Post-diagnosis serum 25-hydroxyvitamin D concentrations in women treated for breast cancer participating in a lifestyle trial in Italy

OBJECTIVE

To report cross-sectionally serum levels of 25-hydroxyvitamin D [25(OH)D] in women living in Italy within 12 months from breast cancer (BC) diagnosis.

METHODS

Baseline data were obtained from 394 women diagnosed with primary BC, enrolled from 2016 to 2019 in a lifestyle trial conducted in Italy. Subjects' characteristics were compared between two 25(OH)D concentrations (hypovitaminosis D<20 and ≥20 ng/mL) with the Chi-squared test or Fisher's exact test for small-expected counts. Using multiple logistic regression-adjusted models, we estimated odds ratios (ORs) of hypovitaminosis D with 95% confidence intervals (CIs) in the total sample and in the unsupplemented subgroup.

RESULTS

Hypovitaminosis D was found in 39% of all subjects, 60% in unsupplemented subjects, and 10% in supplemented subjects. Increasing ORs of hypovitaminosis D were found with increasing body mass index, 25-30, >30, and ≥35 versus <25 kg/m2 (ORs: 2.50, 4.64, and 5.81, respectively, in the total cohort and ORs: 2.68, 5.38, and 7.08 in the unsupplemented); living in the most southern Italian region (OR 2.50, 95%CI 1.22-5.13); and with hypertriglyceridemia (OR 2.46; 95%CI 1.16-5.22), chemotherapy history (OR 1.86, 95%CI 1.03-3.38), and inversely with anti-estrogenic therapy (OR 0.43, 95%CI 0.24-0.75) in the total sample.

CONCLUSIONS

Hypovitaminosis D in women recently diagnosed with BC and participating in a lifestyle trial in Italy was widespread and highest with obesity, hypertriglyceridemia, and chemotherapy use. Considering that hypovitaminosis D is a risk factor for lower efficacy of bone density treatments and possibly BC mortality, our results suggest the need to promptly address and treat vitamin D deficiency.

Secukinumab retention rate is greater in patients with psoriatic arthritis presenting with axial involvement

Psoriatic arthritis (PsA) is an inflammatory disease characterized by peripheral and axial involvement. Biological disease-modifying antirheumatic drugs (bDMARDs) are the mainstream treatment for PsA and bDMARDs retention rate is a proxy for the drug's overall effectiveness. However, it is unclear whether IL-17 inhibitors can have a higher retention rate than tumor necrosis factor (TNF) inhibitors, in particular in axial or peripheral PsA. A real-life observational study was conducted on bDMARD naïve PsA patients initiating TNF inhibitors or secukinumab. Time-to-switch analysis was carried out with Kaplan-Meyer curves (log-rank test) truncated at 3 years (1095 days). Sub-analyses of Kaplan-Meyer curves between patients presenting with prevalent peripheral PsA or prevalent axial PsA were also conducted. Cox regression models were employed to describe predictors of treatment switch/swap. Data on 269 patients with PsA naïve to bDMARD starting either TNF inhibitors (n=220) or secukinumab (n=48) were retrieved. The overall treatment retention at 1 and 2 years was similar for secukinumab and TNF inhibitors (log-rank test p NS). We found a trend towards significance in the Kaplan-Meyer at 3 years in favor of secukinumab (log-rank test p 0.081). Predominant axial disease was significantly associated with a higher chance of drug survival in secukinumab users (adjusted hazard ratio 0.15, 95% confidence interval = 0.04-0.54) but not in TNF inhibitor users. In this real-life, single-center, study on bDMARD naïve PsA patients, axial involvement was associated with longer survival of secukinumab but not of TNF inhibitors. Drug retention of secukinumab and TNF inhibitors were similar in predominantly peripheral PsA.

OP0071 ASSOCIATION BETWEEN LONG-TERM EXPOSURE TO AIR POLLUTION AND IMMUNE-MEDIATED DISEASES: A POPULATION-BASED COHORT STUDY

Background

Environmental air pollution has been associated with disruption of the immune system at a molecular level.

Objectives

The primary aim of the present study is to describe the association between long-term exposure to air pollution and risk of developing immune-mediated conditions.

Methods

We conducted a retrospective observational study on a nation-wide dataset of women and men. Diagnoses of various immune-mediated diseases were retrieved. Data on the monitoring of PM10 and PM2.5 concentrations were retrieved from the Italian institute of environment protection and research (ISPRA). The long-term average PMs concentrations were the exposure of interest. Every study subject was linked to a PMs exposure value, which resulted from the average concentration of urban, rural and near-traffic stations of the subject residency from January 2013 to November 2020. Patients were linked to the nearest air quality station through ZIP code centroids. Generalized linear models were employed to determine the relationship between autoimmune diseases prevalence and PM. The fully adjusted model included age, body mass index (BMI), menopause, glucocorticoid treatment, treatment with adjuvant hormone therapy for breast or prostate cancer, specialty of the physician that entered the data and macro-area of residency (stratified as a categorical variable: northern Italy, central Italy and southern Italy.

Results

81,363 subjects were included in the study. We found a positive association between PM10 and the risk of autoimmune diseases (ρ +0.007, p 0.014). Every 10 µg/m3 increase in PM10 concentration was associated with an incremental 7% risk of having autoimmune disease. Exposure to PM10 above 30 µg/m3 and PM2.5 above 20 µg/m3 was associated with a 12% and 13% higher risk of autoimmune disease pooled together, respectively (aOR 1.12, 95% CI 1.05-1.20 and aOR 1.13, 95% CI 1.06-1.20). Exposure to PM10 was associated with an increased risk of rheumatoid arthritis (aOR 1.408, 95% CI 1.271-1.560) but no other autoimmune diseases, whereas exposure to high levels of PM2.5 were associated with an increased risk of rheumatoid arthritis (aOR 1.559, 95% CI 1.401-1.734), CTDs (aOR 1.147, 95% CI 1.024-1.286) and IBDs (1.206, 95% CI 1.028-1.415) but no other autoimmune diseases.

Conclusion

Long-term exposure to air pollution was associated with higher risk of developing autoimmune diseases, in particular rheumatoid arthritis, CTDs and IBD. Chronic exposure to levels above the threshold for human protection was associated with a 10% higher risk of developing immune-mediated diseases.

Disclosure of Interests

Giovanni Adami Shareholder of: Galapagos, Theramex, Marco Pontalti: None declared, Camilla Benini: None declared, Angelo Fassio: None declared, Eugenia Bertoldo: None declared, Davide Gatti: None declared, Maurizio Rossini Shareholder of: Abbvie, Amgen, Bms, Eli Lilly, Galapagos, Novartis, Pfizer, Sandoz, Theramex, Ucb.

AB1019 THE EFFECTS OF THREE DIFFERENT VITAMIN D3 SUPPLEMENTATION REGIMENS IN DEFICIENT SUBJECTS ON INFLAMMATORY CYTOKINES – A RANDOMISED OPEN-LABEL PARALLEL GROUPS STUDY

Background

The effects of cholecalciferol supplementation on the regulation of inflammatory cytokines are still unclear.

Objectives

This is a preliminary analysis on exploratory outcomes the DIBA/11 RCT [1,2] and aimed to compare the effects on serum inflammatory cytokines of three different regimes of cholecalciferol supplementation in vitamin D-deficient subjects.

Methods

We evaluated, in healthy subjects affected by vitamin D deficiency (defined as 25OHD<20 ng/mL), 18 to 60 years of age, the efficacy of three different oral supplementation regimens: daily 10,000Iu administered for 8 weeks (group A), weekly 50,000Iu (group B) for 12 weeks and biweekly 100,000Iu (group C) for 12 weeks.

Serum TNFα, interleukin-6 (IL6), interleukin-17 (IL17) and interleukin-10 (IL10) were dosed at baseline, Day 28, 53, 84 and 112. This study was approved by the institutional research committee (protocol identification: DIBA/11,EudraCT Number:2017-000194-36). Supported by Abiogen Pharma, Italy).

Results

A total of 75 subjects were randomized to receive one supplementation regimen. The descriptive of the sample at baseline and relative cytokines levels at the various observation points are reported in Table 1. The absolute changes of IL6, IL17 and IL10 are depicted in Figure 1. No significant differences were found among the three groups. TNFα was undetectable at baseline and at any time point.

Table 1.

anthropometrics and laboratory parameters at baseline (mean values ± standard deviation)

ParameterAll patients (N=75)Daily 10.000 Ui(N = 25)Weekly 50.000 Ui(n = 25)Biweekly 100.000 Ui(N = 25)p-value (ANOVA)M:F31:4412:137:1812:13NSAge (years)34.1 ± 10.230.2 ± 9.936.7 ± 8.735.4 ± 11.00.059Body Weight (kg)66.7 ± 12.465.8 ± 13.267.8 ± 10.866.6 ± 13.7NSBMI23.1 ± 2.622.55 ± 2.723.8 ± 2.222.8 ± 2.7NSBaseline 25OHD (ng/mL)13.5 ± 3.714.6 ± 3.912.8 ± 313.5 ± 4.1NSBaseline IL-6 (pg/mL)1.3 ± 1.20.9 ± 0.61.4 ± 1.61.6 ± 1.3NSBaseline IL-17 (pg/mL)0.4 ± 1.80.7 ± 30.2 ± 1.10.2 ± 0.7NSBaseline IL-10 (pg/mL)0.9 ± 0.90.8 ± 0.71.2 ± 1.20.8 ± 0.7NSFigure 1.

absolute changes of IL17, IL6 and IL10. *p<0.05 vs baseline.

Conclusion

In the overall cohort we found slight decreases in serum IL6 and IL17 serum levels. No differences were found among groups.

References

[1]Fassio A, Adami G, Rossini M, et al. Pharmacokinetics of Oral Cholecalciferol in Healthy Subjects with Vitamin D Deficiency: A Randomized Open-Label Study. Nutrients. 2020;12(6).

[2]Fassio A, Gatti D, Rossini M, et al. Pharmacodynamics of Oral Cholecalciferol in Healthy Individuals with Vitamin D Deficiency: A Randomized Open-Label Study. Nutrients. 2021;13(7):2293.

Disclosure of Interests

Angelo Fassio: None declared, Davide Gatti Speakers bureau: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Paid instructor for: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Matteo Gatti: None declared, Maurizio Rossini Speakers bureau: Abiogen, Amgen, Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Grunenthal, MSD, Novartis, Pfizer, Sanofi, Sandoz, Theramex, UCB., Eugenia Bertoldo: None declared, Giovanni Adami: None declared

POS1140 SHORT-TERM EXPOSURE TO FINE PARTICULATE MATTER AND RISK OF FRAGILITY HIP FRACTURES, A CASE-CROSSOVER STUDY ON 1,042 HIP FRACTURES

Background

Fragility femoral fracture is a common, world-spread, medical condition, that has a relevant impact both clinically and economically. Chronic exposure to environmental air pollution has been linked with a higher risk of developing osteoporosis. However, little is known regarding the relationship between short-term exposure to air pollution and bone fractures.

Objectives

Our study aims to investigate the link between short-term exposure to fine particulate matters and fragility hip fractures

Methods

We retrieved data of patients suffering of hip fractures admitted to the Orthopedic Unit of the University of Verona Hospital from 2015 to 2020. We retrieved data on the monitoring of PM10 concentrations from the Italian institute of environment protection and research (ISPRA). We designed a case-crossover study to compare the exposure to particulate matters (PM10) in the 30-day period immediately before the fracture (hazard period) referent to a 30-day control period (from day -30 to -60 from the fracture). Exposure to PM10 was evaluated as mean value and AUC. Case-crossover is a peculiar study design applied to longitudinal datasets that controls for within-person time-invariant and between-patient confounders such as indoor air pollution, chronic comorbidities or concomitant medications and have been used extensively to study the effects of transient, short-term exposures on the risk of acute events (Figure 1A)

Results

1042 patients (73.7% female n=768), with a hip fracture admitted to the hospital were included in the study. Mean age of the cohort was 82.6 years (±9.55). Average exposure to PM 10 in the control period was 33,84 ug/mm3, cumulative exposure (AUC) was 952,42 ug/mm3 compared 31,72 ug/mm3 and AUC of 920,24 ug/mm3 in the hazard period (Figure 1B) The difference between levels of PM10 in the two periods was statistically significant as levels of PM10 was higher in the hazard period compared to control period, with a p-value = 0,027 (α <0,05) when comparing average concentrations in the two groups and a p-value = 0,024 (α <0,05), when comparing AUCs.

Conclusion

Our study suggests that the short-term exposure to environmental air pollution might increase the risk of femoral fragility fractures. Further studies should be taken to further investigate the biological mechanisms underlining this finding.

