A meta-analysis of secondary osteoporosis in systemic lupus erythematosus: prevalence and risk factors

Summary of best evidence on self-management in adult patients with systemic lupus erythematosus

ObjectiveTo evaluate and summarize the best evidence on self-management in adult patients with systemic lupus erythematosus (SLE) and provide evidence-based recommendations in clinical settings.MethodsLiteratures related to self-management of SLE patients were searched in the guideline websites, professional association websites and relevant databases, including clinical decisions, guidelines, expert consensus, best practice recommendations, evidence summaries, meta-analyses, systematic reviews and randomized controlled trials, etc. The search time was from January 2018 to September 2023.ResultsA total of 19 literatures were included, consisting of 9 guidelines, 4 expert consensus, 4 clinical decisions, and 2 systematic reviews, and 49 pieces of evidence were extracted. After sorting and discussing, the evidence were integrated into six aspects: skin management, diet management, exercise management, vaccination management, complication management, as well as follow-up and lifestyle management.ConclusionThe best evidence of self-management in SLE patients summarized in this study is of high quality, which can provide evidence-based recommendations for clinical medical staff and patients, so as to help self-management of SLE patients in a more scientific and effective way.

Osteoporosis and fractures in systemic vasculitides: a systematic review and meta-analysis

Background/aim

We performed a systematic review and meta-analysis of observational studies aimed at investigating the prevalence of osteoporosis and osteoporotic fractures in subjects affected by systemic vasculitides (SVs) as well as to explore their risk of osteoporosis and osteoporotic fractures when compared to healthy controls.

Methods

Scopus, Web of Science and PubMed were systematically searched from inception to February 2024 for observational studies investigating the prevalence of osteoporosis and fragility fractures in adults with SVs. In addition, when available, we assessed the odd ratios (OR) of prevalent osteoporosis and fragility fractures amongst subjects with SVs vs. healthy controls. Data from eligible studies were extracted, and meta-analysis was performed using a random effects model to obtain ORs with 95% confidence intervals (CIs). Subgroup analyses and meta-regressions were also performed. This study was registered in Open Science Framework (DOI: https://doi.org/10.17605/OSF.IO/3G7RJ).

Results

Forty studies with 23,358 individuals affected by SVs were included. The overall prevalence of osteoporosis and fragility fractures in the SV patients were respectively 14.64% (95%CI 12.21-18.89), and 17.08% (95%CI 11.42-24.78). The ORs for osteoporosis and fragility fractures in SV patients when compared with healthy controls were 2.92 (95%CI 1.72-4.98) and 2.39 (95%CI 1.34-4.26) respectively. The univariable meta-regression analysis showed a significant association between cumulative glucocorticoids' dosage (total grams) and risk of prevalent osteoporosis (estimate = 0.0995, R2 = 0.24, p=0.0194).

Conclusion

SVs are associated with an increased risk for osteoporosis and fragility fractures, suggesting that active vigilance and pre-emptive screening are recommended.

Systematic review registration

https://archive.org/details/osf-registrations-3g7rj-v1.

The impact of a fracture liaison service for patients with femoral fractures on subsequent fractures and mortality: focusing on systematic literature review and metaanalysis

The purpose of this study is to scientifically and systematically investigate the clinical effectiveness of a fracture liaison service (FLS) for patients with femoral fractures.

METHODS

The international databases Ovid-MEDLINE, EMBASE, and The Cochrane Library and the Korean databases KISS, RISS, KoreaScience, Koreamed, and Kmbase were used. Risk of bias assessment was conducted at the study design level, and meta-analysis utilized both random-effects and fixed-effects models, along with subgroup analysis.

RESULTS

From the 32 selected articles, 14 articles related to subsequent fracture and 18 articles related to mortality were included in the meta-analysis. As a result of the meta-analysis, the risk of subsequent fracture in the group that participated in the fracture liaison service was 46% lower than that in the non-participated group, and this difference was statistically significant (RR = 0.54, 95% CI = 0.50-0.59). The risk of death in the group that participated in the FLS was 17% lower than that in the non-participating group, and this difference was not statistically significant as well (RR = 0.83, 95% CI = 0.67-1.03). As a result of subgroup analysis, there was a statistically significant difference in the reduction of subsequent fracture in the clinical outcomes, and there was a significant difference in mortality in the intervention follow-up period and clinical outcomes.

CONCLUSION

The global implementation of FLS has played a crucial role in enhancing the clinical management and treatment of patients with femoral fractures, contributing to a decrease in subsequent fracture and mortality. This indicates the significant role of FLS in minimizing the disease burden associated with femoral fractures worldwide.

Endocrine and metabolic comorbidities in juvenile-onset systemic lupus erythematosus

Background and aims

Juvenile-onset systemic lupus erythematosus (JSLE) is a chronic autoimmune disease affecting individuals under 18, causing multi-system impairment. Patients with JSLE exhibit more severe disease when compared to patients with adult-onset SLE. This study aimed to evaluate the prevalence of endocrine and metabolic comorbidities in patients with JSLE, and analyze the factors associated with each comorbidity.

Methods

Anthropometric, clinical, laboratory data, and the details of glucocorticoids and disease-modifying anti-rheumatic drugs use were collected.

Results

A total of 57 patients with JSLE (48 girls and 9 boys) were included in this study. Endocrine and metabolic comorbidities were observed in 64.9% of the patients. The most prevalent comorbidities were dyslipidemia (40.4%), being overweight or obese (26.3%), subclinical hypothyroidism (24.6%), autoimmune thyroid disease (AITD) (21.1%), and low bone mass (20.9%). The risk of dyslipidemia and AITD increased in patients who were overweight or obese. The risk of being overweight or obese was associated with skin involvement at diagnosis and rheumatoid factor positivity. Younger age at diagnosis and longer duration of glucocorticoid exposure increased the risk of low bone mass. The overall prevalence of endocrine and metabolic comorbidities was associated with short stature at diagnosis, being overweight or obese at follow-up, skin involvement at diagnosis, and rheumatoid factor positivity.

