Does low-dose and short-term glucocorticoids treatment increase the risk of osteoporosis in rheumatoid arthritis female patients?

Deciphering the Threshold and Segmented Nonlinear Association Between Systemic Inflammation Response Index and Spinal Bone Density: Insights From a Large-Scale Population Study

Study DesignCross-sectional study.ObjectiveTo examine the association between SIRI and spinal BMD and assess the influence of age, hypertension, and diabetes.MethodsWe analyzed data from 13,950 participants aged ≥20 years. SIRI was calculated using neutrophil, monocyte, and lymphocyte counts, and spinal BMD was measured by DXA. Linear regression, generalized additive models, and segmented regression were used, with subgroup analyses based on age, hypertension, and diabetes.ResultsA threshold effect was observed at SIRI = 0.68. Below this threshold, SIRI negatively correlated with spinal BMD (β = -0.0412, P = 0.0494), while above it, a positive correlation was found (β = 0.0079, P < 0.0001). Subgroup analyses showed stronger positive associations in older adults (≥65 years, β = 0.0136, P < 0.0001), and those with hypertension (β = 0.0089, P = 0.0004) and diabetes (β = 0.0187, P < 0.001).ConclusionA segmented nonlinear relationship exists between SIRI and spinal BMD, with age, hypertension, and diabetes as significant modifiers. SIRI may serve as a biomarker for osteoporosis risk.

Detection of hypophosphatasia in hospitalised adults in rheumatology and internal medicine departments: a multicentre study over 10 years

INTRODUCTION

Hypophosphatasia (HPP) is a rare genetic disease caused by loss-of-function mutations in the ALPL gene encoding the tissue non-specific alkaline phosphatase (ALP). Mild HPP is usually misdiagnosed in adult age. While an elevated serum ALP value draws more attention than a low value, low serum ALP should be better recognised and may lead to HPP detection.

METHODS

Patients were selected from the records of the biochemistry department of six University Hospitals in France. Patients were hospitalised in the departments of rheumatology and internal medicine between 2007 and 2017.

RESULTS

56 321 hospitalised patients had at least 2 serum ALP dosages and 664 of these patients had at least 2 low serum ALP≤35 UI/L. Among these 664 patients, 482 (72.6%) had fluctuating low values (mean age 62.9 years; 60% of women) and 182 patients (27.4%) had persistent low values below 35 IU/L (mean age 53.4 years; 67% of women). Among patients with persistent hypophosphatasaemia treated with bisphosphonates, 70.8% never had ALP measurement before treatment and 20.8% were treated despite an abnormal decrease of ALP. Genetic testing was performed in 18 patients and was positive in 11. Genetic diagnosis of HPP was at least 6.0% in persistent hypophosphatasaemia and at least 15.9% in patients with at least three symptoms suggestive of HPP.

CONCLUSION

In this 10-year retrospective study, 0.32% of adult patients hospitalised in the rheumatology and internal medicine departments had persistently low serum ALP, and among them, 6% had genetically proven HPP. Reported hypophosphatasaemia represented only 3.6% of hospitalised patients.

Prednisone prevents particle induced bone loss in the calvaria mouse model

INTRODUCTION

Glucocorticoids are essential in the treatment of many chronic inflammatory and malignant diseases but are known to have detrimental effects on bone. This study aimed to investigate the effects of prednisone on osteoclast functioning in vivo in the calvaria particle-induced bone loss mouse model.

METHODS

12-week-old male C57BL6/J mice received subcutaneously implanted prednisone (2.5 mg/d, 60 day release (n = 14)) or placebo pellets (n = 10). Osteolysis of the calvaria bone was induced two weeks later by application of ultra-high-molecular-weight polyethylene- (UHMWPE) particles to the dome (vs sham operation). The extent of osteolysis was determined histologically and by micro-computer tomography.