Disclosure of Interests

Giovanni Adami Shareholder of: Theramex, Galapagos, Marco Pontalti: None declared, Angelo Fassio: None declared, Camilla Benini: None declared, Davide Gatti: None declared, Stefano Negri: None declared, Pietro Olivi: None declared, Maurizio Rossini Shareholder of: Abbvie, Amgen, Bms, Eli Lilly, Galapagos, Novartis, Pfizer, Sandoz, Theramex, Ucb.

AB1017 RADIOFREQUENCY ECHOGRAPHIC MULTI-SPECTROMETRY (REMS) AND DUAL-ENERGY X-RAYS ABSORPTIOMETRY FOR THE EVALUATION OF BONE MINERAL DENSITY IN A PERITONEAL DIALYSIS SETTING

Background

Radiofrequency echographic multi-spectrometry (REMS) is a novel ultrasound-based technique that has shown good reliability in the assessment of bone mineral density (BMD).

Objectives

The aim of this study was to compare the performance of the REMS BMD assessment with dual-energy X-rays absorptiometry (DXA) in a cohort of patients affected by end-stage renal disease undergoing peritoneal dialysis (PD).

Methods

Consecutive patients referring to the PD clinic of our hospital were enrolled. Lumbar spine and proximal femur REMS scans were performed, and lumbar spine (anteroposterior and laterolateral) and proximal femur DXA scans were performed as well. Clinical data were extracted from medical records. The risk assessment outputs of two fracture risk algorithms (FRAX and DeFRA), calculated upon the worst BMD obtained from either technique were compared as well. Analysis of variance (ANOVA) with post hoc analysis (Bonferroni) and a two-sided Student’s t-test were used to estimate the absolute differences between groups.

Written informed consent was obtained from all participants included (protocol 1483 CESC).

Results

41 total patients were enrolled (Table 1). No significant differences were documented between the BMD T-scores measured through DXA or REMS at the proximal femur. At the lumbar spine, the DXA laterolateral T-score was not significantly different from that of REMS, while the DXA anteroposterior T-score was significantly higher than both the anteroposterior DXA and the REMS measurements (Figure 1, panel A and B). When either DXA or REMS was adopted, no significant difference in the fracture risk estimate was found for both algorithms (Figure 1, panel C and D).

Table 1.

anthropometrics, clinical and biochemical characteristics of the enrolled sample. CKD, chronic kidney disease; PTH, parathyroid hormone; ALP, alkaline phosphatase; IQR, interquartile range; VFA, vertebral fracture assessment.

Sample size (M)41 (29)Age (y)Median [IQR]62 [52-73]Height (cm)Median [IQR]170 [165-176]Body weight (Kg)Median [IQR]74 [61-83]Body mass index (Kg/m2)Median [IQR]25 [22-27.8]Disease duration – CKD (months)Median [IQR]132 [48-140]Dialysis duration (months)Median [IQR]10 [3-24]S-calcium (mg/dL)Median [IQR]9.1 [8.6-9.4]S-phosphorous (mg/dL)Median [IQR]5.4 [4.6-6.4]PTH (pg/mL)Median [IQR]31.4 [22.8-46.8]25OH Vitamin D (nmol/L)Median [IQR]53 [36-72]Patients with morphometric fractures (VFA)15%Patients with femoral fractures2.4%Total n° of morphometric fractures12Figure 1.

comparison of the mean T-scores (error bars represent 95%CI) measured with DXA and REMS at the lumbar spine (panel A), and at the femur (panel B). Comparison between the DeFRA DXA and REMS-derived outputs (panel C) and FRAX DXA and REMS-derived outputs (panel D) raw and after correction for TBS. DeFRA, FRAX-derived risk assessment tool; FRAX, Fracture Risk Assessment tool; AP, anteroposterior; LL, latero-lateral; TH, total hip; FN, femoral neck; TBS, trabecular bone score.

Conclusion

Our data showed a good agreement, in a real-life PD setting, between the DXA and REMS-derived BMDs and in the consequent fracture risk assessment obtained with the FRAX or DeFRA tools.

Disclosure of Interests

Angelo Fassio: None declared, Stefano Andreola: None declared, Davide Gatti Paid instructor for: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Consultant of: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB., Matteo Gatti: None declared, Giovanni Gambaro Speakers bureau: Vifor Pharma, Maurizio Rossini Speakers bureau: Abiogen, Amgen, Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Grunenthal, MSD, Novartis, Pfizer, Sanofi, Sandoz, Theramex, UCB., Ombretta Viapiana: None declared, Giulia Zanetti: None declared, Francesca Pistillo: None declared, Valeri Messina: None declared, Giovanni Adami: None declared

AB1365 PROPOSAL FOR A STANDARDIZED ULTRASOUND SCANNING PROTOCOL OF THE NAIL PLATE

Background

Ultrasonography of the nails with high frequency linear transducers can properly perform morphological images, achieving highly descriptive power but the lack of standardization may hesitate in lack of reproducibility and scarce usefulness.

Objectives

The aim of this study was to provide a detailed scan protocol of nail plate, including comparison of scan planes and probe positioning.

Methods

Transversal and longitudinal ultrasound scans were performed on each fingernail of both hands in healthy subjects. Nail plate thickness and Power Doppler of the nail bed were recorded. All the images were acquired using Canon Aplio i800 with a linear transducer of 22 MHz (i22LHB). Two different operators performed evaluation of thickness at distal, middle and proximal portion of nail in longitudinal view and at 0°, -45° and +45° for transverse view (Figure 1). ANOVA for repeated measures was used to determine differences between nail of the different digits.

Figure 1.

Longitudinal and transverse view of the nail. In yellow the position and angles of the caliper used for acquiring the measures

Results

The study sample was composed of 27 healthy subjects between 25- and 40- year old with no rheumatological or dermatological nail issues. A total of 270 nails were scanned; none of them was excluded due to comorbidity, trauma or other conditions which can interfere in the evaluation. A decrease in nail thickness was observed from first to fifth digit, regardless the hand (dominant or not), that resulted significant for the ANOVA. No differences were found regarding the thickness in the different segments of nail plate and this occurred both for longitudinal and transverse scans.

Conclusion

We demonstrated the absence of a statistically significant difference between thickness at proximal, middle and distal portion of the nail in longitudinal view or at any different angle in transverse view, concluding the fastest and easiest way to measure the nail plate thickness is in the longitudinal view at the middle segment, avoiding potential issues in positioning the probe in the transverse view or in positioning the caliper at proximal or distal segment in longitudinal view. All the nails should be scanned per protocol, since the thickness is variable and the fifth may be the most interesting in order to consider its highest variance.

References

[1]Fassio A. et al.; Clin Rheumatol. 2020 May;39(5):1391-1404. doi: 10.1007/s10067-019-04748-2. Epub 2019 Aug 22.

Table 1.

ANOVA for repeated measures of the nail plate thickness. A trend in decreasing P value is clearly visible from first to fifth. P considered statistically significant when ≤ 0.05

LONGITUDINALTRANSVERSEPROXIMAL-45°Row-mean1234Row-mean123421.00020.73130.7651.00030.2641.00040.0280.8881.00040.0000.0560.18750.0000.0010.0030.15850.0000.0050.0231.000MIDDLE0°Row-mean1234Row-mean123421.00020.71931.0001.00030.0561.00040.0701.0001.00040.0000.1581.00050.0000.0010.0020.09550.0000.0250.3891.000DISTAL+45°Row-mean1234Row-mean123421.00021.00030.8541.00030.7651.00040.0060.0930.75440.0500.5831.00050.0000.0000.0000.11450.0000.0010.0160.323

Disclosure of Interests

None declared

AB1167 THE USE OF ORAL AMINO-BISPHOSPHONATES AND CORONAVIRUS DISEASE 2019 (COVID-19) OUTCOMES

Background

The determinants of the susceptibility to SARS-CoV-2 infection and severe Coronavirus Disease 19 (COVID-19) manifestations are yet not fully understood. Amino-bisphosphonates (N-BPs) have anti-inflammatory properties and have been shown to reduce the incidence of lower respiratory infections, cardiovascular events and cancer.

Objectives

We conducted a population-based retrospective observational case control study with the primary objective of determining if oral N-BPs treatment can play a role in thesusceptibility to the development of severe COVID-19.

Methods

Administrative ICD-9-CM and ATC data, representative of Italian population (9% sample of the overallpopulation), were analyzed. Oral N-BPs (mainly alendronate and risedronate) were included in the analysis. Patients treated with bisphosphonates (cases) were randomly matched (1:1 ratio) for age, sex and for other clinically relevant variables (presence of treatments other than bisphosphonates and hospitalizations) with all the health-assisted population without this treatment (controls).

Results

Incidence of Covid-19 hospitalization was 12.32 [95%CI 9.61-15.04] and 11.55 [95%CI 8.91-14.20], of ICU utilization due to COVID-19 was 1.25 [95%CI 0.38-2.11] and 1.42 [95%CI 0.49-2.36] and of all-cause death was4.06 [95%CI 2.50-5.61] and 3.96 [95%CI 2.41-5.51] for oral N-BPs users and non-users, respectively (Figure 1A). Figure 1B Incidence and 95% CI of COVID-19 related events in N-BPs treated and untreated subjects with anti-osteoporotic drugs and without corticosteroids. C. Incidence and 95% CI of COVID-19 related events in N-BPs treated and untreated without previous vertebral or hip fragility fractures. D. Incidence of COVID-19related events in bisphosphonates treated and untreated patients without previous vertebral or hip fracture without corticosteroid prescriptions.

Conclusion

In conclusion, we found that the incidence of COVID-19 hospitalization, intensive care unit (ICU) utilization and COVID-19 potentially related mortality were similar in N-BPs treated and non-treated subjects. Similar results were found in N-BPs versus other anti-osteoporotic drugs. We provided real-life data on the safety of oral N-BPs in terms of severe COVID-19 risk on a population-based cohort. Our results strongly support national and international guidelines that advocate against the discontinuation of oral bisphosphonates only for the fear of COVID-19.

Disclosure of Interests

None declared

AB1018 RELATIONSHIP BETWEEN AORTIC CALCIFICATIONS AND DXA AND RADIOFREQUENCY ECHOGRAPHIC MULTI-SPECTROMETRY (REMS) ACQUISITIONS

Background

Data on the relationship between peritoneal dialysis (PD), BMD and aortic calcifications (AOC) are lacking.

Objectives

to study the relationship between the degree of AOC and DXA and Radiofrequency Echographic Multi-Spectrometry (REMS) acquisitions.

Methods

Consecutive patients referring to the PD our clinic were enrolled. Lumbar spine (LS) and proximal femur REMS scans were performed, and LS (anteroposterior and laterolateral) and proximal femur DXA scans were performed as well. The degree of AOC was assessed through the semiquantitative score described by Kauppila et al, and applied to the laterolateral LS DXA scans. To test for correlations between different variables, we used the Pearson’s correlation for continuous variables and Spearman’s rho for discrete variables. Multiple regression analysis was performed to adjust for age and body mass index (BMI) the correlation between BMD and the CKD duration. Written informed consent was obtained from all participants (protocol 1483CESC).

Results

41 total patients were enrolled (29 males, 19 females). Median disease duration of CKD [IQR]: 132 months [48-140]. 15% had vertebral fractures at the DXA Vertebral Fracture Assessment (VFA). The median calcification score [IQR] was 2 [0-6] (min-max 0-20).

We found a statistically significant positive correlation of moderate strength between the total calcification score and the difference between the DXA AP T-score and the DXA LL T-score at the LS (p<0.01, Spearman’s rho = 0.402), Figure 1.

Figure 1.

scatter plot reporting the relationship between the difference between the AP and LL T-scores and the aortic calcifications score.

After adjustment for confounders, we found a significant negative between the LS and femoral neck BMD measured through REMS and CKD duration (Table 1). The same correlation was not significant then BMD was assessed with DXA.

Table 1.

multiple linear regression analysis for REMS T-score at each site after adjustment for age and BMI. BMI, body mass index; β, standardised coefficient.

REMS lumbar spine T-scoreβpCKD duration (months)-0.2280.035Age (years)-0.511<0.01BMI (kg/m2)0.566<0.01REMS femoral neck T-scoreβpCKD duration (months)-0.2100.04Age (years)-0.612<0.01BMI (kg/m2)0.484<0.01REMS total hip T-scoreβpCKD duration (months)-0.1530.219Age (years)-0.523<0.01BMI (kg/m2)0.560<0.01

Conclusion

Our study confirmed that the overestimation of DXA BMD assessed with the anteroposterior scan is indeed influenced by AOC. Furthermore, our data suggest that REMS might be an interesting tool for the investigation of bone changes in CKD.

