Bone Metabolism in a Large Cohort of Patients with Systemic Sclerosis

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Symptomatic fractures in systemic sclerosis: A case-control study

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

Bone metabolism markers in patients with systemic sclerosis

The mechanism of osteoporosis (OP) development in systemic sclerosis (SSc) remains unclear.

Objective: to assess bone mineral density (BMD) and the level of bone metabolism markers (osteocalcin — OC, — C-terminal type I collagen telopeptides — b-CrossLaps) in the blood serum of patients with SSc.

Patients and methods. 65 patients with SSc were examined, 6 (9%) men and 59 (91%) women, the average age was 51 [39; 61] year (main group), and 35 healthy individuals comparable in anthropometric parameters (control group). In all individuals were assessed the most important populational risk factors for OP. BMD was determined using dual energy X-ray absorptiometry (DXA); the level of vitamin D, OC and b-CrossLaps in blood serum — by enzyme immunoassay.

Results and discussion. A decrease in BMD was statistically significantly more common in patients with SSc (46, 71%), than in controls (11, 31%). Significant risk factors for OP in SSc were early menopause, low physical activity, hypovitaminosis D, and probably high activity and duration of the disease. In patients with SSc, there was a significant decrease in the level of OC compared with the controls; in patients with a reduced BMD, the content of OC was significantly less than in patients with normal BMD. The average values of b-CrossLaps in the main and control groups were comparable, but in patients with OP this parameter was lower than in those with normal BMD.

Conclusion. In patients with SSc, OP develops statistically significantly more often than in healthy individuals. Risk factors for OP are early menopause, low physical activity, long duration and high activity of SSc. The predominance of bone formation impairment over bone resorption as a mechanism for the development of secondary OP was noted.

Screening rates and prevalence of osteoporosis in a real-world, Australian systemic sclerosis cohort

AIM

Despite reports of decreased bone mineral density in patients with systemic sclerosis (SSc) in international cohorts, the prevalence of osteoporosis in Australian SSc patients remains unknown. We report rates of dual-energy X-ray absorptiometry (DXA) scanning in an SSc cohort at a tertiary hospital specialized outpatient clinic and the prevalence and associations of osteoporosis in screened patients.

METHOD

We performed retrospective chart review to determine if patients underwent DXA scanning between 2007 and 2018 and extracted lumbar spine and femoral neck T-scores, fracture history, and osteoporosis therapy.

RESULTS

Of 244 patients, 104 (42.6%) underwent DXA scanning and among patients in whom T-scores were available (n = 91), 30 (33.0%) had osteoporosis and 48 (52.7%) had osteopenia. Screened patients were more likely to have longer disease duration (19.9 vs 15.2 years, P = 0.002), calcinosis (50.5% vs 36.4%, P = 0.028), myositis (12.6% vs 0.7%, P < 0.001), synovitis (42.7% vs 28.6%, P = 0.022), ever used prednisolone (76.7% vs 47.1%, P < 0.001) or fractures (23.0% vs 0.0%, P < 0.001). Patients with osteoporosis more commonly had a history of nasogastric feeding, percutaneous endoscopic gastrostomy feeding or intravenous total parenteral nutrition (6.9% vs 0.0%, P = 0.038) and, unexpectedly, less commonly ever used prednisolone (58.6% vs 85.2%, P = 0.005) compared with patients with osteopenia or normal bone density.

CONCLUSION

We identified high rates of osteoporosis among screened Australian SSc patients. Further assessment in larger, prospective studies is needed to establish guidelines for formal osteoporosis screening in SSc patients.

