Impaired ambulation and steroid therapy impact negatively on bone health in multiple sclerosis

Short-Term Risk Factors for Bone Loss in Multiple Sclerosis: A Prospective Study and Literature Review

BACKGROUND

Reduced bone mass and increased osteoporosis risk are common in people with multiple sclerosis (pwMS). The aim of the study was to identify risk factors for short-term bone loss in MS.

METHODS

This prospective study included 139 pwMS (ages 18-65). Baseline data included demographics, body-mass index, physical activity, smoking, menopause status, 25-hydroxy vitamin D levels, and history of glucocorticoid use. Bone mineral density (BMD) was measured at baseline and after 2 years using dual-energy X-ray absorptiometry (DXA) for the lumbar spine and hip. Disability worsening was assessed by the Expanded Disability Status Scale (EDSS). Additionally, a literature review was conducted on longitudinal data regarding BMD in MS.

RESULTS

Over the 2-year follow-up period, significant BMD loss was observed in the hip (baseline g/cm2: median 0.898; IQR 0.808-1.014; 2-year follow-up: 0.882; 0.784-1.01; p < 0.001), but not in the lumbar spine. Overall, 101 (73.1%) experienced hip BMD loss, with a median decrease of 3.5%. Patients with disability worsening had an approximately 7-times higher risk of bone loss compared to those without disability worsening (p = 0.013). PwMS with fractures during the follow-up period had significantly lower hip BMD (0.760, 0.546-0.890 vs. 0.909, 0.828-1.015; p = 0.024), a higher EDSS score (4.4, 2.8-5.8 vs. 2.0, 1.0-4.0 vs. p = 0.026), and were older (59, 46-62 vs. 47, 37-54; p = 0.030) compared to those without fractures.

CONCLUSION

Disability worsening was identified as a risk factor for BMD loss. These findings underscore the need for active monitoring of pwMS with disability worsening to prevent bone loss and, thus, to reduce fracture risk.

Bone loss and fracture in people with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

People with multiple sclerosis (PwMS) exhibit reduced bone mineral density (BMD) across several anatomical regions. Studies have indicated that PwMS are at a heightened risk of fractures due to decreased BMD and increased prevalence of osteopenia and osteoporosis. This study aimed to investigate the prevalence and risk of osteopenia, osteoporosis, and fracture among PwMS.

METHODS

Relevant studies were identified through comprehensive searches of databases (PubMed/MEDLINE, Scopus, Embase, and Web of Science) from January 1, 2000, to January 21, 2024. R software version 4.4.0 and random-effects models were employed to estimate the pooled prevalence, odds ratio (OR), and risk ratio (RR) of osteopenia, osteoporosis, and fracture among PwMS, along with their respective 95 % confidence intervals (CIs).

RESULTS

From a total of 2039 articles, 51 studies with 1,503,785 PwMS met our inclusion criteria. The pooled prevalence of osteopenia, osteoporosis, and overall fracture among PwMS was 41.41 % (95 % CI: 36.14% to 46.69 %, I2=97 %), 14.21 % (95 % CI: 10.75 % to 17.68 %, I2=99 %), and 12.84 % (95 % CI: 8.49 % to 17.19 %, I2 = 100 %), respectively. The likelihood of osteopenia (OR=2.02, 95 % CI: 1.46 to 2.8, p-value<0.01, I2=17 %) and osteoporosis (OR=1.71, 95 % CI: 1.27 to 2.31, p-value<0.01, I2=74 %), as well as the probability of overall fracture (RR=1.86, 95 % CI: 1.61 to 2.14, p-value<0.01, I2=74 %) were significantly higher in PwMS than healthy controls (HCs).

CONCLUSION

PwMS were at a substantially increased risk of developing osteopenia (2-fold), osteoporosis (1.7-fold), and overall fractures (1.9-fold). Well-designed studies are needed to explore these associations further.