Disclosure of Interests

Angelo Fassio: None declared, Stefano Andreola: None declared, Davide Gatti Speakers bureau: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB, Paid instructor for: Amgen, Celgene Eli-Lilly, MSD-Italia, Organon, UCB, Matteo Gatti: None declared, Giovanni Gambaro Speakers bureau: Vitor Pharma, Ombretta Viapiana: None declared, Valeri Messina: None declared, Giulia Zanetti: None declared, Francesca Pistillo: None declared, Maurizio Rossini Speakers bureau: Abiogen, Amgen, Abbvie, BMS, Celgene, Eli-Lilly, Galapagos, Grunenthal, MSD, Novartis, Pfizer, Sanofi, Sandoz, Theramex, UCB., Giovanni Adami: None declared

POS1409 ASSOCIATION BETWEEN SHORT-TERM EXPOSURE TO ENVIRONMENTAL AIR POLLUTION AND PSORIASIS FLARE

Background

Psoriasis is a chronic inflammatory disease with a relapsing-remitting course. Selected environmental factors such as infections, stressful life events or drugs may trigger disease flares. Whether the air pollution could trigger psoriasis flares is still unknown.

Objectives

To investigate whether the short-term exposure to environmental air pollution is associated to psoriasis flares.

Methods

Observational study with both case-crossover and cross-sectional design was conducted. We retrospectively analyzed longitudinal data from 2013 to 2020 of patients with psoriasis attending the outpatient dermatologic clinic of the University Hospital of Verona. For the case-cross over analysis patients with at least one disease flare, defined as PASI increase ≥5 between 2 consecutive assessments in a time frame of 3-4 months, were considered. In the case-crossover analysis each patient serves as its own control; the exposure of interest is compared in two different periods in the same group of patients followed longitudinally (Figure 1). For the cross-sectional analysis, patients receiving any systemic treatment for ≥6 months, with ≥2 consecutive PASI assessment were included. We compared the mean and cumulative (area under the curve) concentrations of several air pollutants (CO, NO2, NOx, C6H6, PM10 and PM2.5) in the 60 days preceding the psoriasis flare and the control visits.

Results

A total of 957 patients with plaque psoriasis with 4,398 follow-up visits were included in the study. More than 15,000 measurements of air pollutants concentration from the official, open-source, bulletin of the Italian Institute for Environmental Protection and Research (ISPRA) were retrieved. Among the overall cohort, 369 (38.6%) patients with psoriasis flare were included in the case-crossover study. We found that concentrations of all pollutants were significantly higher in the 60 days before psoriasis flare (median PASI at the flare 12, IQR 9-18), compared to the control visit (median PASI 1, IQR 1-3, p <0.0001). In the cross-sectional analysis, exposure to mean PM10 over 20 μg/m3 and mean PM2.5 over 15 μg/m3 in the 60 days before assessment were associated with a higher risk of PASI ≥5 point worsening, aOR 1.55, 95% CI 1.21-1.99 and aOR 1.25, 95% CI 1.0-1.57, respectively (Figure 1). Sensitivity analyses that stratified for trimester of evaluation, with various lag of exposure and adjusting for type of treatment yielded similar results.

Conclusion

Air pollution may be a trigger factor for psoriasis flare.

Disclosure of Interests

Giovanni Adami Speakers bureau: Galapagos, Theramex, Francesco Bellinato: None declared, Angelo Fassio: None declared, Camilla Benini: None declared, Giampiero Girolomoni Shareholder of: AbbVie, Abiogen, Almirall, Amgen, Biogen, Bristol-Meyers Squibb, Eli-Lilly, Galderma, Genzyme, Leo Pharma, Pfizer, Regeneron, Samsung and Sanofi, Paolo Gisondi Shareholder of: Abbvie, Almirall, Amgen, Biogen, Eli Lilly, Jansenn, Novartis, Sanofi, UCB, Maurizio Rossini Shareholder of: Abbvie, Amgen, Bms, Eli Lilly, Galapagos, Novartis, Pfizer, Sandoz, Theramex, Ucb

OP0242 ASSOCIATION BETWEEN EXPOSURE TO FINE PARTICULATE MATTER AND OSTEOPOROSIS: A POPULATION-BASED COHORT STUDY

Background

Environmental air pollution has been associated with disruption of bone health at a molecular level. Particulate matter (PM) exposure can simultaneously stimulate bone resorption and halt bone formation.

Objectives

The primary aim of the present study is to describe the association between long-term exposure to PM and osteoporosis in a large cohort of women at high risk of fracture.

Methods

Clinical, demographic and densitometric data were extracted from the DeFRAcalc79 dataset, which gathers data on women at risk for osteoporosis. Data on the monitoring of PM10 and PM2.5 concentrations were retrieved from the Italian institute of environment protection and research (Istituto Superiore per la Protezione e la Ricerca Ambientale, ISPRA). Every study subject was linked to a PM exposure value, which resulted from the average concentration of urban, rural and near-traffic stations of the subject residency (ZIP code centroids 25 km) from January 2013 to December 2019. Generalized linear models with robust estimators were employed to determine the relationship between BMD and PM long-term exposure. We sequentially adjusted for confounders. Model 1 included age, body mass index (BMI), presence of prevalent fragility fractures, family history of vertebral or hip fractures, and menopause. Model 2 was further adjusted for glucocorticoid treatment and comorbidities. Model 3 (main model) added to model 2 the macro-area of residency (stratified as a categorical variable: northern Italy, central Italy and southern Italy).

Results

59,950 women from 110 Italian provinces were included in the study. PM 2,5 exposure was negatively associated with T-score levels at the femoral neck (β -0.005, 95 CI -0.007 to -0.003) and lumbar spine (β -0.003, 95% CI -0.006 to -0.001). Chronic exposure to PM2.5 above 25 μg/m3 was associated with a 16% higher risk of having osteoporotic T-score at any site (aOR 1.161, 95% CI 1.105 to 1.220), exposure to PM10 above 30 μg/m3 was associated with a 15% higher risk of having osteoporotic T-score at any site (aOR 1.148, 95% CI 1.098 to 1.200).

Conclusion

Long-term exposure to air pollution was associated with higher risk of osteoporosis. Femoral neck site seemed to be more susceptible to the detrimental effect of PM exposure than lumbar spine site.

Disclosure of Interests

Giovanni Adami Shareholder of: Galapagos, Theramex, Camilla Benini: None declared, Angelo Fassio: None declared, Eugenia Bertoldo: None declared, Ombretta Viapiana: None declared, Davide Gatti: None declared, Maurizio Rossini Shareholder of: Abbvie, Amgen, Bms, Eli Lilly, Galapagos, Novartis, Pfizer, Sandoz, Theramex, Ucb.

OP0239 REAL-LIFE SHORT-TERM EFFECTIVENESS OF ANTI-OSTEOPOROTIC TREATMENTS: A LONGITUDINAL COHORT STUDY

Background

Data from randomized clinical trials showed that anti-osteoporotic treatments increase bone mineral density (BMD) and reduce the risk of fragility fractures. However, data on the real-life effectiveness of such medications is still scarce.

Objectives

The primary objective of the present study is to assess the real-life effectiveness of anti-osteoporotic treatment in a representative cohort of Italian women at high risk of fracture

Methods

We conducted a cohort study on women at high risk of fracture. We retrieved clinical and densitometric data from the DeFRA database, which derives from the DeFRA tool, a web-based fracture risk assessment tool. Multivariable Cox regression survival models were employed to analyze the effectiveness of different anti-osteoporotic drugs on fracture. In sensitivity analyses we generated 1:1 matched cohorts of patients with prescription of bisphosphonates, denosumab, teriparatide or without any pharmacological prescription at baseline and 1:1 matched cohort based on the T-score variation over the time (increase in T-score vs decrease or stability in T-score values).

Results

Data from 50,862 women were available. Among these, 3,574 individuals had at least 2 consecutive visits. The crude fracture rate was 91.9/1,000 person-year for non-treated patients. The crude fracture rate in bisphosphonate users was 72.1/1,000 person-year, in denosumab users was 58.2/1,000 person-year and in teriparatide users was 19.3/1000 person-year. Overall, we found that bisphosphonates were associated with a 30% lower risk of fracture compared to no treatment (aHR 0.70, 95% CI 0.50-0.98), denosumab and teriparatide were associated with 60% and 90% lower risk of fracture, respectively (aHR 0.43, 95% CI 0.24-0.75 and aHR 0.09, 95% CI 0.01-0.70). Bisphosphonate use was associated with a lower risk of fracture only after one year of treatment. In Figure 1 are presented the Kaplan Meier curves free from fragility fracture after propensity score matching.

Conclusion

In conclusion, we found that all anti-osteoporotic medications effectively reduced the risk of fracture in the real-life. Bisphosphonate’s effect on fracture risk was apparent only after the first year of treatment. Our findings do not support the use of bisphosphonates in patients at imminent risk of fracture.

Disclosure of Interests

Giovanni Adami Shareholder of: Theramex, Galapagos, IRENE GAVIOLI: None declared, Angelo Fassio: None declared, Camilla Benini: None declared, Eugenia Bertoldo: None declared, Ombretta Viapiana: None declared, Davide Gatti: None declared, Maurizio Rossini Shareholder of: Abbvie, Amgen, Bms, Eli Lilly, Galapagos, Novartis, Pfizer, Sandoz, Theramex, Ucb.

Association between exposure to fine particulate matter and osteoporosis: a population-based cohort study

Long-term environmental air pollution exposure was associated with osteoporosis' risk in a cohort of women at high risk of fracture. Cortical sites seemed to be more susceptible to the exposure's effect.

INTRODUCTION

Environmental air pollution has been associated with disruption of bone health at a molecular level. Particulate matter (PM) exposure can simultaneously stimulate bone resorption and halt bone formation. The primary aim of the present study is to describe the association between long-term exposure to PM and osteoporosis in a large cohort of women at high risk of fracture.

METHODS

Clinical, demographic, and densitometric data were extracted from the DeFRAcalc79 dataset, which gathers data on women at risk for osteoporosis. Data on the monitoring of PM10 and PM2.5 concentrations were retrieved from the Italian institute of environment protection and research (Istituto Superiore per la Protezione e la Ricerca Ambientale, ISPRA). Generalized linear models with robust estimators were employed to determine the relationship between BMD and PM long-term exposure.

RESULTS

A total 59,950 women from 110 Italian provinces were included in the study. PM 2.5 exposure was negatively associated with T-score levels at the femoral neck (β -0.005, 95 CI -0.007 to -0.003) and lumbar spine (β -0.003, 95% CI -0.006 to -0.001). Chronic exposure to PM2.5 above 25 μg/m3 was associated with a 16% higher risk of having osteoporotic T-score at any site (aOR 1.161, 95% CI 1.105 to 1.220), and exposure to PM10 above 30 μg/m3 was associated with a 15% higher risk of having osteoporotic T-score at any site (aOR 1.148, 95% CI 1.098 to 1.200).

CONCLUSION

Long-term exposure to air pollution was associated with higher risk of osteoporosis. Femoral neck site seemed to be more susceptible to the detrimental effect of PM exposure than lumbar spine site.

KEY MESSAGE

Exposure to air pollution is associated with osteoporosis, mainly at femoral site.

POS1102 TEMPORAL TRENDS AND FACTORS ASSOCIATED WITH VITAMIN D PRESCRIPTION AND INTAKE

Background:

Vitamin D has proven skeletal effects and its administration is recommended in patients with osteoporosis by many national and international guidelines. Nevertheless, the compliance to treatment of patients with osteoporosis is scarce. Understanding the factors associated with low vitamin D intake and prescription might help design future intervention aimed to improve adherence.

Objectives:

This study aims to investigate the temporal trends and factors associated with vitamin D prescription and intake.

Methods:

Using a web-based fracture risk-assessment tool, we collected demographic, densitometric and clinical data of women at high risk for fractures. To determine the factors associated with low vitamin D intake we ran a multivariable logistic regression analysis. We described the public general interest in the term “vitamin D” using the Google Trends tool.

Results:

12,419 women were included in the study. 6,748 (54.4%) individuals had a prevalent fragility fracture and 8,950 (72.1%) individuals were on <800 IU of vitamin D per day and 11,434 (92.1%) were taking <1,200 IU of vitamin D per day. The factors associated with vitamin D intake were evaluated with a multivariable logistic regression analysis, which results are presented in Table 1. We found that low BMD levels, the presence of associated comorbidities and glucocorticoid utilization were associated with greater vitamin D intake. Falls were associated only with lower risk of receiving very low dose of vitamin D (<250 IU day). Smoking status was associated with lower vitamin D intake. Overall, the internet interest in vitamin D was higher during the winter season Figure 1.

Figure 1.

Google trends interest in the term “vitamin D” from January 2010 to October 2020

Conclusion:

Low vitamin D intake (<800 IU day) was common in our cohort of women at high risk for fractures. The factors associated with greater vitamin D intake were: having low BMD levels, associated rheumatic diseases and glucocorticoid use. Falls were associated with lower risk of receiving very low dose of vitamin D (<250 IU day). Smoking status was associated with lower vitamin D intake.

