitecture were measured by HR-pQCT at tibia and radius.

Results

In patients, BMI was significantly lower, the prevalence of osteoporosis was significantly higher and HR-pQCT analysis showed a significant alteration of the trabecular compartment with a decrease in trabecular vBMD on both sites than in controls. In multivariate analysis, a low lean body mass, presence of anticentromere antibodies and older age were identified as independent factors for decreased BMD at LS (r²=0.43), FN (r²=0.61) and TH (r²=0.73). History or current digital ulcers were also identified as an independent factor for microarchitecture alteration.

Conclusion

In patients an increased prevalence of osteoporosis was found and HR-pQCT showed impaired trabecular bone compartment. Also, low lean body mass, high age, digital ulcers and ACAs were identified as independent risk factors for bone damage.

Rheumatic autoimmune diseases in women and midlife health

Autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (scleroderma) preferentially affect women, and are characterized by systemic inflammation leading to target organ dysfunction. The public health burden of autoimmune diseases, which collectively represent a leading cause of morbidity and mortality among women throughout adulthood, is substantial. While some features of these diseases have been observed to improve over the menopausal transition, such as disease flare rate in SLE and skin softening and thinning in scleroderma, others, such as swollen and tender joints and radiographically confirmed damage in RA may worsen. The general trends, however, are not consistent or conclusive for all disease-related manifestations. Of great importance is the recognition that comorbid diseases, including osteoporosis and accelerated cardiovascular disease, contribute excess morbidity and mortality that becomes increasingly apparent as women with autoimmune diseases undergo the menopausal transition.

Rare causes of osteoporosis

Osteoporosis is a metabolic bone disease characterized by loss of bone mass and strength, resulting in increased risk of fractures. It is classically divided into primary (post-menopausal or senile), secondary and idiopathic forms. There are many rare diseases, that cause directly or indirectly osteoporosis. The identification and classification of most of these rare causes of osteoporosis is crucial for the specialists in endocrinology and not, in order to prevent this bone complication and to provide for an early therapy. Several pathogenic mechanisms are involved, including various aspects of bone metabolism such as: decreased bone formation, increased bone resorption, altered calcium, phosphorus and/or vitamin D homeostasis, and abnormal collagen synthesis. In this review, less common forms of primary and secondary osteoporosis are described, specifying, if applicable: genetic causes, epidemiology, clinical features, and pathogenic mechanisms causing osteoporosis. A greater awareness of all rare causes of osteoporosis could reduce the number of cases classified as idiopathic osteoporosis and allow the introduction of appropriate and timely treatments.

Relationship between Body Mass Composition, Bone Mineral Density, Skin Fibrosis and 25(OH) Vitamin D Serum Levels in Systemic Sclerosis

A reduced bone mineral density (BMD) is observed in several rheumatic autoimmune diseases, including Systemic Sclerosis (SSc); nevertheless, data concerning the possible determinants of bone loss in this disease are not fully investigated. The aim of this study is to evaluate the relationship between BMD, body mass composition, skin sclerosis and serum Vitamin D levels in two subsets of SSc patients. 64 post-menopausal SSc patients, classified as limited cutaneous (lcSSc) or diffuse cutaneous (dcSSc) SSc, were studied. As control, 35 healthy post-menopausal women were recruited. Clinical parameters were evaluated, including the extent of skin involvement. BMD at lumbar spine, hip, femoral neck and body mass composition were determined by dual-energy X-ray absorptiometry. Serum calcium, phosphorus, alkaline phosphatase, urine pyridinium cross-links, intact parathyroid hormone and 25-hydroxyvitamin D (25OHD) were measured. BMD at spine, femoral neck and total hip was significantly lower in SSc patients compared to controls. In dcSSc subset, BMD at spine, femoral neck and total hip was significantly lower compared to lcSSc. No differences in both fat and lean mass were found in the three study groups even if patients with dcSSc showed a slightly lower total body mass compared to healthy controls. Total mineral content was significantly reduced in dSSc compared to both healthy subjects and lcSSc group. Hypovitaminosis D was observed both in healthy post-menopausal women and in SSc patients, but 25OHD levels were significantly lower in dcSSc compared to lcSSc and inversely correlated with the extent of skin thickness. These results support the hypothesis that the extent of skin involvement in SSc patients could be an important factor in determining low circulating levels of 25OHD, which in turn could play a significant role in the reduction of BMD and total mineral content.