RESULTS

Prednisone significantly inhibited particle-induced osteolysis in the skull. No significant difference in osteoclast numbers was seen in mice with prednisone vs placebo treatment. Prednisone treatment alone without particle application did not reduce bone mineral density or deterioration in bone microarchitecture parameters.

CONCLUSIONS

The calvaria particle-induced bone loss mouse model can be adapted to investigate osteoclast activity in vivo and the effect of prednisone on osteoclasts. In this preventive experimental design, the application of short-term low-dose prednisone has osteoprotective effects without measurable systemic side effects on bone parameters.

Bone Loss, Osteoporosis, and Fractures in Patients with Rheumatoid Arthritis: A Review

Rheumatoid arthritis (RA) is often characterized by bone loss and fragility fractures and is a frequent comorbidity. Compared with a matched population, RA patients with fractures have more common risk factors of osteoporosis and fragility fractures but also risk factors resulting from the disease itself such as duration, intensity of the inflammation and disability, and cachexia. The inflammatory reaction in the synovium results in the production of numerous cytokines (interleukin-1, interleukin-6, tumor necrosis factor) that activate osteoclasts and mediate cartilage and bone destruction of the joints, but also have a systemic effect leading to generalized bone loss. Regular bone mineral density (BMD) measurement, fracture risk assessment using tools such as the FRAX algorithm, and vertebral fracture assessment (VFA) should be performed for early detection of osteoporosis and accurate treatment in RA patients.

Evaluation of the Implementation of Guidelines on the Treatment of Osteoporosis in Patients with Rheumatoid Arthritis

OBJECTIVE

To assess whether the 2003 and 2014 French guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) and the 2012 update of the French guidelines for the treatment of postmenopausal osteoporosis (PMOP) were applied in patients with rheumatoid arthritis (RA).

METHODS

We conducted a cross-sectional study of 776 patients with RA (19 centers). We collected the data required for the application of the various recommendations (age, sex, prednisone intake, low-energy fracture, history in the immediate family of hip fractures, and bone densitometry), anti-osteoporotic drugs, and the various factors that may be associated with the application of the recommendations.

RESULTS

Of the patients who should have received antiosteoporosis treatment, there were 22.6% actually treated (according to the 2014 guidelines), 27.3% actually treated according to the 2003 guidelines, and of postmenopausal women, 23.6% (according to the 2012 PMOP guidelines). Applying the 2014 GIOP guidelines increased the theoretical number of patients requiring treatment relative to the 2003 GIOP guidelines (77% vs 53%; p < 0.001). In multivariate analysis, being treated was associated with a spinal T score ≤ -2 SD according to the 2014 guidelines; with not taking part in physical activity for more than 30 min a day according to the 2003 guidelines; and with older age, lower body mass index, and a T score ≤ -2.5 SD in at least 1 site according to the PMOP guidelines.

CONCLUSION

Patients with RA had inadequate prevention of GIOP and PMOP. The management of osteoporosis needs to be improved in this population.

Lean Mass and Disease Activity are the Best Predictors of Bone Mineral Loss in the Premenopausal Women with Rheumatoid Arthritis

BACKGROUND AND OBJECTIVES

Factors determining bone mineral (BM) loss in rheumatoid arthritis (RA) are not well known. This study aimed to determine the occurrence and predictors of BM loss in the young premenopausal women with RA.

METHODS

Ninety-six females with RA and 90 matched controls underwent clinical, biochemical, BM density (BMD), and body composition assessments. RA disease activity was assessed using disease activity score-28 (DAS-28) and hand X-ray.