Medication and bone health in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

People with multiple sclerosis (MS) are often prescribed medications associated with adverse effects on bone health. However, it is unclear whether these medications incur decreases in areal bone mineral density (aBMD) and higher fracture risk in this population.

OBJECTIVE

To investigate the effects of commonly used medications on aBMD and fracture risk among people with MS.

METHODS

MEDLINE, Embase, Scopus, CINAHL, and Web of Science were searched from their inception until February 5, 2023. We included randomized controlled trials as well as cross-sectional, retrospective, and prospective studies investigating whether glucocorticoids, immunomodulators, antidepressants, anticonvulsants, anxiolytics, opioids, or antipsychotics influenced aBMD or fracture risk in people with MS. Data were pooled using random effects meta-analyses to determine hazard ratios (HRs) and 95% CIs.

RESULTS

We included 22 studies (n = 18,193). Six studies were included in the meta-analyses of glucocorticoid use and aBMD, whereas 2 studies were included in the medication use and fracture risk meta-analyses. No studies assessed the effect of antidepressants, anxiolytics, anticonvulsants, opioids, and antipsychotics on aBMD, and no studies assessed the effect of immunomodulators on fracture risk. Glucocorticoid use was significantly negatively associated with femoral neck aBMD (correlation = -0.21 [95% CI = -0.29 to -0.13]), but not with lumbar spine aBMD (correlation = -0.21 [95% CI = -0.50 to 0.12]). There were no differences in fracture risk between users of glucocorticoids (HR = 1.71 [95% CI = 0.04 to 76.47]), antidepressants (HR = 1.84 [95% CI = 0.09 to 38.49]), or anxiolytics (HR = 2.01 [95% CI = 0.06 to 64.22]), compared with nonusers.

CONCLUSIONS

The available evidence is insufficient to support a relationship between greater fracture risk for people with MS taking glucocorticoid, antidepressant, or anxiolytic medication, compared with nonusers, and it is unclear whether these medications are associated with bone loss in people with MS, beyond that in the general population. Additional high-quality studies with homogenous methodology exploring how medications influence aBMD and fracture risk in people with MS are required.

Screening for osteoporosis in people with MS: A new risk score

BACKGROUND

Due to the demographic development and improved treatment options, the role of comorbidities is of increasing importance in the medical care of people with MS (pwMS). A higher risk of osteoporosis is well known in chronic autoimmune diseases, and is also described in MS. While there are several screening guidelines in the elderly or in patients with rheumatoid arthritis, there are no generally accepted recommendations when to perform bone mineral testing in pwMS under the age of 65 years. We aimed to determine risk factors of osteoporosis in pwMS and to develop a risk score which can be applied in daily clinical routine.

METHODS

Densitometry (hip and lumbar spine) was performed in 159 pwMS aged ≤65 years and in 81 age- and sex-matched healthy controls (HC). Osteoporosis was defined according to WHO criteria as a bone density 2.5 standard deviation or more below the mean of young adults. Risk factors were identified by logistic regression analysis.

RESULTS

Osteoporosis occurred more frequently in postmenopausal pwMS and male pwMS as compared to HC. Besides age, sex, menopausal status in females, body-mass-index and smoking, a higher degree of disability - as assessed by the Expanded Disability Status Scale - was identified as MS specific risk factor for osteoporosis, whereas the cumulative glucocorticoid dose was not associated with osteoporosis risk. Based on these risk factors, we developed an MS-specific risk score which allows to estimate the individual probability of osteoporosis.

CONCLUSION

This risk score enables individual screening recommendation for pwMS and, subsequently, early prevention of osteoporosis which probably should result in reduction of fractures and morbidity.

