[Evaluation of the trabecular bone score (TBS) in routine clinical care of patients with inflammatory rheumatic and non-inflammatory diseases : Correlation with conventional bone mineral density measurement and prevalence of vertebral fractures]

Osteoporosis and Rheumatoid Arthritis: A Review of Current Understanding and Practice

This review presents a current perspective on the association between rheumatoid arthritis (RA) and osteoporosis. Many factors contribute to the increased risk of osteoporosis and fracture in RA patients. These factors include advanced age, duration of disease, long-term glucocorticoid use, and poor inflammation control inflammation in RA. This review discusses current guidelines and their limitations in assessing bone health in RA-related osteoporosis. Available anti-osteoporotic treatments, their mechanisms of action, and their potential benefits in managing the interaction between RA and osteoporosis are discussed. We also consider potential advancements, including areas of future development in RA and osteoporosis diagnosis and management.

The influence of severity of hemophilia on bone mineral density and fracture risk

Background

Evidence states that persons with hemophilia are frequently affected by low bone mineral density (BMD). Data assessing the relationship between severity of hemophilia and occurrence of osteoporosis are lacking.

Objectives

This prospective cohort study aimed to assess the impact of hemophilia severity on BMD and to investigate trabecular bone score (TBS) and fracture risk (FRAX).

Methods

This prospective cohort study evaluated the BMD, TBS, and FRAX in 255 persons with hemophilia using dual x-ray absorptiometry. The International Society for Clinical Densitometry guidelines were used for classification: osteoporosis (T-score <-2.5), osteopenia (T-score <-1.0), normal (T-score >-1.0). Patients younger than 50 years of age with a Z-score of <-2.0 were considered below the expected range for age.

Results

Of 255 persons with hemophilia (mild: n = 52, moderate: n = 53, severe: n = 150) aged 43 ± 15 years (mean ± SD), 63.1% showed reduced BMD. Even 11.9% of persons with hemophilia aged <50 years were classified as below the expected range for age. Neck BMD decreased linearly with severity (mild: 0.907 ± 0.229, moderate: 0.867 ± 0.131, severe: 0.799 ± 0.143; P = .01). TBS was classified as "normal" in n = 178 (81.3%) with a mean value of 1.403 ± 0.136, and there were no differences between severity levels (P = .54). The FRAX was 4.4% ± 3.0%. After adjustment of TBS, it was 2.8% ± 3.7%.

Conclusion

The present study shows that BMD is decreased in 63.1% of persons with hemophilia also depending on the severity of hemophilia. However, the largely normal TBS implies that the microarchitecture of the bone does not seem to be affected. It is recommended to include osteoporosis screening, including TBS analysis, in the comprehensive diagnostic work-up of persons with hemophilia, especially as they age.

Evaluation of Trabecular Bone Microarchitecture and Bone Mineral Density in Young Women, Including Selected Hormonal Parameters

The absence of non-invasive methods for assessing bone material and structural changes is a significant diagnostic challenge. Dual-energy X-ray absorptiometry (DXA) bone mineral density (BMD) testing is the gold standard for osteoporosis diagnosis. BMD and the trabecular bone score (TBS) have facilitated targeted osteoporosis prevention and treatment in clinical settings. The findings from this study indicate that BMD modulation in young women is influenced by various hormones, potentially compromising the diagnostic precision of BMD for subclinical bone demineralization. A total of 205 women aged 19 to 37 underwent anthropometric measurements and hormonal tests. BMD was determined using DXA, and TBS values were computed from the lumbar spine L1-L4 segment. The multivariate analysis findings suggest that BMD might not be determined by hormones. The relationship between TBS and TSH was statistically significant in the univariate analysis, which indicates the efficacy of further studies to determine the link between TBS and specific hormones. Analyzing the strength of the correlation between TBS and hormones in the univariate analysis shows which factors are worth considering in further analyses. This makes it possible to create better techniques that will help identify young women who are at a higher risk of developing osteoporosis.

Update on the utility of trabecular bone score (TBS) in clinical practice for the management of osteoporosis: a systematic review by the Egyptian Academy of Bone and Muscle Health

Trabecular bone score (TBS) is a grayscale textural assessment resulting from a computed evaluation of pixel gray-level variations in previously obtained lumbar spine DXA images. It is an index of bone microarchitecture correlated with parameters of bone strength. Higher values of TBS indicate a better microarchitecture, whereas lower values indicate a degraded microarchitecture. TBS can be used alongside Fracture Risk Assessment tool “FRAX” and bone mineral density (BMD) to enhance the assessment of fracture risk and to inform treatment initiation and monitoring. A systematic review was carried out aiming to update the evidence on the clinical use of the TBS in the management of both primary and secondary osteoporosis. Results revealed that in both primary and secondary osteoporosis, TBS enhances the prediction of fracture risk, and when adjust with BMD and clinical risk factors, it is able to inform the decision-making process regarding initiating osteoporosis therapy and the choice of anti-osteoporosis medication. Evidence also implies that TBS provides valuable adjunctive information in monitoring osteoporosis therapy. In conclusion, this work provides an up-to-date evidence-based review and recommendations which informs the utility of trabecular bone score in standard clinical practice.