RESULTS

In the young premenopausal females with RA having median symptom and treatment duration of 30 (18-60) and 4 (2-12) months, respectively, with moderate disease activity (DAS-28, 4.88 ± 1.17), occurrence of osteoporosis and osteopenia was 7.29% and 25% at spine, 6.25% and 32.29% at hip, and 17.7% and 56.25% at wrist, respectively (significantly higher than controls). RA patients had lower BMD at total femur, lumbar spine (LS), radius total, and radius ultra-distal. Total lean mass (LM) and BM content were significantly lower in RA (P = 0.022 and <0.001, respectively). In RA, BMD at majority of sites (LS, neck of femur, greater trochanter, radius total, and radius 33%) had the strongest positive correlation with LM followed by body fat percent. RA patients with most severe disease had lowest BMD at different sites and lowest LM. Stepwise linear regression revealed LM followed by DAS-28 to be best predictors of BMD. RA patients receiving glucocorticoids did not have significantly different BMDs from patients not taking glucocorticoids.

INTERPRETATION AND CONCLUSION

BM loss is a significant problem in the young premenopausal women with recent-onset RA. LM and disease severity were the best predictors of BMD.

Postmenopausal osteoporosis in rheumatoid arthritis: The estrogen deficiency-immune mechanisms link

Rheumatoid arthritis (RA) is characterized, among other factors, by systemic bone loss, reaching ~50% prevalence of osteoporosis in postmenopausal women. This is roughly a doubled prevalence in comparison with age-matched non-RA women. Postmenopausal RA women are more likely to be sero-positive for the anti-citrullinated peptide antibody (ACPA). Our extensive review of recent scientific literature enabled us to propose several mechanisms as responsible for the accelerated bone loss in ACPA(+) RA postmenopausal women. Menopause-associated estrogen deficiency plays a major role in these pathological mechanisms, as follows.

The association between insulin-like growth factor 1 (IGF-1), IGF-binding proteins (IGFBPs), and the carboxyterminal propeptide of type I procollagen (PICP) in pre- and postmenopausal women with rheumatoid arthritis

OBJECTIVES

To assess the association between plasma levels of the insulin-like growth factor (IGF) system including IGF-1, IGF-binding proteins (IGFBPs) including IGFBP-1, total (t-)IGFBP-3 and functional (f-)IGFBP-3, and the carboxyterminal propeptide of type I procollagen (PICP) in pre- and postmenopausal women with rheumatoid arthritis (RA).

METHOD

Plasma concentrations of IGF-1, IGFBP-1, t-IGFBP-3, f-IGFBP-3, and PICP were measured by immunoassay.

RESULTS

No significant difference was observed in plasma IGF-1 levels between pre- and postmenopausal subjects. Plasma levels of IGFBP-1 were elevated in RA. PICP and f-IGFBP-3 were greatly affected by menopausal status. Of the three IGFBPs tested, only f-IGFBP-3 plasma levels in RA women correlated negatively with age and disease duration. A positive correlation was demonstrated between PICP and erythrocyte sedimentation rate (ESR) in RA. Moreover, there was no correlation between PICP and IGF-1 and any of the IGFBPs in RA women.

CONCLUSIONS

Considerable disruption of the IGF system in RA was found to be related to disease activity and duration. Changes in the IGF-IGFBP axis and PICP levels were different in pre- and postmenopausal women with RA. Elevated plasma PICP concentrations may indicate an increased rate of bone formation in postmenopausal RA women. Additionally, the observed changes in the IGF/IGFBP system did not affect bone formation during RA.

Changes in bone mineral density during long-term treatment with adalimumab in patients with rheumatoid arthritis: a cohort study

OBJECTIVE

To investigate the effect of long-term adalimumab treatment on BMD of the lumbar spine, total hip and hands in patients with RA.

METHODS

In 184 established RA patients treated with adalimumab for at least 1 year, BMD measurements of the total hip and lumbar spine were performed using dual-energy X-ray absorptiometry. Metacarpal cortex BMD was measured using digital X-ray radiogrammetry.