High-Dose Intravenous Steroid Treatment Seems to Have No Long-Term Negative Effect on Bone Mineral Density of Young and Newly Diagnosed Multiple Sclerosis Patients: A Pilot Study

High-dose intravenous steroid treatment (HDIST) represents the first choice of treatment for multiple sclerosis (MS) relapses. Chronic oral glucocorticoid (GC) administration correlates with bone loss whereas data regarding HDIST in MS are still conflicting. Twenty-five newly diagnosed MS patients (NDMSP) (median age: 37 years) were prospectively studied for the effects of HDIST on bone mineral density (BMD) and bone metabolism. Patients received 1000 mg methylprednisolone intravenously every day for 5 days followed by oral prednisolone tapering over 21 days. Bone metabolism indices were determined prior to GC, on days 2, 4, 6, and 90, and at months 6, 12, 18, and 24 post GC therapy. Femoral, lumbar-spine BMD, and whole-body measurement of adipose/lean tissue were assessed prior to GC-administration and then every six months. Ten patients completed the study. N-terminal-propeptide-procollagen-type-1 and bone-specific alkaline phosphatase showed a significant increase at day-90 (p < 0.05). A transient non-significant fall of BMD was observed at 6 months after GC-administration, which subsequently appeared to be restored. We conclude that HDIST seems not to have long-term negative effects on BMD, while the observed transient increase of bone formation markers probably indicates a high bone turnover phase to GC-administration. Additional prospective studies with larger sample size are needed.

The prevalence of osteoporosis/osteopenia in patients with multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

The prevalence of osteoporosis is reported differently. We designed this systematic review and meta-analysis to estimate pooled prevalence of osteoporosis and osteopenia in patients with MS.

METHODS

Independently, two researchers searched PubMed, Scopus, EMBASE, Web of Science, and google scholar along with gray literature (conference abstracts and references of the references) up to March 2021. We collected data regarding first author, country of origin, number of enrolled patients, number cases with osteoporosis/ osteopenia, mean age, F/M ratio, mean EDSS, and mean duration of the disease.

RESULTS

Literature search revealed 847 articles and 658 remained after deleting duplicates. Finally, 29 original articles and 6 conference papers remained for meta-analysis. A total of 13,906 patients were evaluated. The pooled prevalence of osteoporosis was 17% (95% CI: 14-20%) (I² = 90.4%, p < 0.001). The pooled prevalence of osteopenia was 43% (95% CI: 35-51%) (I² = 97.9%, p < 0.001).

CONCLUSION

Osteoporosis/osteopenia should be considered in patients with MS.

Effects of Neurological Disorders on Bone Health

Neurological diseases, particularly in the context of aging, have serious impacts on quality of life and can negatively affect bone health. The brain-bone axis is critically important for skeletal metabolism, sensory innervation, and endocrine cross-talk between these organs. This review discusses current evidence for the cellular and molecular mechanisms by which various neurological disease categories, including autoimmune, developmental, dementia-related, movement, neuromuscular, stroke, trauma, and psychological, impart changes in bone homeostasis and mass, as well as fracture risk. Likewise, how bone may affect neurological function is discussed. Gaining a better understanding of brain-bone interactions, particularly in patients with underlying neurological disorders, may lead to development of novel therapies and discovery of shared risk factors, as well as highlight the need for broad, whole-health clinical approaches toward treatment.

Menopause and multiple sclerosis: Influence on prognosis and role of disease-modifying drugs and hormonal replacement therapy

Background:

Sex hormones play a role in both the risk and the prognosis of multiple sclerosis (MS). Considering all stages of women’s reproductive life, data regarding the influence of menopause on MS and vice versa are scarce.

Objective:

The aim of this study was to review the evidence addressing the relationship between menopause and MS.

Methods:

A literature search through PubMed was conducted, selecting studies that assessed (1) the influence of menopause in the MS course, (2) the influence of MS and disease-modifying drugs (DMD) on the development of menopause and (3) the effect of hormone replacement therapy (HRT) on symptoms of menopausal MS patients.