Table 1.

Binary logistic regression to predict the risk of low vitamin D intake (<800 IU/day)

>800 IU day REFaOR (95% CI)p value400-800 IU dayAge1.001 (0.995-1.007)NST-score1.422 (1.342-1.508)<0.001No comorbiditiesREFRheumatoid arthritis0.732 (0.583-0.920)<0.001Psoriatic arthritis0.362 (0.218-0.607)<0.001Connective tissue disease0.630 (0.486-0.816)<0.001No cigarette smokingREFCigarette smoking1.040 (0.893-1.212)NSAlcohol <3 unit dayREFAlcohol ≥3 unit day1.201 (0.660-2.187)NSNo glucocorticoidsREFGlucocorticoids 2.5-5 mg/day0.688 (0.550-0.860)<0.001Glucocorticoids ≥5 mg/day0.739 (0.554-0.986)<0.001No fallsREFFalls0.875 (0.754-1.015)NS250-400 IU dayAge0.994 (0.985-1.002)NST-score1.223 (1.117-1.339)<0.001No comorbiditiesREFRheumatoid arthritis0.670 (0.463-0.970)<0.001Psoriatic arthritis0.300 (0.119-0.752)<0.001Connective tissue disease0.651 (0.435-0.975)<0.001No cigarette smokingREFCigarette smoking1.371 (1.104-1.702)<0.001Alcohol <3 unit dayREFAlcohol ≥3 unit day1.824 (0.865-3.887)NSNo glucocorticoidsREFGlucocorticoids 2.5-5 mg/day0.930 (0.666-1.297)NSGlucocorticoids ≥5 mg/day0.743 (0.464-1.189)NSNo fallsREFFalls0.934 (0.741-1.176)NS<250 IU dayAge0.993 (0.988-0.998)<0.01T-score1.139 (1.079-1.202)<0.001No comorbiditiesREFRheumatoid arthritis0.645 (0.522-0.795)<0.001Psoriatic arthritis0.553 (0.376-0.812)<0.001Connective tissue disease0.697 (0.558-0.871)<0.001No cigarette smokingREFCigarette smoking1.339 (1.171-1.532)<0.001Alcohol <3 unit dayREFAlcohol ≥3 unit day1.267 (0.749-2.145)NSNo glucocorticoidsREFGlucocorticoids <5 mg/day0.964 (0.796-1.168)NSGlucocorticoids ≥5 mg/day0.946 (0.736-1.215)NSNo fallsREFFalls0.615 (0.530-0.712)<0.001

Disclosure of Interests:

None declared.

POS1173 A SHORT DELAY IN ARTHRITIS CARE IS ASSOCIATED WITH HIGHER DISEASE ACTIVITY - LESSONS FROM THE CORONAVIRUS DISEASE 19 (COVID-19) PANDEMIC

Background:

Although disease activity is a significant outcome in rheumatology, few studies have investigated the relationship between routine care of rheumatic conditions and disease activity control.

Objectives:

To determine the association between delay in routine care of chronic inflammatory arthritides (CIAs) and disease activity during the first wave of coronavirus disease 19 pandemic in Verona, Italy.

Methods:

This study enrolled patients with an established diagnosis of rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and undifferentiated arthritis (UA). Between 01/04/2020 and 30/06/2020, participants were emailed an online questionnaire. Items comprised multiple or single-choice questions evaluating routine rheumatology care disruptions/delays and disease characteristics, treatments, comorbidities, and demographics. Compliance to anti-rheumatic medications was evaluated with I-CQR5. Disease activity was assessed with RAPID3, and active disease was defined as a RAPID3 score>1. Study period referred to the time between the last rheumatology assessment and the date of enrolment.

Results:

Of 1210 patients contacted, 450 participated, of whom 219 CIAs patients were included (RA 55.3%, PsA 35.2%, AS 15.1%, UA 3.7%). One hundred twenty-five patients (57.1%) had their routine clinical assessment delayed (median days 68.4; IQR 66.8, 85.9). Patients in this group had significantly higher MDHAQ (p=0.001) and RAPID3 (p=0.031) scores, while they did not differ for disease severity, medications or compliance. Most (87.7%) reported good compliance to therapy; only 5.9% had difficulties in supplying anti-rheumatic medications, and 13.2% discontinued medications for at least four weeks for any reason. However, several patients (37.9%) reported moderate-to-high worse disease activity perception due to routine care delay, and 31.1% self-reported a disease flare (median RAPID3 score 3.8; IQR 2.0, 5.4). One hundred one patients (46.1%) had high disease activity, while only 15.1% were in remission. In logistic regression, active disease was significantly associated with delay of scheduled routine care visit, independent of disease duration, time from last rheumatology assessment, therapy with b/tsDMARDs, and compliance (Table 1, Figure 1 below).

Table 1.PredictorActive(n=186)Remission(n=33)ORP-value95% CIInf.95% CISup.Routine care delay (yes vs no)113(60.8%)12(36.4%).0302.4591.0915.543Disease duration (years)10(4.0, 20.0)10.5(7.0, 19.8).6951.007.9721.044Time since last rheumatology assessment (days)68.4(66.8, 75.8)71.2(66.9, 74.9).8541.002.9781.027b/tsDMARDs (yes vs no)105(56.5%)15(45.5%).6531.202.5382.687I-CPR5 (likely low vs likely high adherent)36(19.4%)10(30.3%).187.563.2401.321Figure 1.

Conclusion:

In patients with established CIAs, a relatively short delay in routine assessment by a rheumatologist resulted in higher disease activity. Frequent rheumatology referrals appear to be a critical factor for disease activity control in CIAs.

Disclosure of Interests:

None declared.

OP0112 FACTORS ASSOCIATED WITH OSTEOPOROSIS CARE OF MEN: A REAL-LIFE STUDY ON A NATION-WIDE DATASET

Background:

Male osteoporosis is associated with an important clinical and economic burden worldwide. Notwithstanding that, undertreatment of men with osteoporosis is common. Understanding the factors associated with less osteoporosis care utilization might help define future intervention to improve access of men to osteoporosis care.

Objectives:

The aim of the study was to describe the factors associated with osteoporosis care in men.

Methods:

We conducted a retrospective analysis of a nation-wide cohort (DeFRACalc79 database). DeFRACalc79 is a tool that estimates the fracture risk considering clinical and densitometric risk factors, including the presence of prior hip or vertebral and non-vertebral or non-hip fractures. We compared the clinical characteristics of male individuals with an age matched cohort of women. Propensity score generation with 2:1 matching for female and male patients was performed matching the cohorts for age, generating propensity estimates with a logistic regression model.

Results:

We analyzed a sample of 4,902 men at high risk of osteoporosis. We found that the factors associated to osteoporosis care utilization in men were: the presence of comorbidities (OR 1.939, 95% CI 1.799-2.090), adjuvant hormonal therapy for prostate cancer (OR 1.482, 95% CI 1.315-1.670), the presence of vertebral or hip fractures (OR 1.490, 95% CI 1.378-1.611) and glucocorticoid treatment (OR 2.573, 95% CI 2.274-2.832) (Table 1)

Table 1.

Clinical and densitometric characteristics of the study population and age-matched cohort of women

Men (n=4,902)Women (n=9,804)OR (95% CI) – p valueAge (±SD)65.1 (±14.2)65.1 (±14.2)NSBMI (±SD)25.31 (±4.91)24.07 (±4.85)<0.0001Lumbar spine T-score (±SD)-2.13 (±1.37)-2.51 (±1.15)<0.0001Osteoporosis at lumbar spine (%)2,601 (53.1%)5,948 (60.7%)0.733 (0.684-0.785)Femoral neck T-score (±SD)-1.93 (±1.04)-2.19 (±0.91)<0.0001Osteoporosis at femoral neck (%)1,412 (28.8%)3,936 (40.1%)0.603 (0.560-0.649)% 10-year risk of fracture (±SD)22.77 (±21.05)20.26 (±4.85)<0.0001Family history of fragility fracture (%)891 (18.2%)2,379 (24.3%)0.693 (0.636-0.756)Secondary osteoporosis (%)2,415 (49.3%)3,092 (31.5%)2.108 (1.965-2.262)Glucocorticoids ≥5 mg/day >3 months (%)768 (17.4%)694 (7.7%)2.573 (2.274-2.832)Glucocorticoids ≥5 mg/day ≥3 months <12 months (%)74 (2.0%)72 (0.9%)2.357 (1.700-3.267)Glucocorticoids ≥5 mg/day ≥12 months (%)119 (3.2%)138 (1.6%)1.977 (1.543-2.534)Adjuvant hormonal therapy for breast cancer or prostate cancer (%)495 (12.0%)766 (8.4%)1.482 (1.315-1.670)Comorbidities (%)1,778 (36.3%)2,225 (22.7%)1.939 (1.799-2.090)Rheumatoid arthritis (%)303 (8.8%)511 (6.3%)1.439 (1.241-1.668)Psoriatic arthritis (%)59 (1.9%)103 (1.3)1.390 (1.006-1.919)Systemic lupus erythematosus (%)22 (0.7%)77 (1.0%)0.693 (0.431-1.115)Systemic sclerosis (%)9 (0.3%)60 (0.8%)0.364 (0.180-0.734)Other rheumatic diseases (%)173 (5.2%)310 (3.9%)1.354 (1.119-1.638)Inflammatory bowel diseases (%)144 (2.7%)126 (1.6%)2.773 (2.175-3.534)Chronic obstructive pulmonary disease (%)281 (8.3%)277 (3.5%)2.461 (2.074-2.920)Diabetes (%)441 (12.4%)478 (5.9%)2.238 (1.954-2.564)Neurological diseases (%)236 (7.0%)260 (3.3%)2.202 (1.837-2.639)HIV infection (%)110 (3.4%)23 (0.3%)11.603 (7.389-18.221)Vertebral or hip fractures (%)1,434 (29.3%)2,130 (21.7%)1.490 (1.378-1.611)Non-vertebral, non-hip fractures (%)534 (10.9%)1,477 (15.1%)0.689 (0.620-0.766)

Conclusion:

We found that men accessed osteoporosis care with more severe osteoporosis and/or with a diagnosis of secondary osteoporosis. Male osteoporosis remains largely underdiagnosed with a dramatic latency in osteoporosis care utilization compared to women.

Disclosure of Interests:

None declared

OP0178 ASSOCIATION BETWEEN ENVIRONMENTAL AIR POLLUTION AND RHEUMATOID ARTHRITIS FLARES

Background:

Environmental air pollution has been linked to the pathogenesis of Rheumatoid Arthritis (RA). Nevertheless, evidence linking higher concentrations of air pollutants with the risk of RA reactivations is missing.

Objectives:

The objective of the present study was to determine the association between RA flares and air pollution.

Methods:

We collected longitudinal data of patients affected by RA and of the daily concentration of air pollutants in the Verona area. We designed a case-crossover study. In case-crossover studies, instead of obtaining information from two groups (cases and controls), the exposure information is obtained comparing two different periods of time in the same group of patients followed longitudinally. We compared the exposure to pollutants in the 30-day and 60-day periods preceding an arthritic flare referent to the 30-day and 60-day preceding a low-disease activity visit. Flare was defined as an increase in DAS28-CRP of >1.2 points with current DAS28-CRP ≥3.2 (OMERACT definition).

Results:

888 patients with RA with 3,396 follow-up visits were included in the study. 13,636 daily air pollution records were retrieved. We found an exposure-response relationship between the concentration of air pollutants and the risk of having abnormal CRP levels (Figure 1). Patients exposed to greater concentrations of air pollutants were at higher risk of having CRP levels ≥5 mg/L. Patients exposed to PM10 concentrations ≥50 μg/m3 had a 70% higher risk of having CRP levels ≥5 mg/L (OR 1.696 95% CI, 1.245-2.311). Among RA patients, 440 patients (49.5%) had at least 2 follow-up visits with a difference in DAS28-CRP of more than 1.2 points (with current DAS28-CRP ≥3.2), serving as our sample for the case-crossover study. Concentrations of CO, NO, NO2, NOx, PM10, PM2.5 and O3 were higher in the 60-day period preceding a flare (Table 1). Sensitivity analyses considering geometric mean and cumulative concentrations yielded similar results (data not shown). Remarkably, we found that the cumulative exposure to NO2 in the 60 days preceding a flare was approximately 500 µg/m3 higher than the low disease activity visit, an exposure that equates to approximately to 200 passively smoked cigarettes (3.5 cigarettes per day on a 60-day period).

Table 1.