Conclusion

Patients with JSLE have higher burdens of endocrine and metabolic comorbidities and should be routinely monitored. Prevention of obesity may be helpful in lowering the risk of comorbidities.

Organ-based characterization of B cells in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a chronic, inflammatory, and progressive autoimmune disease. The unclear pathogenesis, high heterogeneity, and prolonged course of the disease present significant challenges for effective clinical management of lupus patients. Dysregulation of the immune system and disruption of immune tolerance, particularly through the abnormal activation of B lymphocytes and the production of excessive autoantibodies, lead to widespread inflammation and tissue damage, resulting in multi-organ impairment. Currently, there is no systematic review that examines the specificity of B cell characteristics and pathogenic mechanisms across various organs. This paper reviews current research on B cells in lupus patients and summarizes the distinct characteristics of B cells in different organs. By integrating clinical manifestations of organ damage in patients with a focus on the organ-specific features of B cells, we provide a new perspective on enhancing the efficacy of lupus-targeted B cell therapy strategies.

Factors influencing therapeutic efficacy of denosumab against osteoporosis in systemic lupus erythematosus

OBJECTIVE

Osteoporosis is a common comorbidity in patients with SLE, and bone loss in patients with SLE has a multifactorial aetiology. This study aimed to evaluate the therapeutic efficacy of denosumab in patients with SLE with osteoporosis and to analyse the factors influencing therapeutic efficacy.

METHODS

A total of 166 patients with SLE with osteoporosis who initiated denosumab between January 2016 and December 2023 were included. Changes in the T-score and areal bone mineral density (BMD) at the lumbar spine, total hip and femur neck from denosumab initiation to 12 months were measured. Correlation analysis was performed between the degree of BMD improvement and covariates including SLE-specific factors such as SLE duration, SLE Disease Activity Index 2000 (SLEDAI-2K) score, glucocorticoid dose and hydroxychloroquine use. Multiple linear regression analysis was conducted to identify predictors of the therapeutic efficacy of denosumab.

RESULTS

Denosumab significantly increased BMD and decreased bone turnover markers at 12 months compared with baseline. The degree of BMD improvement revealed a significant negative correlation with SLEDAI-2K score, hydroxychloroquine use, prior osteoporosis treatment and baseline BMD values. In contrast, body mass index and c-telopeptide of collagen type 1 levels were positively correlated with the degree of BMD improvement. Higher baseline BMD values, SLEDAI-2K scores and hydroxychloroquine use were significant predictors of attenuated BMD improvement.

CONCLUSIONS

Our study suggests that denosumab is an effective treatment option for osteoporosis in patients with SLE. The therapeutic efficacy of denosumab can be predicted by baseline BMD values, SLEDAI-2K scores and hydroxychloroquine use.

Exercise for improving bone health in patients with AIRDs: Understanding underlying biology and physiology

Exercise has numerous health benefits in patients with autoimmune inflammatory rheumatic diseases (AIRDs). Regular physical activity can help maintain/improve bone health. The aim of the present article was to review current knowledge on the effects of exercise on bone health in patients with AIRDs, particularly in those experiencing a high corticosteroid burden. The article also aimed to discuss potential mechanisms underlying the benefits of physical activity/exercise on bone tissue. Potential explanations regarding the role of exercise on bone health in AIRDs include anti-inflammatory effects, mechanical loading, improvement in muscle strength, hormonal changes, improvement in balance, and effects on telomere erosion, deoxyribonucleic acid methylation, and gene expression. Current evidence regarding the outcomes of exercise on bone health in patients with AIRDs is predominantly derived from studies focused on rheumatoid arthritis. Expanding research to include other rheumatic conditions would enhance the overall understanding of this topic.

Shared molecular signatures between systemic lupus erythematosus and osteoporosis

This study explores the molecular interplay between systemic lupus erythematosus (SLE) and osteoporosis (OP), aiming to uncover shared gene signatures and pathways for better treatment approaches. Leveraging microarray data from the Gene Expression Omnibus (GEO) database, we employed weighted gene coexpression network analysis to identify coexpression modules in SLE and OP, with subsequent protein-protein interaction analysis clarifying the connections among shared genes. Key genes were pinpointed using CytoHubba and random forest algorithms, validated across independent GEO datasets, and further analyzed through gene set enrichment analysis (GSEA) and immune infiltration studies. We discovered two highly correlated modules in SLE and OP, isolating 30 shared genes and identifying GBP1, SOCS1, IFI16, and XAF1 as central to both conditions. Notably, XAF1 and GBP1 mRNA levels were significantly elevated in the peripheral blood of SLE patients compared with healthy and RA counterparts, underscoring their potential as biomarkers. GSEA and immune infiltration analyses indicated pronounced immune and inflammatory responses, especially in interferon signaling pathways, implicating these core-shared gene networks in the diseases' pathogenesis. The findings highlight the involvement of GBP1, SOCS1, IFI16, and XAF1 in SLE with concurrent OP and suggest that targeting immune and inflammatory responses, particularly through interferon pathways, may offer therapeutic promise for these intertwined conditions.

Increased risk of osteoporosis and femoral neck fractures in patients with familial Mediterranean fever-a large retrospective cohort study

OBJECTIVES

The direct impact of inflammatory conditions and their therapy with corticosteroids contribute to an increased risk of osteoporosis with associated fractures. Familial Mediterranean fever (FMF) is an autoinflammatory disorder not commonly treated with corticosteroids. Evidence regarding FMF association with osteoporosis and femur fractures is anecdotal. We aimed to evaluate the incidence and risk of osteoporosis and femoral neck fracture in FMF patients compared with the general population.

METHODS

A retrospective cohort study using the electronic database of Clalit Health Services of all FMF patients first diagnosed between 2000 and 2016 and controls was conducted including age- and sex-matched controls in a 1:1 ratio. Follow-up continued until the first diagnosis of osteoporosis or fracture. Risk for these conditions was compared using univariate and multivariate Cox regression models.