Results:

(1) Most studies suggest menopause may transitorily aggravate MS symptoms. Two studies found an inflexion point on the Expanding Disability Status Scale (EDSS) with clinical worsening during the menopausal transition. Another study considering full EDSS trajectories from clinically isolated syndrome to postmenopause did not find such an EDSS inflection; (2) MS and DMD do not seem to alter the age of menopause onset; and (3) HRT in menopausal MS patients has not shown consistent benefits.

Conclusion:

Menopause seems to be associated with transient symptom worsening, but the existence of an inflection in disability progression is still controversial. Properly designed studies are necessary to achieve conclusive results.

Assessment of Biochemical and Densitometric Markers of Calcium-Phosphate Metabolism in the Groups of Patients with Multiple Sclerosis Selected due to the Serum Level of Vitamin D3

Background

In addition to the widely known effect of vitamin D₃ (vitD₃) on the skeleton, its role in the regulation of the immune response was also confirmed.

Aim

The assessment of biochemical and densitometric markers of calcium-phosphate metabolism in the groups of patients with relapsing-remitting multiple sclerosis (RRMS) selected due to the serum level of vitamin D₃.

Methods

The concentrations of biochemical markers and indices of lumbar spine bone densitometry (DXA) were determined in 82 patients divided into vitamin D₃ deficiency (VitDd), insufficiency (VitDi), and normal vitamin D₃ level (VitDn) subgroups.

Results

The highest level of the parathyroid hormone (PTH) and the highest prevalence of hypophosphatemia and osteopenia were demonstrated in VitDd group compared to VitDi and VitDn. However, in VitDd, VitDi, and VitDn subgroups no significant differences were observed in the levels of alkaline phosphatase (ALP) and ionized calcium (Ca²⁺) and in DXA indices. A negative correlation was observed between the level of vitamin D₃ and the Expanded Disability Status Scale (EDSS) in the whole MS group. The subgroups were significantly different with respect to the EDSS scores and the frequency of complaints related to walking according to the EQ-5D.

Conclusions

It is necessary to assess calcium-phosphate metabolism and supplementation of vitamin D₃ in RRMS patients. The higher the clinical stage of the disease assessed with the EDSS, the lower the level of vitamin D₃ in blood serum. Subjectively reported complaints related to difficulties with walking were reflected in the EDSS in VitDd patients.

Risk of osteoporotic fractures in multiple sclerosis patients in southwest Finland

OBJECTIVES

Increased risk of osteoporotic fractures in multiple sclerosis (MS) patients compared with general population has been reported. The purpose of this study was to assess the risk of osteoporotic and other low-energy fractures in an MS cohort from a large hospital district in southwest Finland. Age-adjusted total and gender-specific prevalence for definite MS per 100 000 in a population of 472 139 was calculated as a point prevalence in December 31, 2012.

MATERIALS AND METHODS

Patients with MS and comorbid fractures were identified by searching for ICD-9 and ICD-10 codes during a period from 2004 to 2012 from hospital administrative data in Turku University Hospital (TYKS) in southwest Finland Case ascertainment was performed by review of medical records. Osteoporotic fracture was defined as a low-energy fracture of the pelvis, hip, femur, tibia, humerus, collar bone, ulna/radius, vertebrae, or rib. The control population was a 10-fold age- and gender-matched population.

RESULTS

The point prevalence (N 1004) of MS was 212.6/10⁵ (CI 199.5-225.8) in December 31, 2012. A total of 100 (9.9%) of 1004 confirmed MS cases experienced at least one fracture during the study period. Relative risks (RRs) for all fractures (1.33, 95% CI 1.10-1.60) and osteoporotic fractures (1.50, 95% CI 1.18-1.90) were significantly increased in patients with MS compared with controls. In particular, RRs for hip fractures (5.00, 95% CI 2.96-8.43) and fractures of humerus (2.36, 95% CI 1.32-4.42) were elevated in patients with MS vs controls.

