Risk factors associated with bone loss and occurrence of fragility fractures in rheumatoid arthritis patients

Osteoporosis in Black South Africans With Rheumatoid Arthritis

Background Osteoporosis is a common comorbidity associated with rheumatoid arthritis (RA). The aim of this study was to determine the risk factors and possible predictors of osteoporosis in black patients with RA. Methods A retrospective study of 120 randomly selected RA patients attending an arthritis clinic in Johannesburg, South Africa, was carried out, in which 60 patients were with and 60 without osteoporosis. The demographics, disease activity, American College of Rheumatology (ACR) functional status, treatment, and dual-energy X-ray absorptiometry (DEXA) characteristics were compared. Statistical analysis was performed using SPSS version 25.0 (IBM Corp, Armonk, NY). Bivariate comparisons of demographic factors, disease factors, and T-scores between patients with and without osteoporosis were performed, using two-sided t-tests for continuous variables and chi-squared tests for categorical variables. Possible predictors of osteoporosis were subsequently entered into a multivariate logistic regression model with osteoporosis being the dependent variable. The level of significance for all analyses was set at p < 0.05. Results The median (IQR) age of the overall cohort was 67 (61.0, 72.8) years, the majority (95.5%) were female, of which 97.4% were postmenopausal. The mean disease duration from diagnosis to the DEXA was 8.6 ± 6.2 years. Rheumatoid factor (RF) positivity was 89.2% and anti-cyclic citrullinated peptide (ACCP) positivity was 82.7%. The median (IQR) for disease activity score 28 swollen and tender joint count using the erythrocyte sedimentation rate (DAS-28 ESR) was 3.4 (2.8-4.7) and the median (IQR) for ESR was 41 (22, 64.3) mm/h. There were significantly more patients treated with triple therapy in the no osteoporosis group, 38 (63.3%), than in the osteoporosis group, 21 (35%) (p = 0.00). The ACR functional class was significantly worse in the RA patients with osteoporosis than in the RA patients without osteoporosis [median (IQR), 2 (2, 3) vs 2 (1, 2), (p = 0.03)], respectively. Conclusion This study found that a worse ACR functional class was significantly associated with osteoporosis. In addition, the use of triple therapy had a protective effect. Early recognition of the risk factors for osteoporosis should be sought, with prompt preventative measures, screening, and treatment.

Prevalence of glucocorticoid-induced osteoporosis among rheumatology patients in Africa: a systematic review and meta-analysis

The prevalence of glucocorticosteroid-induced osteoporosis (GIOP) is well established in higher income countries. There are limited studies showing a wide prevalence of GIOP in Africa. Prospective studies are needed on GIOP in African rheumatology patients to implement appropriate management algorithms.

PURPOSE

The prevalence of glucocorticosteroid-induced osteoporosis (GIOP) is well established in developed countries, but little is known about GIOP in African adult patients with inflammatory rheumatic musculoskeletal diseases (RMDs). This study aimed to determine the prevalence of GIOP and osteoporotic fracture risk in African patients with inflammatory RMDs according to radiographic and bone mineral density (BMD) findings.

METHODS

PubMed, Google Scholar, Scopus, and African Index Medicus were searched up to 31 December 2020. Heterogeneity was assessed using I2 statistic across the included studies. A random-effects model was applied to estimate the pooled effect size across studies. All statistical analyses were performed using STATA™ version 14 software. The study was registered with PROSPERO, number CRD42021256252.

RESULTS

In this meta-analysis, a total of 7 studies with 780 participants, stratified by geographical region were included. The pooled prevalence of GIOP based on BMD data was 47.7% (95% CI 32.9-62.8) with 52.2% (95% CI 36.5-67.6) in North African countries and 15.4% (95% 1.9-45.4%) in South Africa with a high heterogeneity (I2 = 93.3%, p = 0.018). There was no data from the rest of African countries. We were unable to complete the meta-analysis of osteoporotic fractures due to the lack of available data.

CONCLUSION

This study revealed that the prevalence of GIOP varies significantly in Africa. There is no information, however, for most of Africa, and further prospective studies are needed to develop context-specific GIOP preventive strategies in patients with RMDs.