RESULTS

A total of 9769 FMF patients were followed for a median period of 12.5 years. Of these, 304 FMF patients were diagnosed with osteoporosis compared with 191 controls, resulting in an incidence rate (per 10 000 persons-years) of 28.8 and 17.8, respectively, and a crude hazard ratio of 1.62 (95% CI 1.35, 1.93; P < 0.001). Patients were diagnosed with osteoporosis at a considerably younger age than controls [60.1 (s.d. 12.4) vs 62.5 (s.d. 11.0) years; P = 0.028]. A total of 56 FMF patients were diagnosed with femoral neck fracture compared with 35 controls, resulting in an incidence rate of 5.3 and 3.3, respectively, and a crude HR of 1.60 (95% CI 1.05, 2.44; P < 0.05).

CONCLUSION

FMF patients are at increased risk for osteoporosis and consequently femur fracture. Our findings emphasize the importance of considering bone health in the management of FMF patients.

Deficiency of protein C or protein S as a possible cause of osteoporosis

Proteins C and S are vitamin K-dependent anticoagulative factors that also exert a significant influence on bone quality. Clinical studies have linked the deficiency of proteins C and S to lower bone mineral density and the onset of femoral head osteonecrosis in children. Rare foundational studies analyzing this topic have demonstrated that activated protein C, upon binding to the endothelial protein C receptor expressed on the surface of osteoblasts, promotes osteoblast proliferation. It is also established that proteins C and S play crucial roles in proper collagen synthesis and in maintaining the number of osteoclasts and blood vessels. However, the association between protein C and/or S deficiency and the gradual onset of osteoporosis remains largely uninvestigated. Calculations based on data from peer-reviewed journals suggest that approximately one in every 10 individuals may develop osteoporosis due to congenital protein C or S deficiency. Moreover, when secondary causes of protein C and S deficiency are also considered, the proportion likely further increases. In this paper, we discuss the pathophysiological background of the potential relationship between protein C and S deficiency and the genesis of osteoporosis.

Factors affecting bone mineral density in children and adolescents with systemic lupus erythematosus

PURPOSE

Patients with juvenile-onset systemic lupus erythematosus (JSLE) are at a high risk of entering adulthood with disease-related morbidities like reduced bone mass and osteoporosis. This study aimed to evaluate the clinical characteristics of JSLE and to analyze the factors associated with low bone mineral density (BMD) in these patients.

METHODS

Children and adolescents diagnosed with JSLE at a single institution in Korea were included. Demographic, clinical, and laboratory data as well as details about the use of glucocorticoids (GCs) and disease-modifying antirheumatic drugs were collected. The lumbar spine (LS) BMD z-score was measured using dual energy x-ray absorptiometry, and lateral thoracolumbar spine radiographs were collected.

RESULTS

A total of 29 patients with JSLE were included in this study. Of these patients, 7 had a BMD z-score of -2.0 or lower and were designated as the low BMD group. The differences in the clinical parameters and treatment variables between the low BMD and non-low BMD groups were compared. Higher cumulative GC dose, longer GC exposure, and higher cumulative hydroxychloroquine (HCQ) dose were all associated with low BMD; among them, the main factor was the duration of GC exposure. There was no significant correlation between BMD and clinical profile, disease activity, or bone-metabolism markers.

CONCLUSION

The duration of GC exposure, cumulative GC dose, and cumulative HCQ dose were risk factors for low BMD in patients with JSLE, with the main factor being the duration of GC exposure. Thus, patients with JSLE should be routinely monitored for low BMD and potential fracture risks, and GC-sparing treatment regimens should be considered.

The potential causal association between systemic lupus erythematosus and endocrine and metabolic disorders in the East Asian population: A bidirectional two-sample Mendelian randomization study

OBJECTIVES

Observational studies indicate a significant correlation between systemic lupus erythematosus (SLE) and endocrine and metabolic disorders, but the causal association between SLE and endocrine and metabolic disorders remains unclear due to the reverse causality and confounding biases commonly presented in conventional observational research. This study endeavors to uncover the causal association between SLE and three common endocrine and metabolic disorders, including Graves' disease (GD), type 2 diabetes mellitus (T2DM), and osteoporosis (OP).

METHODS

We used genome-wide association study data for SLE and three endocrine and metabolic disorders in an East Asian population, employing bidirectional two-sample Mendelian randomization (MR) analysis and sensitivity analysis to ascertain the causal association between SLE and endocrine and metabolic disorders.

RESULTS

A multiplicative random-effect inverse-variance weighted approach revealed a significant positive correlation between SLE and an elevated risk of GD with an odds ratio (OR) of 1.12 (95% CI: 1.04-1.22, p < .01), and inverse-variance weighted (IVW) analysis also indicated that SLE increased the risk of OP with an OR of 1.035 (95% CI: 1.003-1.068, p < .05). Additionally, GD causally affected SLE in an IVW analysis after Bonferroni correction, with an OR of 1.33 (95% CI: 1.19-1.49, p < .05/3), but the application of multivariable MR analysis resulted in the absence of a causal association of GD on SLE (OR 1.047, 95% CI: 0.952-1.151, p > .05). Lastly, the robustness and validity of the findings were verified through a sensitivity analysis.

CONCLUSIONS

We confirmed that SLE has a causal effect on GD as well as OP, but no evidence exists to substantiate a causal link between SLE and T2DM. Our study offers valuable contributions for uncovering the etiology of SLE and endocrine and metabolic disorders and furthering disease risk research while providing potential targets for disease monitoring and therapeutic intervention.

Systemic lupus erythematosus and damage: What has changed over the past 20 years?