Case-crossover study. Mean concentrations (mean and Area Under the Curve) of air pollutants in the 60 days before low-disease activity visit and flare visit (DAS28-CRP difference >1.2)

PollutantControl period (low disease activity, n=440)Hazard period (flare, n=440)p valueCO μg/m3Mean0.380.420.001AUC22.0024.530.001NO μg/m3Mean19.2324.110.002AUC1,120.531,403.880.002NO2μg/m3Mean30.9132.440.042AUC1,800.961,892.050.040NOxμg/m3Mean60.3469.350.004AUC3,515.774,041.060.004PM10 μg/m3Mean31.2133.650.011AUC1,789.221,942.520.005O3μg/m3Mean31.0833.790.002AUC1,776.371,934.350.001PM2.5 μg/m3Mean23.0824.740.018AUC1,272.611,403.60<0.001Figure 1.

Odds of having abnormal CRP serum levels (≥5 mg/L) at different exposures of PM10 and PM2.5 (mean concentration in the 60 days before assessment)

Conclusion:

We found a striking association between air pollution and RA disease severity and reactivations in a cohort of patients followed over a 5-year period. The exposure to high levels of air pollutants was associated with increased CRP levels and a higher risk of experiencing a flare of arthritis. This excessive risk was evident at very low levels of exposure, even below the proposed threshold for the protection of human health. Our study has important and direct consequences. In order to reduce the burden of RA, public and environmental health policy makers should aim to diminish gaseous and PM emissions to a larger extent as currently recommended.

Disclosure of Interests:

None declared

POS0218 TUMOR-NECROSIS FACTOR INHIBITORS IMPROVE AORTIC STIFFNESS IN PATIENTS WITH LONGSTANDING RHEUMATOID ARTHRITIS

Background:

Major cardiovascular disease (CVD) benefits of disease-modifying anti-rheumatic drugs (DMARDs) therapy occur in early RA patients with treat-to-target strategy. However, it is unknown whether long-term DMARDs treatment in established RA could be useful to improve CVD risk profile.

Objectives:

The aim of this study was to comparatively describe aortic stiffness progression in patients with longstanding and established RA treated with tumor necrosis factor inhibitors (TNFi) or conventional synthetic DMARDs (csDMARDs).

Methods:

Ultrasound aortic stiffness index (AoSI) has to be considered a proxy outcome measure in established RA patients. We measured AoSI in a group of RA patients on long-term treatment with TNFi or csDMARDs. Eligible participants were assessed at baseline and after 12 months; changes in serum lipids, glucose and arterial blood pressure were assessed. All patients were on stable medications during the entire follow-up.

Results:

We included 107 (64 TNFi and 43 csDMARDs) RA patients. Most patients (74%) were in remission or low disease activity and had some CVD risk factors (45.8% hypertension, 59.8% dyslipidemia, 45.3% smoking; table 1). The two groups did not differ significantly for baseline AoSI (5.95±3.73% vs 6.08±4.20%, p=0.867). Follow-up AoSI was significantly increased from baseline in the csDMARDs group (+1.00%; p<0.0001) but not in the TNFi group (+0.15%, p=0.477). Patients on TNFi had significantly lower follow-up AoSI from baseline than the csDMARDs group (-1.02%, p<0.001; ANCOVA corrected for baseline AoSI, age and systolic blood pressure). Furthermore, follow-up AoSI was significantly lower in TNFi users with 1-2 or >2 CVD risk factors than in those without (figure 1).

Conclusion:

Long-term treatment with TNFi was associated with reduced aortic stiffness in patients with established RA and several CVD risk factors.

Baseline characteristics of the study population.csDMARDs(n=43)TNFi(n=64)P valueAge, median years (IQR)58.6 (53.0, 66.0)58.1 (49.3, 67.0)0.839Female sex33 (76.7)54 (84.4)0.321Obesity5 (11.6)7 (10.9)0.999Hypertension19 (44.2)30 (46.9)0.784Anti-hypertensive drug17 (39.5)28 (43.8)0.784Smoking status, ever18 (42.9)30 (46.9)0.684Dyslipidemia30 (40.2)34 (59.8)0.085Current statin use13 (34.2)10 (15.9)0.033Diabetes mellitus3 (7.0)3 (4.7)0.676Anti-diabetic medication1 (2.3)1 (1.5)0.999CVD risk factors, median (IQR)2 (1, 3)2 (1, 3)0.199RF and/or ACPA positive28 (65.1)33 (51.6)0.165Disease duration, median years (IQR)14.1 (11.5)15.4 (10.5)0.538Methotrexate38 (88.4)52 (81.3)0.192Leflunomide5 (17.9)12 (19.0)0.999Hydroxychloroquine9 (31.0)5 (7.8)0.009Prednisone > 5 mg daily7 (7.7)5 (5.5)0.823NSAIDs6 (20.7)22 (34.4)0.227

ACPA, anti-citrullinated peptides antibodies; csDMARDs, conventional synthetic disease-modifying anti-rheumatic drugs; IQR, interquartile range; NSAIDs, non-steroidal anti-inflammatory drugs; RF, rheumatoid factor; TNFi, tumor necrosis factor inhibitors. All data reported as absolute numbers (percentage) otherwise specified. P-value refers to Chi-squared or Fisher test for categorical variables or ANOVA for continuous variables.

Disclosure of Interests:

None declared

POS0644 AIR POLLUTION IS A PREDICTOR OF POOR RESPONSE TO BIOLOGICAL THERAPIES IN CHRONIC INFLAMMATORY ARTHRITIDES

Background:

There is increasingly evidence that environmental air pollution is associated with both development of chronic inflammatory arthritides (CIA). The role of air pollutants on the treatment response of CIA (including psoriatic arthritis [PsA] and ankylosing spondylitis [AS]) is still unclear.

Objectives:

The objective of the present study is to determine the association between the concentration of air pollutants and biological drug retention rates in CIA.

Methods:

We retrieved longitudinal data of patients affected by CIA on biological therapies and of the daily concentration of air pollutants in the Verona area. We designed a case-crossover study to compare the exposure to pollutants in the 30-day and 60-day periods preceding a drug switch or swap due to disease progression referent to the 30-day and 60-day periods preceding a visit with stable treatment for at least 6 months.

Results:

1,286 patients with CIA (888 with RA, 260 with PsA and 138 with AS) with 5,454 follow-up visits were included in the study. 13,636 daily air pollution records were retrieved. We found an exposure-dependent relationship between exposure to air pollutants and CRP serum levels in CIA. At PM10 exposures of >50 μg/m3 and >40 μg/m3 we found a 150% and 65% higher risk of having CRP above 5 mg/L respectively (OR 2.564, 95% CI 2.114-3.110 and OR 1.659, 95% CI 1.440-1.910, respectively.). If the threshold was set at >30 μg/m3 of PM10 (below the European Union health protection limit) we still found a 38% higher risk of having altered CRP (OR 1.383, 95% CI 1.206-1.588). Among CIA patients, 280 patients (21.7%) had at least 2 follow-up visits with at least one drug switch or swap due to drug inefficacy and one visit with stable treatment for at least 6 months, serving as our sample for the case-crossover study. We found that air pollutants concentrations were higher before a switch or swap due to drug inefficacy (Figure 1A). Figure 1B shows the receiver operating characteristic (ROC) curve for the prediction of switch or swap due to drug inefficacy. Discriminatory capacity of disease activity alone was the highest (AUC 0.841) but when the prediction model included the concentrations of air pollutants in the 60 days before the visit the discriminatory capacity increased (AUC 0.879).

Figure 1.

A) Mean concentrations of air pollutants in the 60-day period before switch or swap visit compared to the stable treatment visit. p <0.001 between all groups. B) Receiving operating characteristics (ROC) curves for the prediction of switch or swap due to drug inefficacy

Conclusion:

We found that environmental air pollution was a determinant of poor response to biological treatment in a cohort of patients with CIA followed over a 5-year period. Intervention aimed to decrease the fossil combustion emissions might have beneficial effects on biologics persistence rate of patients with CIA.

Disclosure of Interests:

None declared

Vitamin D and disease severity in coronavirus disease 19 (COVID-19)

The role of 25-OH-vitamin D in the assessment of coronavirus disease 19 (COVID-19) has not been investigated. We sought to investigate the prevalence of 25-OH-vitamin D deficiency among COVID-19 patients, and to determine the associations between 25-OH-vitamin D status and the severity of the disease. We have conducted a retrospective observational study of COVID-19 patients admitted to the University of Verona Hospital Trust. Demographic, clinical and biochemical parameters were collected at hospital admission, and serum 25-OH-vitamin D levels were measured. The following outcomes were assessed: arterial partial oxygen pressure (PaO2); C-reactive protein (CRP); length of hospitalization; requirement of oxygen therapy; non-invasive ventilation (NIV); mechanical ventilation; and death. Among 61 patients enrolled, 72.1% was 25-OH-vitamin D deficient (<20 ng/mL) and 57.4% had 25-OHvitamin D <15 ng/mL. Patients with arterial PaO2 <60 mmHg had significantly lower mean 25-OH-vitamin D levels compared to patients with PaO2 ≥60 mmHg (13.3 ng/mL vs 20.4 ng/mL respectively, p=0.03). Vitamin D deficiency was associated with 3-fold higher risk of having arterial pO2 <60 mmHg. 25-OH-vitamin D deficiency was associated with increased CRP and dyspnea. 25-OH-vitamin D deficiency was associated with more severe systemic inflammatory response and respiratory failure in COVID-19 patients.

Risk of fragility fractures in obesity and diabetes: a retrospective analysis on a nation-wide cohort

This study aims to investigate the role of obesity and diabetes on bone health in a nation-wide cohort of women with high risk of fracture.

INTRODUCTION

The role of obesity and diabetes on fracture risk is yet poorly understood. Body mass index (BMI) and bone mineral density (BMD) are strongly correlated; however, patients with elevated BMI are not protected against fractures, configuring the obesity paradox. A similar controversial association has been also found in diabetic patients. Herein, we present a retrospective analysis on 59,950 women.

METHODS

Using a new web-based fracture risk-assessment tool, we have collected demographic (including BMI), densitometric, and clinical data (including history of vertebral or hip and non-vertebral, non-hip fractures, presence of comorbidities). We performed a propensity score generation with 1:1 matching for patients in the obese (BMI ≥ 30) and non-obese (BMI < 30) groups, in the diabetics and non-diabetics. Propensity score estimates were estimated using a logistic regression model derived from the clinical variables: age, lumbar spine T-score, and femoral neck T-score.

RESULTS

We found an association between diabetes and fractures of any kind (OR 1.3, 95% CI 1.1-1.4 and 1.3, 95% CI 1.2-1.5 for vertebral or hip fractures and non-vertebral, non-hip fractures, respectively). Obesity, on the other hand, was significantly associated only with non-vertebral, non-hip fractures (OR 1.3, 95% CI 1.1-1.6). To estimate the individual effect of obesity and diabetes on bone health, we ran sensitivity analyses which included obese non-diabetic patients and non-obese diabetic patients, respectively.

CONCLUSIONS

Non-obese diabetics had the highest risk of vertebral or hip fracture, whereas obese non-diabetics predominantly had non-vertebral, non-hip fracture's risk. These results should raise awareness in clinical practice when evaluating diabetic and/or obese patients.

Different fracture risk profile in patients treated with anti-osteoporotic drugs in real-life

In this retrospective study, we intended to investigate the baseline fracture risk profile in patients who started treatment with different anti-osteoporotic medications. We analyzed retrospectively the fracture risk calculated with DeFRA, a validated FRAX derived tool, in women who started an anti-osteoporotic treatment from 2010 to 2017. We analyzed baseline data of 12,024 post-menopausal women aged over 50 years. Teriparatide initiators had a baseline 10-year risk of major osteoporotic fracture of 82.1% with a Standard Deviation (SD) of 66.5%. Denosumab initiators and zoledronic acid initiators had a greater 10-year baseline risk of fracture (54.3%, SD 46.5% and 47.0%, SD 42.0 respectively) than patients initiated on alendronate (24.9%, SD 34.6%) and patients initiated on risedronate (23.9%, SD 24.1%). Using DeFRA, a FRAX™ derived tool, we showed significantly different fracture risk profiles in women who were started on various therapeutic agents for the treatment of osteoporosis in routine clinical practice.

THU0479 ASSOCIATION BETWEEN CENTRAL SENSITIZATION AND CLINICAL AND ULTRASONOGRAPHIC PARAMETERS IN INFLAMMATORY ARTHRITIDES

Background:

Central sensitization (CS) is an important feature of patients with chronic pain, especially rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients. CS might interfere with the clinical evaluation of inflammation. Central Sensitization Inventory (CSI) is a validated instrument for assessing central sensitization.

Objectives:

We seek to investigate the inference of central sensitization (assessed with the CSI) on clinical (disease activity scores) and ultrasound parameters (US 7-joints score) in RA and PsA patients.

