Age at natural menopause in women on long-term methotrexate therapy for rheumatoid arthritis

Early menopause is associated with higher disease activity independent of inflammation in postmenopausal-onset rheumatoid arthritis

OBJECTIVE

Early menopause (EM, age ≤ 45 years) is associated with an increased risk of developing rheumatoid arthritis (RA). We aimed to investigate its impact on disease characteristics in RA patients.

METHODS

This cross-sectional study included natural post-menopausal RA patients from an observational RA cohort recruited between January 2015 and October 2023. Demographic characteristics and clinical data were collected. Patients were divided into EM and usual menopause (UM, menopause age > 45 years) groups. Patients-reported outcomes (PROs, included patient global assessment of disease activity [PtGA], pain visual analogue scale [VAS] and Stanford health assessment questionnaire disability index [HAQ-DI]), and PROs-associated indicators (included 28-joint tender joint count [TJC28] and provider global assessment of disease activity [PrGA]) were assessed.

RESULTS

Among 1427 female RA patients, 557 natural post-menopausal RA patients were enrolled. The peak menopause age was between 46 and 50 years, with RA incidence peaking 5 years post-menopause. Compared with UM patients, RA patients with natural EM (n = 98,17.6%) exhibited more serious disease, including worse PROs and PROs-associated indicators, as well as higher C-reactive protein (CRP, all P < 0.05). Among 344 (61.8%) patients with RA onset after menopause, EM patients (n = 62, 18.0%) were characterized with worse PROs and PROs-associated indicators than those with UM patients (all P < 0.05), but no difference in inflammatory makers. Multivariate linear regression showed that menopause age was independently and negatively associated with PROs, including PtGA (β = -0.872, 95% CI -1.619, -0.125), HAQ-DI (β = -0.646, 95% CI -1.059, -0.233) in RA patients especially in those onset after menopause (PtGA [β = -1.028, 95% CI -2.022, -0.034]; HAQ-DI [β = -0.916, 95% CI -1.461, -0.370]).

CONCLUSION

Early menopause impacts on PROs independent of inflammation in patients with RA especially in those with postmenopausal-onset RA, which imply the importance of differentiation of non-inflammatory disease activity.

Yi Shen Juan Bi Pill alleviates bone destruction in inflammatory arthritis under postmenopausal conditions by regulating ephrinB2 signaling

Yi Shen Juan Bi Pill (YSJB) is a traditional Chinese medicine (TCM) formulation that has a therapeutic effect upon rheumatoid arthritis (RA), but how YSJB affects bone destruction in arthritis under postmenopausal conditions is not known. We evaluated the therapeutic role of YSJB in bone destruction in postmenopausal arthritis, We used collagen-induced arthritis (CIA) rats who had been ovariectomized (OVX) as models and explored the possible mechanism from the synovium and bone marrow (BM). Arthritis was generated after ovariectomy or sham surgery for 12 weeks. After 14 days of primary immunization, rats were administered YSJB or estradiol valerate (EV) for 28 days. YSJB could prevent bone destruction in the inflamed joints of rats in the OVX + CIA group. CIA promoted osteoclast differentiation significantly in the synovial membrane according to tartrate resistant acid phosphatase (TRACP) staining, and OVX tended to aggravate the inflammatory reaction of CIA rats according to hematoxylin-and-eosin staining. Immunohistochemistry revealed that the synovium did not have significant changes in erythropoietin-producing hepatocellular interactor (ephrin)B2 or erythropoietin-producing hepatocellular (eph) B4 expression after YSJB treatment, but YSJB treatment reduced nuclear factor of activated T cells (NFATc)1 expression. The BM of rats in the OVX + CIA exhibited remarkable increases in the number of osteoclasts and NFATc1 expression, as well as significantly reduced expression of ephrinB2 and ephB4 compared with the CIA group and sham group. YSJB treatment reduced NFATc1 expression significantly but also increased ephrinB2 expression in the BM markedly. These data suggest that YSJB exhibit a bone-protective effect, it may be a promising therapeutic strategy for alleviating bone destruction in arthritis under postmenopausal conditions, and one of the mechanisms is associated with the modulation of ephrinB2 signaling.