[Trabecular bone score in rheumatology : Are there benefits in comparison to bone densitometry alone?]

Patients with inflammatory rheumatic diseases have an increased risk of fractures due to the inflammatory potential of the disease and also because of the treatment with glucocorticoids that is often necessary. According to the current guidelines of the Governing Body on Osteology (DVO), the fracture risk can be assessed using dual energy X‑ray absorptiometry and can also be supplemented by measuring the trabecular bone score (TBS). The assessment of the TBS offers additional advantages, for example in glucocorticoid-induced osteoporosis and in patients with osteoproliferative changes of the spine (spondylarthritis) and thus optimizes the fracture risk assessment in the rheumatological patient population.

Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging

PURPOSE

Trabecular bone score (TBS) is a grey-level textural measurement acquired from dual-energy X-ray absorptiometry lumbar spine images and is a validated index of bone microarchitecture. In 2015, a Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) published a review of the TBS literature, concluding that TBS predicts hip and major osteoporotic fracture, at least partly independent of bone mineral density (BMD) and clinical risk factors. It was also concluded that TBS is potentially amenable to change as a result of pharmacological therapy. Further evidence on the utility of TBS has since accumulated in both primary and secondary osteoporosis, and the introduction of FRAX and BMD T-score adjustment for TBS has accelerated adoption. This position paper therefore presents a review of the updated scientific literature and provides expert consensus statements and corresponding operational guidelines for the use of TBS.

METHODS

An Expert Working Group was convened by the ESCEO and a systematic review of the evidence undertaken, with defined search strategies for four key topics with respect to the potential use of TBS: (1) fracture prediction in men and women; (2) initiating and monitoring treatment in postmenopausal osteoporosis; (3) fracture prediction in secondary osteoporosis; and (4) treatment monitoring in secondary osteoporosis. Statements to guide the clinical use of TBS were derived from the review and graded by consensus using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

A total of 96 articles were reviewed and included data on the use of TBS for fracture prediction in men and women, from over 20 countries. The updated evidence shows that TBS enhances fracture risk prediction in both primary and secondary osteoporosis, and can, when taken with BMD and clinical risk factors, inform treatment initiation and the choice of antiosteoporosis treatment. Evidence also indicates that TBS provides useful adjunctive information in monitoring treatment with long-term denosumab and anabolic agents. All expert consensus statements were voted as strongly recommended.

CONCLUSION

The addition of TBS assessment to FRAX and/or BMD enhances fracture risk prediction in primary and secondary osteoporosis, adding useful information for treatment decision-making and monitoring. The expert consensus statements provided in this paper can be used to guide the integration of TBS in clinical practice for the assessment and management of osteoporosis. An example of an operational approach is provided in the appendix. This position paper presents an up-to-date review of the evidence base, synthesised through expert consensus statements, which informs the implementation of Trabecular Bone Score in clinical practice.

Trabecular bone score in rheumatic disease

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

Trabecular Bone Score in Rheumatic Disease

PURPOSE OF REVIEW

Patients with rheumatic disease are at high risk of low bone mass and osteoporotic fracture. Trabecular bone score (TBS), derived from lumbar spine dual-energy x-ray absorptiometry (DXA), is a novel measure of bone texture that independently predicts fracture risk. This review examines the role of TBS in rheumatic disease including fracture prediction.

RECENT FINDINGS

Most studies concerning TBS and rheumatic disease are cross-sectional, with consistent evidence of lower TBS in patients with rheumatic disease compared to controls. Recent studies have shown association and predictive ability of TBS for prevalent fracture, and the few longitudinal studies showed predictive ability of TBS for incident fracture. TBS in ankylosing spondylitis is of interest given the high rates of vertebral fracture and technical difficulty with lumbar spine bone mineral density. TBS degradation has been associated with disease activity in ankylosing spondylitis, systemic sclerosis, and rheumatoid arthritis. Glucocorticoid exposure is associated with lower TBS, and predicts prevalent fracture, in patients with rheumatic conditions.