The young age of onset and chronic/relapsing nature of systemic lupus erythematosus (SLE) make SLE patients prone to develop and accrue organ damage as a result of long-standing disease activity and side effects of treatment. There is a growing interest in objectifying damage and identifying its risk factors. Still, the lack of therapeutic alternatives has led to difficulties in avoiding immunosuppressives particularly corticosteroids, which have been implicated in a large spectrum of organ damage in SLE patients. Moreover, it continues to be very challenging to determine what actually causes damage in different organ-systems. Cardiovascular disease continues to be one of the leading types of damage in patients with SLE, reported as early as 1976. Since then, many researchers have focused on identifying SLE or treatment-related and traditional risk factors. The same considerations are valid for other conditions, such as the occurrence of metabolic syndrome, osteoporosis, avascular necrosis, susceptibility to infections, etc. On the other hand, diverse risk factors contribute to the development of chronic kidney disease (CKD) in SLE. Most evidence suggests that high initial levels of serum creatinine, hypocomplementemia, nephrotic range proteinuria, concomitant uncontrolled hypertension, Black and Hispanic ancestry, non-adherence to treatment, and biopsy findings such as diffuse proliferative lupus nephritis (LN), a high chronicity index, tubular atrophy, and tubulointerstitial inflammation are risk factors for progression to end stage renal disease (ESRD) in LN. While cardiovascular disease, CKD and infections are leading causes of mortality in patients with SLE, hospitalizations are caused mostly by SLE disease flares and infections. Cognitive impairment and mood disorders are common in SLE but continue to impose a challenge on how to measure, manage and decipher the underlying pathogenesis. Nevertheless, they have a great impact on SLE patients' health-related quality of life (HRQoL) and social functioning. Also, skin manifestations, such as alopecia and scaring, cataracts, and sicca symptoms result in a significant decrease in HRQoL. In light of recent developments in SLE treatment, we can expect to enter a period of new-age targeted therapies that will enable us to reduce disease activity and glucocorticoid usage further and positively alter the trajectory of damage development and accrual in SLE.

Comorbidities among Egyptian systemic lupus erythematosus: The COMOSLE-EGYPT study

OBJECTIVE

To study the prevalence and impact of comorbidities among a cohort of patients with systemic lupus erythematosus (SLE).

METHODS

This study is retrospective, multicenter including 902 Egyptian patients with SLE. Medical records were reviewed for demographic data, clinical characteristics, routine laboratory findings, immunological profile, and medications. Moreover, SLE Disease Activity Index (SLEDAI), and the Systemic Lupus International Collaborating Clinics/American College Rheumatology Damage Index scores were calculated.

RESULTS

Comorbidities were found in 75.5% of the studied group with hypertension and dyslipidemia as the most frequent comorbidities (43.1% and 40.1%, respectively), followed by sicca features, avascular necrosis, diabetes, osteoporosis and renal failure (11.5%,9%, 9%,8.9%, and 7.1%, respectively). Multivariate regression model showed statistically significant relation between the presence of comorbid condition and each of age (P = 0.006), disease duration (P = 0.041), SLEDAI at onset (P < 0.001), cyclophosphamide intake (P = 0.001), and cumulative pulse intravenous methylprednisone (P < 0.001). Also, when adjusted to age and sex, those with multiple comorbid conditions had 18.5 increased odds of mortality compared to those without comorbidities (odds ratio (OR), 95% confidence interval (CI) = 18.5 (6.65-51.69)].

CONCLUSION

Patients with SLE suffer from several comorbidities, with an increasing risk with age, longer disease duration, higher SLEDAI at onset, cyclophosphamide intake and cumulative pulse intravenous methylprednisone. Risk of mortality is exponentiated with multiple comorbidities.

Impact of T helper cells on bone metabolism in systemic lupus erythematosus

Systemic lupus erythematosus (SLE), an autoimmune disease affecting multiple organs and tissues, is often complicated by musculoskeletal diseases. T helper cells (Th) play an important role in mediating lupus. With the rise of osteoimmunology, more studies have shown shared molecules and interactions between the immune system and bones. Th cells are vital in the regulation of bone metabolism by directly or indirectly regulating bone health by secreting various cytokines. Therefore, by describing the regulation of Th cells (including Th1, Th2, Th9, Th17, Th22, regulatory T cells (Treg), and follicular T helper cells (Tfh) in bone metabolism in SLE, this paper offers certain theoretical support for abnormal bone metabolism in SLE and provides new prospects for future drug development.

Exercise as adjunctive therapy for systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is a rare, chronic autoimmune inflammatory disease with a prevalence varying from 4.3 to 150 people in 100,000, or approximately five million people worldwide. Systemic manifestations frequently include internal organ involvement, a characteristic malar rash on the face, pain in joints and muscles, and profound fatigue. Exercise is purported to be beneficial for people with SLE. For this review, we focused on studies that examined all types of structured exercise as an adjunctive therapy in the management of SLE.

OBJECTIVES

To evaluate the benefits and harms of structured exercise as adjunctive therapy for adults with SLE compared with usual pharmacological care, usual pharmacological care plus placebo and usual pharmacological care plus non-pharmacological care.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 30 March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise as an adjunct to usual pharmacological treatment in SLE compared with placebo, usual pharmacological care alone and another non-pharmacological treatment. Major outcomes were fatigue, functional capacity, disease activity, quality of life, pain, serious adverse events, and withdrawals due to any reason, including any adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our major outcomes were 1. fatigue, 2. functional capacity, 3. disease activity, 4. quality of life, 5. pain, 6. serious adverse events, and 7. withdrawals due to any reason. Our minor outcomes were 8. responder rate, 9. aerobic fitness, 10. depression, and 11. anxiety. We used GRADE to assess certainty of evidence. The primary comparison was exercise compared with placebo.