The Emerging Roles of Endocrine Hormones in Different Arthritic Disorders

The relationship between endocrine hormones and the spectrum of rheumatic conditions has long been discussed in the literature, focusing primarily on sexual hormones, such as estrogens, androgens, prolactin (PRL). Estrogens are indeed involved in the pathogenesis of the main inflammatory arthritis thanks to their effects on the immune system, both stimulatory and inhibitory. The PRL system has been discovered in synovial tissue of rheumatoid arthritis (RA) and psoriatic arthritis (PsA), patients and has been propose as a new potential therapeutic target. Besides sexual hormones, in the last years scientific interest about the crosstalk of immune system with other class of hormones has grown. Hormones acting on the bone tissue (i.e. parathyroid hormone, vitamin D) and modulators of the Wnt pathway (i.e. Dickkopf-1) have been demonstrated to play active role in inflammatory arthritis course, defining a new field of research named osteoimmunology. PTH, which is one of the main determinants of Dkkopf-1, plays a crucial role in bone erosions in RA and a correlation between PTH, Trabecular Bone Score (TBS) and disease activity has been found in ankylosing spondylitis (AS). In PSA is under studying the interaction among IL-17 and bone metabolism. The purpose of this review is to discuss and summarize the recent data about the interaction between endocrine hormone and immune system in the main rheumatic disorders, covering in particular the role of bone-related hormones and cytokines. We will describe this relationship from a biochemical, diagnostic and therapeutic perspective, with a particular focus on RA, PsA and AS.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Osteoporosis in Rheumatic Diseases

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

Comorbidity burden in systemic sclerosis: beyond disease-specific complications

Systemic sclerosis (SSc) is a chronic, systemic disease characterized by fibrosis of the skin and internal organs, vasculopathy, and auto-immune activation. On the top of severe organ involvement such as interstitial lung and myocardial fibrosis, pulmonary hypertension, and renal crisis, individuals diagnosed with SSc may suffer from a number of comorbidities. This is a narrative review according to published recommendations and we searched the online databases MEDLINE and EMBASE using as key words the following terms: systemic sclerosis, scleroderma, myocardial fibrosis in combination with micro- and macro-vascular disease, cardiac involvement, atherosclerosis, cardiovascular disease and coronary arteries, infections, cancer, depression, osteoporosis, and dyslipidemia. Although data are usually inconclusive it appears that comorbidities with significant impact on life expectancy, namely cardiovascular disease, infections, and cancer as well as phycological disorders affecting emotional and mental health are highly prevalent in SSc population. Thereafter, the aim of this review is to summarize the occurrence and the clinical significance of such comorbidities in SSc population and to discuss how rheumatologists can incorporate the management of these conditions in daily clinical practice.

Malnutrition and sarcopenia in a large cohort of patients with systemic sclerosis

Systemic sclerosis (SSc) is an autoimmune disease which may lead to malnutrition. Previous studies have defined it with different criteria. No thorough evaluations of sarcopenia in SSc are available. The aim of the present study was to assess the prevalence and the potential association of malnutrition and sarcopenia in a large cohort of SSc cases. A total of 141 SSc consecutive outpatients were enrolled. Body composition was analyzed by densitometry. Malnutrition was defined according to recently published ESPEN criteria, whereas sarcopenia was diagnosed in patients with reduced skeletal muscle index. Malnutrition was diagnosed in 9.2% of patients (95% CI, 4.4-14.0%). Malnourished patients had worse gastrointestinal symptoms according to UCLA SCTC GIT 2.0 questionnaire (p = 0.007), lower physical activity (p = 0.028), longer disease duration (p = 0.019), worse predicted DLCO/VA and FVC (p = 0.009, respectively), worse disease severity according to Medsger severity score (p < 0.001), lower hemoglobin (p = 0.023), and fat-free mass (p < 0.001) and were more often sarcopenic (p < 0.001). In multivariate analysis, only FVC (p = 0.006) and disease severity (p = 0.003), in particular for the lungs (p = 0.013), were confirmed to be worse in malnourished patients. Sarcopenia was diagnosed in 29\140 patients (20.7%; 95% CI, 14.0-27.4%); 11\29 were also malnourished. In multivariate analysis, sarcopenic patients had longer disease duration (p = 0.049), worse DLCO/VA (p = 0.002), and lung (p = 0.006) and skin (p = 0.014) involvement. In SSc, malnutrition defined with ESPEN criteria was found to be lower than previously reported. Sarcopenia was found to be somewhat common. Lung involvement was significantly associated with nutritional status and may not be explained only by muscle weakness.

Imaging in osteoporosis in rheumatic diseases

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