CONCLUSIONS

We observed high prevalence of MS in southwest Finland and confirmed increased age-adjusted comorbid risk for osteoporotic fractures and other low-energy fractures compared with individually matched controls.

The effect of high-dose steroid treatment used for the treatment of acute demyelinating diseases on endothelial and cardiac functions

Objective:

The cardiovascular effects of short-term high-dose steroid treatment (pulse steroid treatment) have not yet been clarified. We exa- mined the short- and long-term effects of pulse steroid treatment in demyelinating diseases on endothelial and cardiac functions.

Methods:

In this prospective study, we included 35 patients (20 females and 15 males; mean age, 32.8±9.3 years) who were not treated with steroids and who were previously diagnosed with multiple sclerosis or neuromyelitis optica. Patients were evaluated before, 1 week after, and 3 months after the steroid treatment. Brachial artery flow-mediated relaxation and cardiac systolic/diastolic function were evaluated using echocardiography to assess physical examination results, carotid intima–media thickness, and endothelial function.

Results:

There was no difference between biochemical values, systolic function, left ventricular dimensions, and carotid intima–media thicknesses in the three evaluation periods. There were significant increases in the body mass index, body weight, and systolic/diastolic blood pressure measurements at 1 week and 3 months after treatment (p<0.001). There was a significant decrease in brachial artery flow-mediated relaxation at 1 week and 3 months (1 versus 2, p=0.042; 1 versus 3, p=0.003). In Doppler measurements at 1 week and 3 months, there was an increase in mitral A velocity, IVRT, and EDT values and a decrease in the E/A ratio in line with diastolic dysfunction.

Conclusion:

Pulse steroid therapy used for demyelinating diseases deteriorated endothelial and left ventricular diastolic functions in the early and late periods. Future studies are needed to evaluate the development of cardiovascular mortality and morbidity in patients receiving this type of treatment.

Risk Factors, Epidemiology and Treatment Strategies for Metabolic Bone Disease in Patients with Neurological Disease

Metabolic bone disease is a major public health concern, especially when it manifests as hip fracture which carries significant morbidity and mortality. Individuals with neurological disease are at higher risk of osteopenia, osteoporosis and fragility fracture compared to age-matched controls, yet this is under-appreciated by these patients. Clinician attention to this topic is therefore of importance and should address the bone health of men as well as women, a group in whom it may be an under-recognised problem. Evidence for optimal management of bone health in neurological disease remains to be defined, but a growing literature provides some useful guidance. This review focuses on two conditions, multiple sclerosis and Parkinson's disease, where research has been active over recent years. In neuroinflammation, shared immunological pathways between bone and brain are a current domain of interest and it will be intriguing to interrogate the action of emerging immunotherapies on these dual compartments.

Lack of Association between Pulse Steroid Therapy and Bone Mineral Density in Patients with Multiple Sclerosis

Multiple sclerosis (MS) has been associated with reduced bone mineral density (BMD). The purpose of this study was to determine the possible factors affecting BMD in patients with MS. We included consecutive 155 patients with MS and 90 age- and sex-matched control subjects. Patients with MS exhibited significantly lower T-scores and Z-scores in the femoral neck and trochanter compared to the controls. Ninety-four (61%) patients had reduced bone mass in either the lumbar spine or the femoral neck; of these, 64 (41.3%) had osteopenia and 30 (19.4%) had osteoporosis. The main factors affecting BMD were disability, duration of MS, and smoking. There was a negative relationship between femoral BMD and EDSS and disease duration. No association with lumbar BMD was determined. There were no correlations between BMD at any anatomic region and cumulative corticosteroid dose. BMD is significantly lower in patients with MS than in healthy controls. Reduced BMD in MS is mainly associated with disability and duration of the disease. Short courses of high dose steroid therapy did not result in an obvious negative impact on BMD in the lumbar spine and femoral neck in patients with MS.