MAIN RESULTS

We included 13 studies (540 participants) in this review. Studies compared exercise as an adjunct to usual pharmacological care (antimalarials, immunosuppressants, and oral glucocorticoids) with usual pharmacological care plus placebo (one study); usual pharmacological care (six studies); and another non-pharmacological treatment such as relaxation therapy (seven studies). Most studies had selection bias, and all studies had performance and detection bias. We downgraded the evidence for all comparisons because of a high risk of bias and imprecision. Exercise plus usual pharmacological care versus placebo plus usual pharmacological care Evidence from a single small study (17 participants) that compared whole body vibration exercise to whole body placebo vibration exercise (vibrations switched off) indicated that exercise may have little to no effect on fatigue, functional capacity, and pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). The study did not report disease activity, quality of life, and serious adverse events. The study measured fatigue using the self-reported Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue), scale 0 to 52; lower score means less fatigue. People who did not exercise rated their fatigue at 38 points and those who did exercise rated their fatigue at 33 points (mean difference (MD) 5 points lower, 95% confidence interval (CI) 13.29 lower to 3.29 higher). The study measured functional capacity using the self-reported 36-item Short Form health questionnaire (SF-36) Physical Function domain, scale 0 to 100; higher score means better function. People who did not exercise rated their functional capacity at 70 points and those who did exercise rated their functional capacity at 67.5 points (MD 2.5 points lower, 95% CI 23.78 lower to 18.78 higher). The study measured pain using the SF-36 Pain domain, scale 0 to 100; lower scores mean less pain. People who did not exercise rated their pain at 43 points and those who did exercise rated their pain at 34 points (MD 9 points lower, 95% CI 28.88 lower to 10.88 higher). More participants from the exercise group (3/11, 27%) withdrew from the study than the placebo group (1/10, 10%) (risk ratio (RR) 2.73, 95% CI 0.34 to 22.16). Exercise plus usual pharmacological care versus usual pharmacological care alone The addition of exercise to usual pharmacological care may have little to no effect on fatigue, functional capacity, and disease activity (low-certainty evidence). We are uncertain whether the addition of exercise improves pain (very low-certainty evidence), or results in fewer or more withdrawals (very low-certainty evidence). Serious adverse events and quality of life were not reported. Exercise plus usual care versus another non-pharmacological intervention such as receiving information about the disease or relaxation therapy Compared with education or relaxation therapy, exercise may reduce fatigue slightly (low-certainty evidence), may improve functional capacity (low-certainty evidence), probably results in little to no difference in disease activity (moderate-certainty evidence), and may result in little to no difference in pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). Quality of life and serious adverse events were not reported.

AUTHORS' CONCLUSIONS

Due to low- to very low-certainty evidence, we are not confident on the benefits of exercise on fatigue, functional capacity, disease activity, and pain, compared with placebo, usual care, or advice and relaxation therapy. Harms data were not well reported.

Gender differences in SLE: report from a cohort of 417 Caucasian patients

BACKGROUND

SLE is an autoimmune disease that predominantly affects women. As most epidemiological and interventional studies are on populations with a clear female prevalence, the influence of gender in disease course, drug response and damage accrual is yet to be fully explored and comprehended.

OBJECTIVES

To describe gender differences in disease course, comorbidities, use of medications and long-term outcomes of a large cohort of patients with SLE.

METHODS

Retrospective gender-based analysis of prospectively collected data from a monocentric cohort of Caucasian patients with SLE with at least 1 year of follow-up.

RESULTS

417 patients were included, 51 men and 366 women. Men displayed a significantly higher median age at disease onset and diagnosis and a higher prevalence of late-onset SLE, serositis at disease onset, antiphospholipid syndrome (APS) and use of mycophenolate within the first year of disease. Women had a higher prevalence of haematological abnormalities, a higher cumulative exposure to azathioprine and higher cumulative dose of glucocorticoids at 5 years. Male patients had a shorter time to first damage item and a higher prevalence of damage at 1 and 5 years, but this association was no longer significant when late-onset patients were excluded. No differences were found in prevalence of childhood onset, delay between onset and diagnosis, time to renal involvement and histology, cumulative autoantibody positivity, number of flares and hospitalisations, median SLE Damage Index score, type of damage, age and time to first cardiovascular event, chronic kidney disease and death.

CONCLUSIONS

In our cohort, clinical manifestations and disease course were similar in male and female patients; however, male patients displayed higher prevalence of APS and early damage accrual probably due to the later disease onset. These data highlight the importance of an intensive follow-up, prevention and treatment of complications in this category of patients, especially in the first years of disease.

Telehealth-supervised exercise in systemic lupus erythematosus: A pilot study

OBJECTIVES

To explore the feasibility and effectiveness of telehealth-supervised exercise for adults with Systemic lupus erythematosus (SLE).

METHODS

This was a non-randomised controlled pilot trial comparing telehealth-supervised exercise (8 weeks, 2 days/week, 45 min, moderate intensity) plus usual care with usual care alone. Mixed methods were used to assess change in fatigue (FACIT-fatigue), quality of life (SF36), resting fatigue and pain (11-point scale), lower body strength (five-time sit-to-stand) and endurance (30 s sit-to-stand), upper body endurance (30 s arm curl), aerobic capacity (2 min step test), and experience (survey and interviews). Group comparison was performed statistically using a two-sample T-test or Mann-Whitney U-test. Where known, we used MCID or MCII, or assumed a change of 10%, to determine clinically meaningful change within groups over time. Interviews were analysed using reflexive thematic analysis.

RESULTS

Fifteen female adults with SLE were included (control group n = 7, exercise group n = 8). Statistically significant differences between groups, in favour of the exercise intervention, were noted for SF36 domain emotional well-being (p = 0.048) and resting fatigue (p = 0.012). There were clinically meaningful improvements over time for FACIT-fatigue (+6.3 ± 8.3, MCID >5.9), SF36 domains physical role functioning (+30%), emotional role functioning (+55%), energy/fatigue (+26%), emotional well-being (+19%), social functioning (+30%), resting pain (-32%), and upper body endurance (+23%) within the exercise group. Exercise attendance was high (98%, 110/112 sessions); participants strongly agreed (n = 5/7, 71%) or agreed (n = 2/7, 29%) they would do telehealth-supervised exercise again and were satisfied with the experience. Four themes emerged: (1) ease and efficiency of exercising from home, (2) value of live exercise instruction, (3) challenges of exercising at home, and (4) continuation of telehealth-supervised exercise sessions.

CONCLUSION

Key findings from this mixed-method investigation suggest that telehealth-supervised exercise was feasible for, and well-accepted by, adults with SLE and resulted in some modest health improvements. We recommend a follow-up RCT with more SLE participants.