Methods:

We conducted a cross-sectional analysis on patients with an established diagnosis of RA or polyarticular PsA. Demographic, anamnestic and clinical parameters were collected. Disease activity was measured with SDAI in RA patients and with DAPSA in PsA patients. The presence and severity of synovitis was measured with the US 7-joints score. Exclusion criteria included: diagnosis of fibromyalgia, depression and patients with PsA with enthesitis predominant and/or spondylitis subtypes. Differences between variables were analysed with t-test and ANOVA for multiple comparisons. Correlation between continuous variables was analysed with Pearson correlation. CSI was analysed either as positive\negative (threshold 40 points) or divided in four categories, i.e., subclinical (≤29), mild (30-39), moderate (40-49), severe (50-59) and extreme (≥60).

Results:

We enrolled 42 patients in the study. Descriptive characteristics of the study population are presented in table 1. We found no difference in clinical parameters between diseases, sex or age. Women had a higher CSI score compared to men (mean 39.3 vs 26.7 p=0.005). We found a correlation between CSI score and DAPSA (r20.39, p =0.001), number of tender joints (r20.13, p=0.02) and HAQ (r20.47, p<0.001) (Figure 1) while we found no correlation between CSI score and SDAI or other clinical parameters. We found a significant difference in DAPSA, tender joints count and HAQ between CSI categories (ANOVA p=0.01, p=0.02 and p<0.001 respectively). US 7-joints score was associated with SDAI (r20.33, p=0.03), number of swollen joints (r20.28, p=0.002) and disease duration (r20.35, p<0.001) but not with DAPSA or tender joints.

Table 1.

Descriptive characteristics of the study population

Age (mean, SD in years)55.9 (12.3)BMI25.9 (3.9)CSI questionnaire score (mean)35 (16)CSI categories (n, %)Subclinical18 (42.9%)Mild9 (21.4%)Moderate8 (19.0%)Severe4 (9.5%)Extreme3 (7.1%)Diagnosis (n, %)PsA 52.4%9 men 13 womenRA 47.6%2 men 18 womenCSI score in PsA (mean, SD)34.4 (16.5)CSI score in RA (mean, SD)34.8 (15.5)CRP (median, IQR in mg/L)1.85 (1.0-4.6)Tender joints (mean, SD)2 (2)Swollen joints (mean, SD)1 (2)SDAI categories (n, %)Remission4 (20.0%)Low disease activity8 (40.0%)Moderate disease activity7 (35.0%)Severe disease activity1 (5.0%)DAPSA categories (n, %)Remission6 (33.3%)Low disease activity4 (22.2%)Moderate disease activity7 (38.9%)Severe disease activity1 (5.6%)US 7-joints score (mean, SD)6 (7)HAQ (mean, SD)0.6 (0.6)Prednisone equivalent (mean, SD in mg/day)1.47 (3.2)Biological DMARD (n, %)No15 (35.7%)Yes27 (64.3%)Conventional DMARD (n, %)No13 (31.0%)Yes29 (69.0%)Figure 1.

Correlation between DAPSA score and CSI score and between HAQ and CSI score

Conclusion:

We found an association between CS and sex, functional disability, tender joints count and disease activity score in PsA patients while there was no correlation between RA disease activity and central sensitization. US 7-joints score was associated with swollen joints count, disease duration and disease activity in RA patients but not in PsA patients. In PsA patients, DAPSA might be more influenced by central sensitization, especially in female individuals.

Disclosure of Interests:

Giovanni Adami: None declared, Elisabetta Gerratana: None declared, Alessandro Giollo: None declared, Camilla Benini: None declared, Elisabetta Vantaggiato: None declared, Denise Rotta: None declared, Luca Idolazzi: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work.

AB1094 SCAR IMAGING ECHOCARDIOGRAPHY WITH ULTRASOUND MULTI-PULSE SCHEME [eSCAR] FOR THE DETECTION OF MYOCARDIAL FIBROSIS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: PRELIMINARY RESULTS

Background:

Myocardial fibrosis is a severe complication of immune-mediated diseases, occurring in up to 30% of systemic lupus erythematosus (SLE) patients. Cardiovascular magnetic resonance imaging allows myocardial scar detection in SLE patients, but it is costly, time consuming, and unfit for patients with renal disease. Scar imaging echocardiography with ultrasound multi-pulse scheme (eSCAR) is a novel and promising technique that proved to be effective in detecting ischemic myocardial scars in patients with coronary artery disease (CAD).

Objectives:

To evaluate if the eSCAR technique is feasible and to better characterize SLE patients with cardiac involvement by eSCAR.

Methods:

We recruited consecutive patients with SLE classified according to the 2019 EULAR/ACR recommendations. Patients with diabetes mellitus, obesity, prior cardiovascular (CV) disease or anti-phospholipid (aPL) syndrome were excluded. Eligible participants underwent a thorough clinical assessment and a full echocardiography examination, including the eSCAR technique. Data on clinical variables were collected; disease activity was estimated by the SLE Disease Activity Index (SLEDAI) score. Lupus flare was defined as new/worse clinical signs and symptoms and/or lab measurements and a change/increase in treatment. Patients were compared according to the presence or absence of eSCAR. In this preliminary report, only descriptive analyses are provided. Continuous data are reported as median [25th; 75thpercentile].

Results:

We enrolled fifteen patients diagnosed with SLE (age 45 years [36; 47], disease duration 14 years [12; 20]), 13 (87%) were females. Median SLEDAI was 5 [2; 8]. The most frequent disease involvement included arthritis (73%), skin and mucous membranes (60%), lupus nephritis (47%) and cytopenias (47%). Patients had received treatment for lupus with 5 drugs [5; 8]. Cumulative prednisone dosage was 25 g [20; 44], whilst the current daily dosage of prednisone was 4 mg [0.0; 5.0]. Hypertension was present in 4 (27%) and hypercholesterolemia in 2 (13%) subjects; 4 patients (27%) were current or past smokers. The eSCAR technique was feasible in all participants with no adverse effects. Myocardial scars were detected in 2 patients (eSCAR-positive 13%; figure and table); eSCAR positive patients were females and had no history of cardiovascular involvement (including pericarditis); they had at least one relapse within the prior 12 months before enrollment; at least one cardiovascular risk factor was found in both patients (one was a smoker and the other one had hypertension); none received prior treatment with cyclophosphamide or rituximab; they had no renal involvement; arthritis and cytopenia were the prominent features of disease; anti-dsDNA titer was higher than eSCAR-negative patients.

Conclusion:

Echocardiography allowed detection of myocardial scars in patients with SLE. Our preliminary data show that eSCAR is feasible and well tolerated in a SLE population. Further data from this ongoing study will help investigate whether eSCAR might improve risk stratification, by identifying myocardial involvement in SLE patients with a more active disease.

eSCAR positivePatient 1eSCAR positivePatient 2eSCAR negativeSLE patients (n=13)Age, years324545SexFemaleFemale11 F / 2 MESR mm/h29715CRP mg/L30.62Anti-dsDNA (IF)PositivePositivePositive 7 (47)Anti-dsDNA (CLIA)10514934 [7; 66]C3 (mg/L)618085 [70; 94]C4 (mg/L)41310 [9; 16]P-Cr (mg/dL)0.60.80.7 [0.6; 0.7]aPLPositiveNegative7 (47)Disease duration, years152814 [12; 15]SLEDAI1205 [2; 8]Lupus flare in the past 12 monthsyesyes5 (33)Cumulative prednisone dosage (g)606124 [19, 32]Previous use of cyclophosphamideNoNo3 (20)Previous use of rituximabNoNo1 (1)

Acknowledgments:

This study was granted by Gruppo LES Italia Onlus

Disclosure of Interests:

Alessandro Giollo: None declared, Giulia Vinco: None declared, Giovanni Orsolini: None declared, Giovanni Cioffi: None declared, Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Luca Idolazzi: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Flavio Luciano Ribichini: None declared, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Ombretta Viapiana: None declared

SAT0452 DIFFERENT PROFILE OF RISK OF FRACTURE IN PATIENTS TREATED WITH ANTI-OSTEOPOROTIC DRUGS IN ITALY USING A NEW ALGORITHM

Background:

A new algorithm for management of patients at low, high and very high risk of osteoporotic fractures has been recently proposed, has been also recommended treating those patients at very high risk of fracture with bone anabolics (1). A similar treatment algorithm has been applied in Italy since 2015, when the “Nota 79”, that regulates the reimbursability for osteoporosis medications, has been developed by the Italian Agency for Drugs (AIFA) (2).

Objectives:

In the present study, using a new mathematical and computerized algorithm, we seek to investigate the profile of risk of fracture of patients starting treatment with different anti-osteoporotic medications in Italy.

Methods:

We retrospectively analyzed the 10-year risk of major osteoporotic fracture calculated with the DeFRAcalc79 tool in postmenopausal women aged over 50 years that were initiating an anti-osteoporotic treatment (fully reimbursed according to the Nota 79). DeFRAcalc79 is a new web-based fracture risk-assessment tool (https://defra-osteoporosi.it) that arithmetically adjusts the risk based on the integration of multiple risk factors contemplated by the AIFA’s Nota 79, including: demographic and anthropometric data, femoral and/or lumbar spine BMD T-score, family history of femoral or vertebral fractures, number and site of previous osteoporotic fracture (including vertebral, femoral, and nonvertebral nonfemoral fractures), glucocorticoid treatment (> 3 or > 12 months, ≥5 mg prednisone or equivalent), adjuvant hormone therapy for breast or prostate cancer, and comorbidities that increase the risk (rheumatoid arthritis and other connective tissue diseases, chronic obstructive pulmonary disease, inflammatory bowel diseases, Parkinson’s disease, multiple sclerosis, HIV infection, diabetes, or severe physical handicap).

Results:

We retrieved data for 10,235 women prescribed with an anti-osteoporotic treatment.Figure 1shows the mean 10-year fracture risk estimated with DeFRAcalc79 tool at the time of the treatment initiation. Teriparatide users had the highest 10-year risk of fracture (67.4% Standard Deviation [SD] 21.5%). We found that in 2,231 patients starting denosumab, the 10-year baseline risk of fracture was 38.5%, SD 22.8%. In 5,759 patients initiating alendronate was 25.7%, SD 15.3% and in patients initiating risedronate was 27.9%, SD 26.9%. Patients prescribed with zoledronic acid had a mean 10-year risk of fracture of 35.6%, SD 21.6. P values between means were all <0.01.

Figure 1.

Mean 10-year risk of fracture estimated with DeFRAcalc79 tool at the time of treatment initiation, p< 0.01 between all means.

Conclusion:

The risk of fracture of Italian post-menopausal women initiating different anti-osteoporotic medications varies significantly. Teriparatide is prescribed to patients with greater risk of fracture. The Nota 79 correctly individuates patients at very high risk of fracture that merit treatment with a bone anabolic. Denosumab and zoledronic acid are prescribed to patients with a greater risk of fracture compared to oral bisphosphonates.

DeFRAcalc79 is a useful and practical tool for the integrated evaluation of the profile of risk of fracture.

References:

[1]Kanis JA et al. Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporos Int 2019 31:1–12.https://doi.org/10.1007/s00198-019-05176-3

[2]Adami G et al. Comments on Kanis et al.: Algorithm for the management of patients at low, high, and very high risk of osteoporotic fractures. Osteoporos Int. 2020. doi: 10.1007/s00198-020-05302-6. [Epub ahead of print]

Disclosure of Interests:

Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Alessandro Giollo: None declared, Giovanni Orsolini: None declared, Ombretta Viapiana: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

SAT0456 REAL-LIFE RISK OF FRACTURE AND TREATMENT PREVALENCE IN DRUG-INDUCED OSTEOPOROSIS IN ITALY USING A NEW ALGORITHM

Background:

Glucocorticoid-induced osteoporosis and osteoporosis induced by adjuvant hormone therapy for breast cancer are the most common forms of secondary osteoporosis.

Objectives:

The exact real-life prevalence of treatment with anti-osteoporotic drugs in women with drug-induced osteoporosis is not known. In the present study, using a new mathematical and computerized algorithm, we investigate the profile of risk of fracture of women with drug-induced osteoporosis and the prevalence of treatment with anti-osteoporotic drugs.