RESULTS

After 1 year of treatment, BMD of the hip and lumbar spine remained stable, while BMD of the hands decreased significantly by -1.41% (P < 0.0001). After a mean follow-up of 4.0 (s.d. 1.0) years, mean BMD change per year was -0.58% and 0.07% for the hip and lumbar spine, respectively (overall P-value of hip was <0.0001 and spine was 0.67). Predictors for BMD loss of the hip were anti-CCP positivity, non-use of bisphosphonates at baseline and BMI. In European League Against Rheumatism (EULAR) non-responders at 52 weeks, BMD change of the hip and spine was -1.25% and 1.08%, respectively, for moderate responders -0.61% and -1.87%, respectively, and in EULAR good responders, BMD remained stable: -0.02% and 0.06%, respectively. BMD of the hands decreased in non-, moderate and good responders (-2.85%, -1.47% and -1.26%, respectively).

CONCLUSION

In patients with severe, established RA, loss of BMD in the spine was arrested over 4 years of adalimumab treatment, whereas BMD of the hands and hip continued to decrease after 1 and 4 years, respectively. The changes in BMD are related to disease activity, underlining the importance of monitoring disease activity.

Osteoporosis in psoriatic arthritis: is there any?

AIMS

Although considered as a feature of inflammatory rheumatic diseases, there is a lot of controversy around low bone mass in patients with psoriatic arthritis. The aim of this cross-sectional study was to analyze bone mineral density in patients with psoriatic arthritis, as well as to investigate its possible association with some measures of disease activity and functional capacity.

SUBJECTS AND METHODS

Sixty-nine patients with established psoriatic arthritis (mean age 56.20 ± 12.23 years) and who have not been treated with specific antiosteoporotic drugs were recruited from the out-patient clinic database. Bone mineral density was measured by dual-energy X-ray absorptiometry at the lumbar spine and at the left hip. Disease activity measures included: duration of morning stiffness, tender and swollen joint count, patient's and physician's global assessment, presence of dactylitis and enthesitis, ESR, CRP and Disease Activity Score 28. Health Assessment Questionnaire was used to assess functional status.

RESULTS

According to WHO definition, spinal osteoporosis was found in 7.2% of patients, total hip osteoporosis in 1.4% of patients and femoral neck osteoporosis in 2.9% of patients. There was no significant association of any of the measures of disease activity with BMD at any site. Higher HAQ scores were associated with lower total hip BMD.

CONCLUSIONS

In our sample of patients with psoriatic arthritis we did not find increased prevalence of osteoporosis. There was no association of BMD with indices of disease activity, while negative correlation was found between HAQ and total hip BMD.

Risk of osteoporotic fracture in a large population-based cohort of patients with rheumatoid arthritis

Introduction

Although osteoporosis has been reported to be more common in patients with rheumatoid arthritis (RA), little is known whether the risk of osteoporotic fractures in these patients differs by age, sex, and anatomic site.

Methods

A retrospective cohort study was conducted using a health care utilization database. Incidence rates (IRs) and rate ratios (RRs) of osteoporotic fractures with 95% confidence intervals (CIs) were calculated. Multivariable Cox proportional hazards models compared the risk of osteoporotic fracture at typical sites between RA and non-RA patients.

Results

During a median 1.63-year follow-up, 872 (1.9%) of 47,034 RA patients experienced a fracture. The IR for osteoporotic fracture at typical sites among RA patients was 9.6 per 1,000 person-years, 1.5 times higher than the rate of non-RA patients. The IR was highest for hip fracture (3.4 per 1,000 person-years) in RA. The IRs across all age groups were higher for women than men and increased with older age in both groups. The RRs were elevated in RA patients across all common sites of osteoporotic fracture: hip (1.62, 95% CI 1.43 to 1.84), wrist (1.15, 95% CI 1.00 to 1.32), pelvis (2.02, 95% CI 1.77 to 2.30), and humerus (1.51, 95% CI 1.27 to 1.84). After confounding adjustment, a modest increase in risk for fracture was noted with RA (hazard ratio 1.26, 95% CI 1.15 to 1.38).

Conclusions

Our study showed an increased risk of osteoporotic fractures for RA patients across all age groups, sex and various anatomic sites, compared with non-RA patients.