Quantitative lateral flow immunoassay for rapid detection of procollagen type I N-terminal propeptide in the monitoring of osteoporosis treatment

Appropriate follow-up after treatment initiation in patients with osteoporosis is challenging. Serum biomarkers may offer more efficient monitoring of bone mineral density (BMD) than the currently used dual X-ray absorptiometry; however, significant changes in BMD often occur over at least 12 months. During teriparatide treatment for osteoporosis, monitoring with markers such as procollagen type I propeptide (PINP), which is derived from osteoblasts, can provide clinically useful information for disease management. However, rapid and cost-effective methods for detecting serum PINP are lacking, necessitating a point-of-care test (POCT) for enhanced follow-up efficiency in osteoporosis management. For the quantitative detection of PINP, we developed a high-sensitivity lateral flow immunoassay with a stacking pad (sLFIA). We established a calibration equation based on the test line/control line ratio obtained from our PINP sLFIA results of various nonspiked serum samples to calculate the PINP concentrations in 40 serum samples and compared the result with those obtained using a fully automated electrochemiluminescence immunoassay. PINP concentrations between these two methods exhibited excellent correlation (R = 0.991). In addition, we assessed the serum PINP concentrations of patients with osteoporosis treated with teriparatide. At the 3-month follow-up, their PINP levels were nearly twice as high as those at baseline, thus implying that our method can be used for osteoporosis treatment monitoring. Our findings thus indicate that the PINP sLFIA can serve as a POCT for monitoring medication response and managing osteoporosis.

Regulatory effects of autoantibody IgG on osteoclastogenesis

Inflammatory arthritis is common in both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), and eventually leads to bone homeostasis disorders. However, RA patients generally have severe bone destruction, which is rare in SLE patients. Recent studies have demonstrated that anti-citrullinated protein antibodies are important factors leading to bone destruction in RA. On the other hand, SLE patients present deposition of autoantibodies in the joints, which plays an important role in bone protection. These different phenomena occur because of the effects of the autoantibodies on the monocytes/macrophages during osteoclastogenesis, and the mechanisms underlying these effects differ between SLE and RA patients.

Dual nuclear magnetic resonance for probing intrinsic bone structure and a potential gut-bone axis in ovariectomized rats

Currently, the existence of a gut-bone axis receives massive attention, and while sound premises and indirect proofs exist for the gut-bone axis concept, few studies have provided actual data linking the gut and bone physically. This study aimed to exploit the versatile nature of nuclear magnetic resonance (NMR) to link NMR relaxometry data on bone mineralization with NMR spectroscopic profiling of gut metabolites. For this purpose, sample material was obtained from a 6-week intervention study with ovariectomized (OVX) rats (n = 49) fed with seven different diets varying in calcium content (0.2-6.0 mg/kg) and prebiotic fiber content (0-5.0% w/w). This design ensured a span in (i) calcium available for bone mineralization and (ii) metabolic activity in the gut. After termination of the intervention, longitudinal (T₁ ), transverse (T₂ ) relaxation, and mechanical bone strength were measured on the excised femur bones. A PLS model with high predictability (Q²  = 0.86, R²  = 0.997) was demonstrated between T₂ decay curves and femur mechanical strength. Correlations were established between bone T₂ populations and gut short-chain fatty acids. In conclusion, the present dual NMR approach showed strong correlation between T₂ relaxation and mechanical strength of the bone, and when metabolic activity in the gut was modulated by inulin, the potential existence of a gut-bone axis was demonstrated.

Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club

Glucocorticoids are effective immunomodulatory drugs used for many inflammatory disorders as well as in transplant recipients. However, both iatrogenic and endogenous glucocorticoid excess are also associated with several side effects including an increased risk of osteoporosis and fractures. Glucocorticoid-induced osteoporosis (GIOP) is a common secondary cause of osteoporosis in adults. Despite availability of clear evidence and international guidelines for the prevention of GIOP, a large treatment gap remains. In this narrative review, the Belgian Bone Club (BBC) updates its 2006 consensus recommendations for the prevention and treatment of GIOP in adults. The pathophysiology of GIOP is multifactorial. The BBC strongly advises non-pharmacological measures including physical exercise, smoking cessation and avoidance of alcohol abuse in all adults at risk for osteoporosis. Glucocorticoids are associated with impaired intestinal calcium absorption; the BBC therefore strongly recommend sufficient calcium intake and avoidance of vitamin D deficiency. We recommend assessment of fracture risk, taking age, sex, menopausal status, prior fractures, glucocorticoid dose, other clinical risk factors and bone mineral density into account. Placebo-controlled randomized controlled trials have demonstrated the efficacy of alendronate, risedronate, zoledronate, denosumab and teriparatide in GIOP. We suggest monitoring by dual-energy X-ray absorptiometry (DXA) and vertebral fracture identification one year after glucocorticoid initiation. The trabecular bone score might be considered during DXA monitoring. Extended femur scans might be considered at the time of DXA imaging in glucocorticoid users on long-term (≥ 3 years) antiresorptive therapy. Bone turnover markers may be considered for monitoring treatment with anti-resorptive or osteoanabolic drugs in GIOP. Although the pathophysiology of solid organ and hematopoietic stem cell transplantation-induced osteoporosis extends beyond GIOP alone, the BBC recommends similar evaluation, prevention, treatment and follow-up principles in these patients. Efforts to close the treatment gap in GIOP and implement available effective fracture prevention strategies into clinical practice in primary, secondary and tertiary care are urgently needed.