The association of serum RANKL levels with disease activity and hematological parameters in Syrian patients with rheumatoid arthritis

Our study aims to detect whether the serum RANKL could be a novel potential biomarker for activity and diagnosis of rheumatoid arthritis (RA). It included fifty-eight of RA patients and thirty of equal age and sex matched controls. Disease activity was determined by using DAS28-ESR. Serum Levels of RANKL were assayed by ELISA and compared with parameters such as ESR, CRP, Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibodies (ACPA). The serum RANKL levels were higher in RA patients compared to controls. There was an increase in its levels mean among post-menopausal patients compared to post-menopausal healthy group. RANKL levels were also higher in ACPA positive patients than ACPA negative. Our study found a correlation between RANKL levels and some parameters: DAS28, ACPA, CRP, and symptom duration. There was a moderate inverse correlation between RANKL levels and BMD. By ROC curve, our results displayed that the best cut-off value of RANKL was 178.99 pg/ml (sensitivity 79.31%; specificity 90%) to differentiate between RA patients and controls. In conclusion, elevated serum RANKL can be used as an indicator of disease activity and a diagnostic new biomarker in patients with early RA.

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Rheumatoid arthritis (RA) is categorized by chronic synovitis leads to cartilage degradation, and bone erosions.

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RANKL/RANK/OPG pathway stimulates osteoclasts and bone resorption.

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ACPA are associated with bone erosions.

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Serum RANKL correlates disease activity of Rheumatoid Arthritis.

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Serum RANKL is an innovative indicator in of Rheumatoid Arthritis patients.

The prevalence of osteoporosis in rheumatoid arthritis patient: a systematic review and meta-analysis

Osteoporosis (OP) is one of the most commonly known extra-articular complications of rheumatoid arthritis (RA). Since the prevalence of OP is diverse in different studies and there is no general consensus about it, in this systematic review, we aimed to investigate the global prevalence of OP among RA patients. In this review, three databases including Medline via PubMed, Scopus, and Web of Science (Clarivate analytics) were searched by various keywords. After screening of retrieved papers, the related data of included papers were extracted and analyzed. To assess the risk of methodological bias of included studies, quality assessment checklist for prevalence studies was used. Because of heterogeneity among studies, random-effect model was used to pooled the results of primary studies. In this review, the results of 57 studies were summarized and the total included sample size was 227,812 cases of RA with 64,290 cases of OP. The summary point prevalence of OP among RA was estimated as 27.6% (95%CI 23.9-31.3%). Despite significant advances in prevention, treatment and diagnostic methods in these patients, it still seems that the prevalence of OP in these patients is high and requires better and more timely interventions.

Bone mineral density, vitamin D receptor (VDR) gene polymorphisms, fracture risk assessment (FRAX), and trabecular bone score (TBS) in rheumatoid arthritis patients: connecting pieces of the puzzle

Purpose

To assess vitamin D receptor (VDR) gene polymorphisms and bone mineral density and to investigate the possible risk factors of osteoporosis and fracture in rheumatoid arthritis (RA).

Methods

A total of 97 RA patients and 45 matched controls were enrolled. Serum vitamin D level, VDR genotyping, dual-energy X-ray absorptiometry (DEXA) scan, trabecular bone score (TBS), and fracture risk assessment (FRAX) in 10 years were assessed. Disease activity score (DAS28) and modified health assessment questionnaire (MHAQ) were measured.

Results

The mean age of the patients was 47.9 ± 8.9 years; 85 females, 12 males (F:M 7.1:1) and mean disease duration 9.4 ± 6.2 years. DAS28 was 4.52 ± 1.04 and MHAQ 0.6 ± 0.4. There was a significant difference between cases and controls as regards DEXA and FRAX (p < 0.0001) but the TBS and VDR genotyping were comparable (p = 0.29 and p = 0.12, respectively). The vitamin D level was comparable with the control (9.3 ± 6.5 vs 10.4 ± 7.5 ng/mL, p = 0.4). None of the patients was receiving anti-osteoporotic therapy or biologic therapy. There was a significant association between the presence of osteoporosis and age, disease duration, menopause, and rheumatoid factor (RF) positivity. The TBS was significantly lower and FRAX higher in patients with positive RF and anti-CCP. FRAX was significantly related and the TBS inversely with the age, disease duration, serum uric acid, alkaline phosphatase, and MHAQ.

Conclusions

Reduced BMD and increased tendency to fractures are remarkable in RA patients. Vitamin D level was decreased in patients and control, and VDR gene polymorphisms were not linked to RA. TBS and FRAX are effective tools to assess osteoporotic fractures in RA.

Key Points • Reduced bone mineral density (BMD) and increased tendency to fractures are remarkable in rheumatoid arthritis (RA) patients. • Vitamin D level was decreased in patients and control, and VDR gene polymorphisms were not linked to RA. • Trabecular bone score (TBS) and fracture risk assessment (FRAX) in 10 years are effective tools to assess osteoporotic fractures in RA.