Osteoporosis in rheumatic diseases

Rheumatic diseases, characterized by chronic inflammation and damage to various organs and systems, include systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis and other connective tissue diseases. Bone is a target in many inflammatory rheumatic diseases. In recent years, the survival of patients with rheumatic diseases has increased markedly and the relationship between rheumatic diseases and osteoporosis (OP) has become more prominent. OP and related fragility fractures increase the morbidity and mortality of rheumatic disease. The cause of OP in rheumatic diseases is complex. The pathogenesis of OP in rheumatic diseases is multifactorial, including disease and treatment-related factors. Osteoimmunology, a crosstalk between inflammatory and bone cells, provides some insight into the pathogenesis of bone loss in systematic inflammatory diseases. The aim of this article is to review different risk factors in rheumatic diseases. Several factors play a role, such as chronic inflammation, immunological factors, traditional factors, metabolism and drug factors. Chronic inflammation is the most important risk factor and drug treatment is complex in patients with OP and rheumatic disease. Attention should be paid to bone loss in rheumatic disease. Optimal treatment of the underlying rheumatic disease is the first step towards prevention of OP and fractures. Apart from that, a healthy lifestyle is important as well as calcium and vitamin D supplementation. Bisphosphonates or denosumab might be necessary for patients with a low T score.

mTOR inhibition rescues osteopenia in mice with systemic sclerosis

Chen et al. show that treatment with rapamycin, a drug known to inhibit mTOR signaling, rescues low bone density in mice with systemic sclerosis.

Fibrillin-1 (FBN1) deficiency-induced systemic sclerosis is attributed to elevation of interleukin-4 (IL4) and TGF-β, but the mechanism underlying FBN1 deficiency–associated osteopenia is not fully understood. We show that bone marrow mesenchymal stem cells (BMMSCs) from FBN1-deficient (Fbn1^+/−) mice exhibit decreased osteogenic differentiation and increased adipogenic differentiation. Mechanistically, this lineage alteration is regulated by IL4/IL4Rα-mediated activation of mTOR signaling to down-regulate RUNX2 and up-regulate PPARγ2, respectively, via P70 ribosomal S6 protein kinase (P70S6K). Additionally, we reveal that activation of TGF-β/SMAD3/SP1 signaling results in enhancement of SP1 binding to the IL4Rα promoter to synergistically activate mTOR pathway in Fbn1^+/− BMMSCs. Blockage of mTOR signaling by osteoblastic-specific knockout or rapamycin treatment rescues osteopenia phenotype in Fbn1^+/− mice by improving osteogenic differentiation of BMMSCs. Collectively, this study identifies a previously unrecognized role of the FBN1/TGF-β/IL4Rα/mTOR cascade in BMMSC lineage selection and provides experimental evidence that rapamycin treatment may provide an anabolic therapy for osteopenia in Fbn1^+/− mice.

Musculoskeletal involvement in systemic sclerosis

Musculoskeletal (MSK) involvement is a very frequent manifestation of patients with systemic sclerosis (SSc). There are several reports about clinical trials assessing musculoskeletal involvement in SSc. However, only few controlled studies have been conducted. The prevalence of musculoskeletal symptoms, clinical and radiographic findings has been assessed. The most important articular (arthralgia, synovitis, contractures), tendon (tendon friction rubs, tenosynovitis) and muscular manifestations (myalgia, muscle weakness, myositis) should be carefully evaluated during the assessment of SSc patients, because these are not only common, but substantially influence the quality of life and some of them also have predictive value concerning disease activity and severity.