Secondary Osteoporosis and Metabolic Bone Diseases

Fragility fracture is a worldwide problem and a main cause of disability and impaired quality of life. It is primarily caused by osteoporosis, characterized by impaired bone quantity and or quality. Proper diagnosis of osteoporosis is essential for prevention of fragility fractures. Osteoporosis can be primary in postmenopausal women because of estrogen deficiency. Secondary forms of osteoporosis are not uncommon in both men and women. Most systemic illnesses and organ dysfunction can lead to osteoporosis. The kidney plays a crucial role in maintaining physiological bone homeostasis by controlling minerals, electrolytes, acid-base, vitamin D and parathyroid function. Chronic kidney disease with its uremic milieu disturbs this balance, leading to renal osteodystrophy. Diabetes mellitus represents the most common secondary cause of osteoporosis. Thyroid and parathyroid disorders can dysregulate the osteoblast/osteoclast functions. Gastrointestinal disorders, malnutrition and malabsorption can result in mineral and vitamin D deficiencies and bone loss. Patients with chronic liver disease have a higher risk of fracture due to hepatic osteodystrophy. Proinflammatory cytokines in infectious, autoimmune, and hematological disorders can stimulate osteoclastogenesis, leading to osteoporosis. Moreover, drug-induced osteoporosis is not uncommon. In this review, we focus on causes, pathogenesis, and management of secondary osteoporosis.

Therapeutic approaches targeting CD95L/CD95 signaling in cancer and autoimmune diseases

Cell death plays a pivotal role in the maintenance of tissue homeostasis. Key players in the controlled induction of cell death are the Death Receptors (DR). CD95 is a prototypic DR activated by its cognate ligand CD95L triggering programmed cell death. As a consequence, alterations in the CD95/CD95L pathway have been involved in several disease conditions ranging from autoimmune diseases to inflammation and cancer. CD95L-induced cell death has multiple roles in the immune response since it constitutes one of the mechanisms by which cytotoxic lymphocytes kill their targets, but it is also involved in the process of turning off the immune response. Furthermore, beyond the canonical pro-death signals, CD95L, which can be membrane-bound or soluble, also induces non-apoptotic signaling that contributes to its tumor-promoting and pro-inflammatory roles. The intent of this review is to describe the role of CD95/CD95L in the pathophysiology of cancers, autoimmune diseases and chronic inflammation and to discuss recently patented and emerging therapeutic strategies that exploit/block the CD95/CD95L system in these diseases.

Exploring the relationship between systemic lupus erythematosus and osteoporosis based on bioinformatics

OBJECTIVE

This study aimed to explore the relationship between systemic lupus erythematosus (SLE) and osteoporosis (OP) based on bioinformatics.

METHODS

The expression profiles of SLE and OP gene chips were searched through the GEO database, and the differentially expressed genes (DEGs) were screened out to obtain the intersection. Then, the Funrich software was used to predict the upstream miRNAs of the intersection genes, and the miRNA-mRNA relationship network was constructed. Afterward, the String database and Cytoscape software were used to construct the protein interaction network of the intersection genes to screen out the key genes. Finally, the functions and related pathways of key genes were analyzed by using the DAVID database.

RESULTS

①A total of 140 intersection genes of SLE and OP were obtained; ②There were 217 miRNAs regulating the intersection genes; ③IL-4, FOS, TLR1, TLR6, CD40LG, CCR1 were the key genes in the protein interaction network; ④The DAVID enrichment analysis mainly covered the positive regulation of cytokine production, the regulation of osteoclast differentiation, macrophage activation and other biological processes, involving Toll-like receptor signaling pathway, T cell receptor signaling pathway, Th1, Th2, and Th17 cells Differentiation, IL-17 signaling pathway.

CONCLUSIONS

SLE and OP still have some highly overlapping differential gene expressions under the background of complex gene networks. The gene functions and signaling pathways involved can simultaneously regulate the two diseases, suggesting that there is a close relationship between the molecular mechanisms of the two diseases, and that it may be a target of drugs that interfere with two diseases at the same time.

Prevalence of periapical abscesses in patients with systemic lupus erythematosus

AIMS

To assess the prevalence of periapical abscesses in patients with systemic lupus erythematosus (SLE), and to evaluate the effect of glucocorticoids (GCs) used to treat SLE, on the prevalence of such lesions.

METHODS

Integrated data of hospital patients was used. Data from the corresponding diagnosis codes for SLE and periapical abscess was retrieved by searching the appropriate query in the database. The odd ratio (OR) of periapical abscesses and its association with SLE and intake of GCs were calculated and analyzed statistically.

RESULTS

The prevalence of periapical abscesses in patients treated with GCs was 1.5% compared to 0.39% in patients who were not treated with GCs. The OR for periapical abscesses in patients treated with GCs was 2.53 compared with OR of 0.66 in patients not treated with GCs. The differences were statistically significant (p < .0001). The prevalence of periapical abscesses in patients with SLE was 1.88%. The OR was 3.18 and the difference statistically significant (p < .0001).

CONCLUSIONS

Under the conditions of this study, it appears that the prevalence of periapical abscesses is higher in patients with SLE. Patients receiving GCs therapy, either for SLE or for other conditions, may present higher prevalence of periapical abscesses.

Fracture Patterns in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review of Recent Literature

PURPOSE OF REVIEW

In this narrative review, we have summarized the literature on fracture risk in T1DM and T2DM with a special focus on fracture site, time patterns, glucose-lowering drugs, and micro- and macrovascular complications.

RECENT FINDINGS

T1DM and T2DM were associated with an overall increased fracture risk, with preferent locations at the hip, vertebrae, humerus, and ankle in T1DM and at the hip, vertebrae, and likely humerus, distal forearm, and foot in T2DM. Fracture risk was higher with longer diabetes duration and the presence of micro- and macrovascular complications. In T2DM, fracture risk was higher with use of insulin, sulfonylurea, and thiazolidinediones and lower with metformin use. The increased fracture risk in T1DM and T2DM concerns specific fracture sites, and is higher in subjects with longer diabetes duration, vascular complications, and in T2DM with the use of specific glucose-lowering medication.

German Society of Rheumatology recommendations for management of glucocorticoid-induced osteoporosis

BACKGROUND

Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use.

OBJECTIVE

To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment.

METHODS

A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process.

RESULTS

Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment.

CONCLUSION

This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.