Time-averaged disease activity of rheumatoid arthritis associated with long-term bone mineral density changes

Background:

Rheumatoid arthritis (RA) is associated with poor bone mineral density (BMD). We designed the current study owing to the lack of long-term prospective studies regarding whether a high disease activity leads to increased bone loss.

Methods:

We have continually enrolled patients with RA. According to the average disease activity score in 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR) during follow-up, the patients were classified into remission, low disease activity, and moderate or high disease activity groups. Patients were examined with dual-energy X-ray absorptiometry at baseline and after 3 years of follow-up. BMD changes were compared among the groups.

Results:

We have studied 477 patients. Overall BMD was significantly reduced from baseline to the 3-year follow-up (p < 0.05). After stratifying according to the time-averaged DAS28-ESR levels and use of anti-osteoporosis treatment (AOT), the BMD values of the femur and spine significantly increased in patients in the remission group with AOT. The BMD changes of different DAS28-ESR patients were further compared using the generalized estimation equation model. For the patients on AOT, the negative change in femoral BMD values of the moderate or high activity group was significant when compared with the remission group with positive BMD changes (regression coefficient, –0.038; 95% confidence interval, –0.055 to –0.021).

Conclusion:

For RA patients, if remission is achieved, AOT can better improve BMD, especially in the femur. In addition, moderate or high disease activity will lead to significant bone loss; therefore, disease activity must be actively controlled.

Serum sclerostin in rheumatoid-induced osteoporosis

Background

Rheumatoid arthritis (RA) is characterized by presence of localized and generalized osteoporosis. The mechanism of decreased bone mass is complex and multifactorial, a possible mechanism behind increased bone loss in RA is upregulation of sclerostin. The aim of this work was to evaluate serum sclerostin level in RA patients and its relation with bone mineral density (BMD) and disease activity.

Results

Serum sclerostin level in RA patients was significantly higher than the controls (p < 0.001). Osteopenia and osteoporosis were more prevalent in RA patients (22.5% and 7.5% respectively) compared to controls (15% and 2.5% respectively) (p = 0.006). Serum sclerostin level was significantly correlated with tender joint count (p = 0.014), swollen joint count (p = 0.036), erythrocytes sedimentation rate (p = 0.010), C reactive protein serum level (p = 0.025), disease activity score (DAS) 28-ESR (p = 0.018), DAS28-CRP (p = 0.005), and radiological modified Sharp erosion score (p = 0.049). The correlation of serum sclerostin level in RA patients with BMD and with T-score in all sites revealed an inverse relationship with p values insignificant.

Conclusion

Serum sclerostin is a major player in bone metabolism as a negative regulator of bone growth through inhibition of Wnt signaling that is largely influenced by the disease activity. Controlling the disease activity is a major factor for prevention of local as well as generalized osteoporosis and is essential for the reparative local and systemic bone health.

An epidemiological analysis of osteoporotic characteristics in patients affected with rheumatoid arthritis in Kazakhstan

PURPOSE

We aimed to assess which of the major risk factors associated with rheumatoid arthritis (RA) severity are also associated with osteoporosis-related phenotypes (OP-RP) in the native population of Kazakhstan.

METHODS

Four hundred six RA patients (90.6% females) with 397 controls-unaffected first-degree relatives were recruited. Biochemical factors were recorded, and OP-RP were assessed using QCT scans and ultrasound densitometry (US) of the forearm to estimate cortical indices (CI), spongial bone mineral density (BMD_SPN), and US_T-scores.

RESULTS

In the RA affected female population, ~ 80% suffered from osteopenia or osteoporosis. All OP-RP were negatively correlated with age and female's sex, as expected, and thus accordingly adjusted, resulting in consistent, significantly [p = 0.016 (CI), p < 0.0001 (both BMD_SPN and US_T-scores)] lower OP-RP estimates in affected females. Using multiple regression analysis for OP-RP manifestations, only age and disease duration appeared consistently associated with all three studied phenotypes, while menopause status or years following the onset of menopause were also significant for BMD_SPN and US_T-scores. However, when disease duration was examined, we found that it was significantly dependent on morning stiffness, ESR, total cholesterol levels, weight, and menopause status, which explains 38.6% of the disease duration.

CONCLUSIONS

Approximately 80% of female RA patients suffer from osteoporosis or osteopenia in the study group, which appears from a young age. RA disease duration is the major risk factor for OP-RP deterioration, especially as assessed by BMD_SPNG, and US_T-scores. As a result, all OP-RP demonstrate significantly lower levels in comparison to sex- and age-matched unaffected individuals.