The applicability of trabecular bone score for osteoporosis diagnosis in ankylosing spondylitis

Ankylosing spondylitis (AS) patients have a high risk of osteoporotic fractures. The aim of this study was to evaluate the usefulness of trabecular bone score (TBS) in assessing fracture risk in patients with AS. 67 patients meeting the ASAS classification criteria were enrolled in the study. Fracture risk for each patient was assessed based on a lumbar spine exam encompassing bone mineral density (BMD), and TBS through a dual-energy X-ray absorptiometry (DXA) exam. In addition, each patient had an X-ray taken of their lumbar and thoracic spine to determine the presence of syndesmophytes and bony bridges, as well as spinous process and vertebral body fractures. Moreover, each patient's medical history was analyzed for other osteoporotic fractures. A major osteoporosis fracture (MOF) was found in 11 (16%) patients in total, of which 7 (10%) were vertebral body fractures. The mean TBS in patients with MOF and no MOF were, respectively, 1.12 and 1.29 (p < 0.001). No significant differences were found in BMD scores between the two groups. Syndesmophytes and bony bridges occurred more frequently in patients with MOF (p = 0.02). Age of 50 or more (RR = 9.86, p = 0.002), TBS score ≤ 1.31 (RR = 2.07, p < 0.0001), and presence of syndesmophytes and bony bridges (RR = 2.14, p = 0.04) were considered a relative risk (RR) increasing factors. TBS is a markedly more sensitive method of identifying patients with a high fracture risk compared to BMD measurement in a DXA exam in patients with AS.

Vertebral fractures are increased in rheumatoid arthritis despite recent therapeutic advances: a case-control study

Prevalence and risk factors of vertebral fractures in postmenopausal RA women were assessed in 323 patients and compared with 660 age-matched women. Of patients, 24.15% had at least one vertebral fracture vs.16.06% of controls. Age, glucocorticoids and falls were the main fracture risks. Vertebral fractures were associated with disease severity.

INTRODUCTION

There is little quality data on the updated prevalence of fractures in rheumatoid arthritis (RA) that may have changed due to advances in the therapeutic strategy in recent years. This study was aimed at analysing the prevalence and risk factors of vertebral fractures in postmenopausal women with RA and comparing it with that of the general population.

METHODS

We included 323 postmenopausal women diagnosed with RA from 19 Spanish Rheumatology Departments, randomly selected and recruited in 2018. Lateral radiographs of the thoracic and lumbar spine were obtained to evaluate morphometric vertebral fractures and the spinal deformity index. We analysed subject characteristics, factors related to RA, and fracture risk factors. The control group consisted of 660 age-matched Spanish postmenopausal women from the population-based Camargo cohort.

RESULTS

Seventy-eight (24.15%) RA patients had at least one vertebral fracture. RA patients had increased fracture risk compared with controls (106 of 660, 16.06%) (p = 0.02). Logistic regression analysis showed that age (OR 2.17; 95% CI 1.27-4.00), glucocorticoids (OR 3.83; 95% CI 1.32-14.09) and falls (OR 3.57; 95% CI 1.91-6.86) were the independent predictors of vertebral fractures in RA patients. The subgroup with vertebral fractures had higher disease activity (DAS28: 3.15 vs. 2.78, p = 0.038) and disability (HAQ: 0.96 vs. 0.63, p = 0.049), as compared with those without vertebral fractures.

CONCLUSION

The risk of vertebral fracture in RA is still high in recent years, when compared with the general population. The key determinants of fracture risk are age, glucocorticoids and falls. Patients with vertebral fractures have a more severe RA.

Trabecular Bone Score-An Emerging Tool in the Management of Osteoporosis

Areal bone mineral density (aBMD) is currently the gold standard for the diagnosis of osteoporosis, however, it has its own pitfalls. Trabecular bone score (TBS), a novel tool in the evaluation of osteoporosis is an indirect indicator of bone microarchitecture. It is a textural index that evaluates pixel gray-level variations in the lumbar spine DXA (dual energy X-ray absorptiometry) image. Both cross-sectional and longitudinal studies have demonstrated that TBS may independently predict fragility fractures. TBS can also be used to adjust FRAX probabilities of fracture, though data available till date doesn't support any additional benefit. TBS also shows an improving trend with anti-osteoporotic treatment; however, the least significant change (LSC) is high that it takes more than 2 years for the change to manifest. TBS is also used in the evaluation of bone strength in cases of secondary osteoporosis. Though TBS predicts fracture risk independently in both genders, with the currently available data, it cannot be recommended as a standalone tool for decision regarding treatment of osteoporosis. TBS can be used as a tool to complement BMD in assessment of bone health. Additional studies are needed to assess its utility in clinical practice.