Factors associated with the use of complementary therapies in Taiwanese patients with systemic lupus erythematosus: a cross-sectional study

Background

This study aimed to investigate the prevalence of and the factors associated with the regular use of complementary therapies for Taiwanese patients with systemic lupus erythematosus (SLE).

Methods

In this cross-sectional study, 351 patients with SLE were consecutively recruited from a regional hospital in southern Taiwan from April to August 2019. Demographic and clinical information, including the use of different types of complementary therapies, was ascertained using a self-constructed questionnaire. Disease-specific quality of life was measured using the Lupus Quality of Life (LupusQoL) questionnaire. SLE disease activity was assessed using the rheumatologist-scored Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K). Factors associated with the regular use of complementary therapies were evaluated using multiple logistic regression analyses.

Results

Of the 351 patients with SLE, 90.3% were female, and 60.1% were ≥ 40 years of age. The prevalence of the regular use of any type of complementary therapy was 85.5%. The five most popular types of complementary therapy used were (1) fitness walking or strolling, (2) Buddhist prayer or attending temple, (3) vitamin consumption, (4) calcium supplementation, and (5) fish oil supplementation. Multiple logistic regression analyses revealed that the significant and independent factors associated with the regular use of complementary therapies in patients with SLE were age ≥ 40 years (adjusted odds ratio [aOR] 2.76, p = 0.013), nonoverweight or nonobesity (aOR 0.29, p = 0.004), engagement in vigorous exercise in the past year (aOR 4.62, p = 0.002), a lower SLEDAI-2 K score (aOR 0.90, p = 0.029), and a lower score in the physical health domain of the LupusQoL (aOR 0.57, p = 0.001).

Conclusions

A high prevalence of complementary therapy use in Taiwanese patients with SLE was observed. Rheumatologists should routinely ask patients about their use of supplements to minimize the risk of interaction with medical therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03416-w.

[German Society of Rheumatology Recommendations for the management of glucocorticoid-induced Osteoporosis. German version]

BACKGROUND

Glucocorticoids are of substantial therapeutic importance in the treatment of inflammatory diseases, but are also associated with bone mineral density loss, osteoporosis, and fractures, especially with long-term use.

OBJECTIVE

To develop recommendations for the management of glucocorticoid-induced osteoporosis (GIOP) in adult patients on long-term glucocorticoid (GC) treatment.

METHODS

A systematic literature search (SLR) was conducted to synthesize the evidence for GIOP prevention and treatment options. Recommendations were developed based on SLR/level of evidence and by previously defined questions and in a structured group consensus process.

RESULTS

Recommendations include supplementation with calcium and vitamin D under long-term GC therapy in adults. If specific osteologic treatment is indicated, we recommend bisphosphonates or denosumab as first-line treatment. If fracture risk is high, we recommend teriparatide as primary specific osteologic treatment. Denosumab should be used in cases of severe renal insufficiency, and specific osteologic treatment should not be given in pregnancy. For patients who have not reached the treatment goal, a switch to another class of specific osteologic drugs should be performed. We recommend re-evaluation after a treatment duration of 3-5 years or after termination of long-term GC treatment.

CONCLUSION

This work aims to provide evidence-based and consensus-based recommendations for the best possible management of GIOP in Germany and to support treatment decisions.

[Safety aspects of the treatment with glucocorticoids for rheumatoid arthritis]

Glukokortikoide (GC) werden für die initiale Therapie der RA nach wie vor empfohlen – zeitlich befristet und in geringstmöglicher Dosierung. Ihre komplexe Wirkweise geht mit Nebenwirkungen einher, die v. a. in der Dauertherapie oberhalb von 5 mg Prednisolon pro Tag eine Rolle spielen. In diesem Dosisbereich begünstigen sie Osteoporose, Diabetes/Hyperglykämie, kardiovaskuläre Ereignisse und Infektionen und tragen damit zu einer vermehrten Frühsterblichkeit bei. Dabei sind die Risiken der GC-Therapie von patientenbezogenen Faktoren abhängig wie Alter, Komorbidität und Begleitmedikation. Ein negativer Einfluss sehr niedriger Steroiddosen auf das Gesamtüberleben ist möglicherweise bei hoher kumulativer Dosis nachweisbar, die Datenlage ist hier jedoch widersprüchlich. Das Monitoring einer GC-vermittelten Toxizität mithilfe eines validierten Index sollte in Zukunft dazu beitragen, die Vorteile einer steroidsparenden Behandlungsstrategie besser zu beschreiben. Selektiver wirkende Substanzen könnten in Zukunft eine Abkopplung der erwünschten Wirkungen von den Nebenwirkungen ermöglichen.

Seventy years after Hench’s Nobel prize: revisiting the use of glucocorticoids in systemic lupus erythematosus

In 1950, Hench, Kendall and Reichstein were awarded with the Nobel Prize in Physiology and Medicine for the isolation and first therapeutic use of glucocorticoids. Since then, they have become one of the main agents in the treatment of systemic lupus erythematosus (SLE). The use of high-dose oral glucocorticoids (usually 1 mg/kg/day of prednisone equivalent) have become the rule for treating moderate to severe lupus activity. In addition, tapering schemes have not been well defined, all this leading to prolonged exposures to potentially damaging amounts of glucocorticoids. Several studies have shown that glucocorticoids are a major cause of toxicity in SLE in a dose-dependent manner, with prolonged doses greater than 7.5 mg/day being associated with damage accrual. Thus, there is an urgent need for different therapeutic schedules that can achieve a rapid and durable control of lupus activity while reducing the many unwanted effects of glucocorticoids. Recent data show that pulses of methyl-prednisolone are an effective first-line therapy to treat lupus flares (not only severe ones) without major short or long-term toxicity and allowing a reduction in oral prednisone doses. Universal use of hydroxychloroquine – always recommended, infrequently accomplished – and early therapy with immunosuppressive drugs also help control SLE and reduce prednisone load. Results from observational studies confirm the more rapid achievement of remission and the reduction of long-term damage using these combination schedules with reduced prednisone doses. Seventy years after their first therapeutic use, we are learning to use glucocorticoids in a more efficient and safe manner.