Methods:

We have retrospectively analyzed the 10-year risk of major osteoporotic fracture calculated with the DeFRAcalc79 tool in postmenopausal women aged over 50 years that were initiating an anti-osteoporotic treatment (fully reimbursed according to the Nota 79). DeFRAcalc79 is a new web-based fracture risk-assessment tool (https://defra-osteoporosi.it) that arithmetically adjusts the risk based on multiple risk factors contemplated by the Nota 79, which regulates the reimbursability for osteoporosis medications in Italy (Italian Agency for Drugs, AIFA), including demographic and anthropometric data, femoral and/or lumbar spine BMD T-score, family history of femoral or vertebral fractures, number and site of previous osteoporotic fracture (including vertebral, femoral, and non-vertebral non-femoral fractures), glucocorticoid treatment (> 3 or > 12 months, ≥5 mg prednisone or equivalent), adjuvant hormone therapy for breast cancer, and comorbidities that induce an increased risk of fracture (rheumatoid arthritis and other connective tissue diseases, chronic obstructive pulmonary disease, inflammatory bowel diseases, Parkinson’s disease, multiple sclerosis, human immunodeficiency virus infection, diabetes, or severe physical handicap). This is a sub-analysis of the cross-sectional observational study to validate and further develop the DeFRA algorithm for the estimation of the risk of osteoporotic fractures, promoted by Verona hospital with the unconditional support of Amgen Srl.

Results:

Among 208 women, 116 (55.8%) were treated with adjuvant hormone therapy for breast cancer and 92 (44.2%) were on glucocorticoid ≥5 mg/day. Women on glucocorticoids had a greater mean 10-year risk of fracture compared to women on adjuvant hormone therapy for breast cancer (67.0% vs 39.1% p<0.01). 50.7% of women on adjuvant hormone therapy for breast cancer used denosumab, 28.0% zoledronic acid and 17.3% alendronate. In glucocorticoid-induced osteoporosis, 17.6% of the women used teriparatide, 37.3% alendronate, 29.4% zoledronic acid and 13.7% denosumab.

Conclusion:

In our cohort of patients, treatment with adjuvant hormone therapy for breast cancer was slightly more common than glucocorticoids. Women with glucocorticoid-induced osteoporosis had a greater risk of fracture compared to patients treated with adjuvant hormone therapy for breast cancer. Half of the patients on adjuvant hormone therapy for breast cancer were prescribed with denosumab. One-fifth of the patients with glucocorticoid-induced osteoporosis was treated with teriparatide. DeFRAcalc79 is a useful and practical tool for the integrated evaluation of fracture risk in drug-induced osteoporosis.

Disclosure of Interests:

Giovanni Adami: None declared, Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Alessandro Giollo: None declared, Giovanni Orsolini: None declared, Ombretta Viapiana: None declared, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work., Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB

AB0893 THE EFFECTS OF THREE DIFFERENT VITAMIN D3 SUPPLEMENTATION REGIMENS IN DEFICIENT SUBJECTS - A RANDOMIZED OPEN-LABEL PARALLEL GROUP STUDY

Background:

Currently, most experts agree that levels of serum 25OH-Vitamin D (25OHD) lower than 20 ng/mL represent an acceptable threshold for deficiency (1). However, recommendations for vitamin D supplementation vary between scientific societies, and the best regimen to treat deficient patients is still not clear (1).

Objectives:

The aim of our study was to compare the pharmacokinetic profile of three different regimes of cholecalciferol supplementation in terms of 25OHD exposure and their safety profiles.

Methods:

We evaluated, in healthy subjects affected by vitamin D deficiency (defined as 25OHD<20 ng/mL), 18 to 60 years of age, the efficacy of three different oral supplementation regimens: daily 10,000Iu administered for 8 weeks, weekly 50,000Iu for 12 weeks and biweekly 100,000Iu for 12 weeks. Serum 25OHD was dosed at baseline, at week 2, 4, 8 in all three groups and also at week 12 in the 50,000 and 100,000Iu groups (the blood sample was taken before the drug administration if scheduled on the same day). Baseline characteristics and 25OHD changes from baseline to the various observation points were tested with ANOVA and t-test. 25OHD was measured by the IDS-ISYSMulti-Discipline automated analyser (Immunodiagnostic System, Boldon, UK) based on chemiluminescence technology. The CV intra-assay measured in our laboratory was 6% (inter-assay CV 9%). The study was authorized by the local ethical committee (protocol DIBA/11. Supported by Abiogen Pharma, Italy).

Results:

A total of 75 subjects were randomized to receive one supplementation regimen. The descriptive of the sample at baseline and relative 25OHD levels at the various observation points are reported in table 1. 25OHD increased significantly already at week 2 in all three groups (p=0.000). At week 2, 100% of the subject of the daily regimen group presented 25OHD levels >20ng/mL, 96% in the weekly and 88% in the biweekly ones.

Table 1.

mean values ± SD at the different observation points.

ParameterDaily 10.000 Ui(N = 25)Weekly 50.000 Ui(n = 25)Biweekly 100.000 Ui(N = 25)p-valueM:F12:137:1812:13Age (years)30.2 ± 9.936.7 ± 8.735.4 ± 11.0*0.059Body Weight (kg)65.8 ± 13.267.8 ± 10.866.6 ± 13.7*NSHeight (m)1.7 ± 0.11.68 ± 0.11.7 ± 0.1*NSBMI22.55 ± 2.723.8 ± 2.222.8 ± 2.7*NSBaseline 25OHD (ng/mL)14.6 ± 3.912.8 ± 313.5 ± 4.1*NS25OHD week 232.3 ± 526.5 ± 3.425.6 ± 5a0.007b0.00025OHD week 455 ± 10.139.9 ± 4.236.9 ± 7.2a0.000b0.00025OHD week 879.1 ± 16.253.5 ± 7.246.4 ± 8.2a0.000b0.000c0.00125OHD week 12NA58.5 ± 7.850.6 ± 9.6b0.000c0.001

*ANOVA test.

aDaily 10.000 Ui vs weekly 50.000 Ui.

bDaily 10.000 Ui vs Biweekly 100.000 Ui.

cWeekly 50.000 Ui vs biweekly 100.000 Ui.

In addition, the 25OH levels of the daily regimen group at week 8 were higher than both the ones of the weekly and the biweekly regimen groups both at week 8 and week 12 (p<0.000 vs both groups).

No serious adverse event occurred.

Conclusion:

All the three different regimens proved to be effective in correcting vitamin D deficiency already after 1 months (2 weeks for the daily regimen). A more refracted approach seems to more effective than the bolus-based regimens. The safety profile was excellent in all groups.

References:

[1]R. Bouillon, Comparative analysis of nutritional guidelines for vitamin D, Nat. Rev. Endocrinol. 13 (2017) 466–479.https://doi.org/10.1038/nrendo.2017.31.

Disclosure of Interests:

Angelo Fassio Speakers bureau: Angelo Fassio reports personal fees from: Abiogen and Novartis, outside the submitted work., Giovanni Adami: None declared, Ombretta Viapiana: None declared, Giovanni Orsolini: None declared, Alessandro Giollo: None declared, Maurizio Rossini Speakers bureau: AbbVie, Abiogen, Amgen, BMS, Eli-Lilly, Novartis, Pfizer, Sanofi, Sandoz and UCB, Davide Gatti Speakers bureau: Davide Gatti reports personal fees from Abiogen, Amgen, Janssen-Cilag, Mundipharma, outside the submitted work.

Vitamin D supplementation: much ado about nothing

The scientific interest and the number of papers dealing with vitamin D supplementation has greatly grown in the last decades. Unfortunately, expert consensus on many clinical aspects of this topic is still lacking. In addition, data coming from recent clinical trials and meta-analyses seem to strongly put into doubt the real benefit of vitamin D supplementation, on both skeletal and extra-skeletal outcomes. This is further confusing since they seem to completely contradict the considerable body of evidence provided from previous epidemiological studies. This paper aims to analyze these new data in order to shed light onto the debated issues.

Nail ultrasonography for psoriatic arthritis and psoriasis patients: a systematic literature review

To systematically review the role of ultrasound (US) in the assessment of the joint-enthesial-nail apparatus in patients with psoriatic arthritis (PsA) or psoriasis (PSO) in terms of prevalence, diagnosis, prognosis, monitoring and treatment. A systematic literature review was conducted through medical databases (PubMed, Embase) and the grey literature up to February 2018. The main areas of application of nail US were first identified, allowing the development of research questions, which were rephrased following the PICOs methodology to develop inclusion criteria. Of the 585 studies produced by PubMed and Embase searches, 17 studies met the criteria for inclusion. Five additional studies were included: 1 from the hand search and 4 from the 2016-2017 ACR and EULAR congresses. The prevalence of nail plate changes varied from < 10 to 97%, for power Doppler signal from 20-30 to 96% and distal interphalangeal joint (DIJ) involvement from 8.9 to 100%. The performance of US nail/DIJ abnormalities in the diagnosis of PsA and PSO elementary lesions was analysed by five studies, with a wide heterogeneity. Reproducibility and reliability of US nil/DIJ were assessed by interclass correlation coefficient or Cohen's k and their values ranged from 0.6 to 0.9. The value of US nail/DIJ in the monitoring of the lesions was analysed only by a single study. The analysis revealed applications for US nail/DIJ in PsA and PSO and highlights limitations. Validation is strongly needed to demonstrate its appropriateness in the clinical practice and to define its diagnostic and prognostic role.

Vitamin D: no efficacy without deficiency. What's new?

Not available.

Radiological features of knee joint synovial chondromatosis

Synovial chondromatosis (SC) is a rare condition with a very variable clinical presentation, thus making the diagnosis not immediate. We report a case of massive primary SC of the knee, properly evaluated with X-rays, ultrasonography and magnetic resonance imaging and successfully treated with an arthroscopic approach.

Changes in Dkk-1, sclerostin, and RANKL serum levels following discontinuation of long-term denosumab treatment in postmenopausal women

PURPOSE

The positive effects of denosumab (DMAb) on bone mineral density (BMD) are quickly reversible after its discontinuation. We investigated whether this rebound was associated with dysregulation of the Wnt canonical pathway and/or by the increase in the receptor-activator of nuclear factor-kappa B ligand (RANKL) serum levels.

METHODS

The study included patients (n = 15) with postmenopausal osteoporosis to whom DMAb was administered for 78 months and then discontinued. We collected BMD data at baseline/month 0 (M0), M60, M84 (6 months after last DMAb administration, coinciding when the next DMAb dose would typically be due), and after 3 and 12 months of follow-up (FU-M3 and FU-M12, respectively). Serum C-terminal telopeptide of type 1 collagen (CTX-I), Dickkopf-1 (Dkk-1), and sclerostin were measured at M0, M60, M84, FU-M3, and FU-M12. Serum N-terminal propeptide of type 1 procollagen (PINP) and RANKL were dosed at M60, M84, FU-M3, and FU-12.

RESULTS

We found a significant decrease in the T-score at all sites at FU-M12, when compared to M84 (-0.51 ± 0.91 at the lumbar spine; -0.72 ± 0.33 at the total hip; and -0.42 ± 0.27 at the femoral neck, p < 0.05). After DMAb discontinuation (M84 vs FU M12) CTX-I, PINP increased already at FU-M3 (+0.921 ± 0.482 ng/mL, +126.60 ± 30.36 ng/mL, respectively, p < 0.01), RANKL increased at FU-M12 (+0.041 ± 0.062 ng/mL, p < 0.05), while Dkk-1 and sclerostin decreased at FU-M12 (-10.90 ± 11.80 and - 13.00 ± 10.52 pmol/L, respectively, p < 0.01). No changes in BMD or any of the markers were found between M60 and M84.

CONCLUSIONS

RANKL serum levels progressively increased after discontinuation of long-term DMAb while Dkk-1 and sclerostin serum levels decreased. The increase in RANKL serum levels supports the hypothesis of a sudden loss of inhibition of the resting osteoclast line after DMAb clearance, with a hyperactivation of these cells. Our results suggest that the changes in serum Wnt inhibitors after DMAb suspension might represent a mere feedback response to the increased bone turnover.

Inhibition of tumor necrosis factor-alpha (TNF-alpha) in patients with early rheumatoid arthritis results in acute changes of bone modulators

OBJECTIVE

Dicckopf-1 (Dkk-1) is a potent inhibitor of the Wnt canonical pathway. In rheumatoid arthritis (RA), Dkk-1 is upregulated by tumor necrosis factor-α (TNF). Certolizumab pegol (CMZ) is a biologic TNF-inhibitor (TNFi) effective in RA and slows radiographic progression. Data on the immediate effects (≤1-8 weeks) of TNFi on Wnt modulators are lacking. This study investigated the acute influence of TNFi treatment on Wnt modulators (Dkk-1 and sclerostin) and bone turnover markers (BTM), including intact N-terminal propeptide of collagen type I (PINP) and C-terminal telopeptide of type I collagen (CTX-I).

METHODS

This longitudinal, uncontrolled study involved female RA patients with inadequate response to conventional methotrexate who underwent treatment with CMZ. ESR, Dkk-1, sclerostin, BTM, parathyroid hormone (PTH), and 25OH-vitamin D levels were evaluated at baseline, week 1, week 4, and week 8. Radiographs of the hands and feet were obtained at baseline and the total and erosion scores were assessed using the Simple Erosion Narrowing Score method (SENS).