Effects of Methotrexate Therapy on the Levels of Gonadotropic Hormones in Rheumatoid Arthritis Patients of Reproductive Age

Background: Methotrexate (MTX), which is the anchor drug in rheumatoid arthritis (RA), targets actively proliferating cells including the oocytes and granulosa cells which may impair the ovarian reserve. The purpose of this study was to determine the effects of MTX therapy on gonadotropic hormones, i.e. follicular stimulating hormone (FSH) and luteinizing hormone (LH) in female RA patients of reproductive age.

Materials and methods: This is a cross-sectional study conducted at the Universiti Kebangsaan Malaysia Medical Centre (UKMMC), from January 2018 to July 2018. Women with RA aged between 15 and 49 years who were on MTX therapy for at least six months, were consecutively recruited. All subjects were interviewed to gather information on their menstrual history and menopausal symptoms. The medical records were reviewed to obtain further data on the disease characteristics and RA treatment. The RA disease activity was determined using the DAS 28 scoring system. All subjects were tested for their serum FSH and LH levels.

Results: A total of 40 patients were included in this study. The median dose of MTX used by the subjects was 12.5 mg weekly. The mean cumulative MTX dose was 1664.92 ± 738.61 mg. More than half (53.1%) of the subjects reported menopausal symptoms especially hot flushes. We found that FSH levels had a significant positive correlation with cumulative MTX dose [(r = 0.86), p < 0.001] and the duration of MTX therapy [(r = 0.84), p < 0.001]. Besides, there was a significant relationship between disease activity based on DAS 28 and FSH levels (p < 0.01). Age, body mass index, disease duration, and weekly MTX dose showed no associations with the FSH levels. On multivariate analysis, DAS 28 was found to be the only parameter that remained significant [β = 1.74 (95% CI 1.17-2.31), p < 0.001]. The LH levels, on the other hand, were not associated with MTX therapy or disease activity.

Conclusion: Higher levels of FSH, which is an indicator of diminished ovarian reserve, have a significant positive relationship with disease activity, cumulative dose, and duration of MTX therapy in RA. 

A novel quantitative method for estimating bone mineral density using B-mode ultrasound and radiofrequency signals-a pilot study on patients with rheumatoid arthritis

The objective of the present study was to evaluate whether an innovative quantitative ultrasound (QUS) technique, Radiofrequency Echographic Multi Spectromety, which combines B-mode ultrasound and radiofrequency signals, is reliable in typical Romanian patients compared to previous results obtained using dual-energy X-ray absorptiometry (DXA). The study prospectively included previously unscreened post-menopausal females with rheumatoid arthritis (RA) and age-matched healthy controls. Bone mineral density (BMD) measurements were performed with an EchoS machine (Echolight®), which combines B-mode ultrasound and radiofrequency signals. The study included 106 RA patients, with a median disease duration of 3.2 (0.5-22) years and 119 controls. RA patients had a significantly lower body weight, body mass index (BMI) and basal metabolic rate (BMR) than the controls, while the prevalence of obesity and body fat differed insignificantly. RA patients had a significantly lower spine and hip BMD, higher fracture risk and higher prevalence of osteoporosis. Compared to RA patients without osteoporosis, those with osteoporosis were significantly older and had a longer menopause duration, but they had a significantly lower BMI, body fat, BMR and prevalence of obesity. Among the controls and RA patients, the median spine and hip BMD became significantly higher as the BMI increased from underweight to obesity. In conclusion, osteoporosis is prevalent among RA patients, as a part of a complex transformation of body mass composition, involving BMI and fat mass. The novel QUS scanning technique was able to replicate the results of the established DXA measurement of BMD and is potentially suitable for screening wide populations for osteoporosis.