RESULTS

Seventeen patients were enrolled. Dkk-1 and CTX-I significantly decreased after one week of treatment with CMZ (-49.1 ± 17.1% and -25.0 ± 20.6%, respectively, p < 0.01), whereas PINP increased (+43.2 ± 31.5%, p < 0.01). These changes persisted at week 4 and 8.

CONCLUSIONS

Our study showed that TNF-alpha inhibition with CMZ promptly results in a rapid decline of serum Dkk-1 levels, alongside decreased bone resorption and increased bone formation.

Treatment with neridronate in children and adolescents with osteogenesis imperfecta: Data from open-label, not controlled, three-year Italian study

INTRODUCTION

The present study assessed the long-term efficacy and safety of intravenous (i.v.) neridronate in children and adolescents affected by osteogenesis imperfecta (OI).

METHODS

55 young patients (mean age 12.6±3.9years) affected by OI were included in the study. Neridronate was administered by i.v. infusion at a dose of 2mg/kg (maximum dose of 100mg) at intervals of three-months for three years. Dual X-ray absorptiometry of the lumbar spine, hip and ultradistal and proximal radius were evaluated every 6months. Blood calcium, phosphate, albumin, fasting urinary calcium/creatinine ratio were obtained at baseline and every 3months. Serum bone turnover markers total and bone alkaline phosphatase were performed every 12months in a proportion of patients.

RESULTS

Mean lumbar spine and total hip bone mineral density (BMD) and bone mineral content significantly increased from baseline compared to all subsequent time points (p<0.001). Mean ultradistal radius BMD significantly increased from month 18 (p=0.026). Levels of bone turnover markers significantly decreased from baseline to all post-baseline observation time points. There was no statistically significant effect on fracture risk (p=0.185), although a significant reduction was observed in the mean number of fractures occurring during treatment compared to pre-treatment values. The most frequent adverse events were arthralgia, fever, joint sprain. An acute phase reaction was reported in 26 (22.8%) patients. None of the reported serious adverse events was considered as treatment-related.

CONCLUSION

Long-term i.v. neridronate treatment has positive effects on BMD, bone turnover markers and fracture risk with a good safety profile.

Effects of secukinumab on serum adipocytokines: preliminary data

Psoriatic arthritis (PsA) is a chronic inflammatory disease that affects joints, connective tissues and the axial skeleton. Metabolic syndrome is an independent risk factor for psoriasis (Pso) development and is associated with more severe forms of Pso. Adipocytokines are secreted by white adipose tissue and are thought to link obesity with the development of metabolic and cardiovascular diseases. Secukinumab is a new monoclonal antibody with a different mechanism of action. This antibody selectively binds to and neutralizes interleukin-17 (IL-17) and it has shown efficacy in the treatment of PsA. The aim of this study was to evaluate the possible interferences of secukinumab on different adipocytokines. We enrolled 28 patients with PsA, classified with the CASPAR criteria. Serum samples were stored at baseline and then at the first, the third and the sixth month of therapy. Resistin, chemerin, adiponectin and C-reactive protein (CRP) were dosed. When tested globally, none of the adipokine tested showed any statistically significant variation. However, when the male group was tested, both resistin and chemerin at M6 showed a significant decrease from baseline. CRP did not show any variation at any time point. Our study demonstrated that treatment with secukinumab has little influence on the levels of adipokines tested within the first six months of treatment even though it might exert different influence between males and females from a metabolic perspective. Further studies with greater numbers of patients are needed to determine whether these preliminary results have clinical relevance.

Drug-induced osteonecrosis of the jaw: the state of the art

Osteonecrosis of the jaw (ONJ) is a rare adverse event of antiresorptive drugs such as bisphosphonates (BP) and denosumab (DMAb). The diagnosis of ONJ is considered in cases where exposed bone in the maxillofacial region does not heal within 8 weeks in a patient previously treated with an antiresorptive agent. In patients with osteoporosis, ONJ is reported as a very rare adverse event while in oncologic patients with bone metastases or malignant hypercalcemia the incidence is significantly higher (up to the 1-10% of the patients). The pathophysiology of ONJ is still not completely understood but it is multi-factorial. ONJ is a condition associated with poor oral health, oral surgery, and use of antiresorptive agents. Prevention is of paramount importance especially in cancer patients, in whom the large majority of cases of ONJ (&gt;90%) are reported, but it should also be considered in osteoporotic patients, especially during dental surgical procedure. Some simple prevention procedures are effective in reducing the risk of its appearance. When ONJ unfortunately occurs, the large majority of patients can be managed conservatively. In conclusion, ONJ is a rare condition associated with antiresorptive drugs. Both osteoporotic and oncologic patients should be well informed about its low absolute risk and regarding the fact that the benefits of antiresorptive therapy far outweigh this potential risk of ONJ.

Long-term Effects of Neridronate in Adults with Osteogenesis Imperfecta: An Observational Three-Year Italian Study

The aim of this study was to assess the long-term efficacy and safety of i.v. neridronate in the treatment of osteogenesis imperfecta (OI). One hundred and fourteen patients affected by OI were included in the study. Neridronate was administered by i.v. infusion at the dosage of 2 mg/kg, up to a maximum of 100 mg at three-month intervals for 3 years. Dual X-ray absorptiometry of the lumbar spine, hip, and ultradistal and proximal radius were evaluated every 6 months. Blood calcium, phosphate, albumin, fasting urinary calcium/creatinine ratio, total serum alkaline phosphatase, and bone alkaline phosphatase were obtained at baseline and every 3 months. The mean lumbar spine and total hip BMD significantly increased from baseline to any time point (p < 0.001). The mean ultradistal radius BMD significantly increased from baseline only at month 18 (p = 0.026), 30 (p = 0.046), and 36 (p = 0.013), respectively. The mean proximal radius BMD did not change during the whole observation. The levels of bone turnover markers significantly decreased from baseline to any post-baseline observation time. The study was not able to find any statistically significant effect on fracture risk (p = 0.185). The percentage of patients with fractures was unaltered during treatment as compared to the 3-year period before treatment. The most common AEs were fragility fractures, back pain, arthralgia, fever, and joint sprain. An acute phase reaction was reported in 26 (22.8%) patients. None of the reported SAEs were considered as treatment-related. Long-term treatment with i.v. neridronate has positive effects on BMD and bone turnover markers with a good safety profile, although no significant effect on the risk of fracture was observed.

Periostin: The bone and beyond

In recent years the relationship between bone, metabolism and many pathophysiologic mechanisms involving other organs and the immune system, was increasingly apparent. This observation concerns vitamin D, osteopontin and periostin (PO). PO is expressed in the periosteum of long bones but also in many other tissues and organs, including heart, kidney, skin and lungs, being enhanced by mechanical stress or injury. PO has a relevant physiological function in promoting injury repair in a large number of tissues. However, its overexpression was observed in different diseases characterized by inflammation, fibrosis and tumorigenesis. Here we review the current knowledge on the role of PO in physiologic and pathologic pathways of different diseases. A specific focus regards the correlation between the level of PO and lung diseases and the identification of PO also as an inflammatory key effector in asthma, strongly associated with airways eosinophilia. In fact PO seems to be a useful biomarker of "Th2-high" asthma compared to "Th2-low" asthma phenotype and a predictor of response to therapeutic agents. Currently, a growing number of studies suggests a possible role of PO as a new diagnostic marker and/or therapeutic target for different diseases and its usefulness in clinical practice should be supported and confirmed by further and larger studies.

A case of mandible Paget’s disease of the bone treated with intravenous neridronate

Paget's disease of bone (PDB) is a focal disorder of osteoclasts, leading to chaotic bone remodelling, and it is characterized by the presence of focal areas of excessive bone formation alongside with areas of focal bone resorption. The typical radiographic feature is the cotton wool appearance. To date, bisphosphonates are the mainstay of the treatment. We hereby report the case of a young woman presenting with mandible PDB, with a relevant diagnostic delay and mistakenly treated for five years with chronic oral corticosteroids. After our evaluation, the patient received treatment with intravenous neridronate (an amino-bisphosphonate licensed in Italy for the treatment of this disease), with achievement of clinical remission.

Teriparatide and denosumab combination therapy and skeletal metabolism

Several therapies are available for osteoporis. Understanding the bone turnover changes and their mutual realtionship gives an overall view and might lead to a target therapy INTRODUCTION: The aim of this study is to compare the changes in bone turnover markers in patients treated with either denosumab alone, teriparatide (TPTD) alone, or in a third therapeutic scheme, when TPTD was added to patients previously treated with denosumab.

METHODS

Fifty-nine women over 65 years old with severe postmenopausal osteoporosis (evidence of at least two moderate-severe vertebral fractures) were enrolled in the study. Serum samples were collected every 3 months. They were assayed for intact N-propeptide of type I collagen (P1NP), C-terminal telopeptide of type I collagen (CTX), intact parathyroid hormone (PTH), 25 hydroxy-vitamin D (25 OHD), Sclerostin (SOST), and Dickkopf-related protein 1 (DKK1). Bone mass density was assessed by dual-energy X-ray absorptiometry at the lumbar spine and at the total hip.

RESULTS

In the groups treated only with TPTD or with denosumab, bone turnover markers increased and decreased, respectively. In TPTD group, a later significant increase in DKK1 was observed, while in denosumab group, a progressive increase in SOST was associated with a progressive significant decrease in DKK1. In the group treated first with denosumab and in which TPTD was added 3 months later, both CTX and P1NP increased 3 months after the beginning of TPTD. The strong effect of denosumab on bone turnover seems to be reversed by TPTD treatment.

CONCLUSIONS

In this study, we showed that TPTD is able to express its biological activity even when bone turnover is fully suppressed by denosumab treatment. The combination therapy is associated with significant increases in both DKK1 and SOST.

The negative bone effects of the disease and of chronic corticosteroid treatment in premenopausal women affected by rheumatoid arthritis

Osteoporosis is a well-known extra-articular complication in rheumatoid arthritis (RA). The chronic corticosteroid treatment, the functional impairment associated with RA and the disease itself appear to be the most relevant determinants. Most of the previous studies involved postmenopausal women, in whom the estrogenic deficiency might amplify the negative effect towards bone of both RA and corticosteroid therapy. We decided to evaluate bone health in a cohort of premenopausal RA patients. The study population includes 47 premenopausal women attending our outpatient clinic for RA and twice as many healthy age-matched control women selected from the hospital personnel. The bone density at the spine and femoral neck were significantly lower in patients with RA as compared with controls. When spine bone mineral density (BMD) values were adjusted for the cumulative glucocorticoid (GC) dose alone and for the cumulative GC dose plus body mass index (BMI) the mean differences between two groups decreased but they remained statistically significant. We found no difference when the spine BMD was adjusted for cumulative GC dose, BMI and health assessment questionnaire. The difference in femoral neck BMD remained statistically significant also after all the same adjustments. In conclusion, our study shows that a BMD deficiency is frequent also in premenopausal women affected by RA, especially at femoral site and that the main determinants of this bone loss are not only the disease-related weight loss, corticosteroid therapy and functional impairment, but also the systemic effects of the disease itself.

Insight into the WNT system and its drug related response

The WNT signalling pathway is a complex system for transferring information for DNA expression from the cell surface receptors to cytoplasm and then to the nucleus. It is based on several proteins that work together as agonists and antagonists in order to maintain homeostasys and to promote anabolic processes. The WNT system acts on all cellular lines involved in bone resorption and formation. WNT pathway can mainly be triggered by two different signalling cascades. The first is well known and is the so-called WNT-beta catenin system (or the canonical pathway), the second is known as the non canonical WNT pathway. WNT proteins form a superfamily of secreted glycoproteins. The association with surface receptors, called Frizzled, that are members of the G protein-coupled receptors superfamily and co receptors like low-density lipoprotein receptor-related proteins 5 and 6 (LRP5/6) complete the WNT system. LRP5/6 show high affinity for WNT antagonists that modulate the activity of this pathway: DKK1 and sclerostin (SCL), that play a crucial role in modulating the WNT system. The WNT-pathway and in particular its antagonists SCL and DKK1 seems to play a key role in the regulation of bone remodeling during treatment with bone active agents such as bisphosphonates, but not only. Their effects become relevant especially in the course of long-term treatments.

Duration of treatment for osteoporosis

Many treatments for postmenopausal osteoporosis with proven efficacy in lowering fracture risk had become available since many years now. In the last few years the issue about treatment duration has become a matter of importance. In this paper the pivotal trials for alendronate, risedronate, zoledronate and other anti reabsorptive drugs such as denosumab are revised with particular attention to the extension studies aimed to verify the effect of drug discontinuation. The results of the review highlight differences among the available drugs and the practical clinical consequences also in terms of cost-effectiveness.