Prevalence and incidence of osteoporotic fractures in patients on long-term glucocorticoid treatment for rheumatic diseases: the Glucocorticoid Induced OsTeoporosis TOol (GIOTTO) study

Recommendations of the French Society of Rheumatology for the management in current practice of patients with polymyalgia rheumatica

OBJECTIVE

To develop recommendations for the routine management of patients with polymyalgia rheumatica (PMR).

METHODS

Following standard procedures, a systematic review of the literature by five supervised junior rheumatologists, based on the questions selected by the steering committee (5 senior rheumatologists), was used as the basis for working meetings, followed by a one-day plenary meeting with the working group (15 members), leading to the development of the wording and determination of the strength of the recommendations and the level of agreement of the experts.

RESULTS

Five general principles and 19 recommendations were drawn up. Three recommendations relate to diagnosis and the use of imaging, and five to the assessment of the disease, its activity and comorbidities. Non-pharmacological therapies are the subject of one recommendation. Three recommendations concern initial treatment based on general corticosteroid therapy, five concern the reduction of corticosteroid therapy and follow-up, and two concern corticosteroid dependence and steroid-sparing treatments (anti-IL-6).

CONCLUSION

These recommendations take account of current data on PMR, with the aim of reducing exposure to corticosteroid therapy and its side effects in a fragile population. They are intended to be practical, to help practitioners in the day-to-day management of patients with PMR.

Concordance and agreement between different activity scores in polymyalgia rheumatica

OBJECTIVE

The C reactive protein polymyalgia rheumatica activity score (CRP-PMR-AS) is a composite index that includes CRP levels and was developed specifically for PMR. As treatments such as interleukin-6 antagonists can normalise CRP levels, the erythrocyte sedimentation rate (ESR) of PMR-AS, the clinical (clin)-PMR-AS and the imputed-CRP (imp-CRP)-PMR-AS have been developed to avoid such bias. Our primary objective was to measure the correlation of these activity scores. Our secondary objective was to evaluate the concordance between different cutoffs of the PMR-ASs.

METHOD

Data from the Safety and Efficacy of tocilizumab versus Placebo in Polymyalgia rHeumatica With glucocORticoid dEpendence (SEMAPHORE) trial, a superiority randomised double-blind placebo-controlled trial, were subjected to post hoc analysis to compare the efficacy of tocilizumab versus placebo in patients with active PMR. The CRP-PMR-AS, ESR-PMR-AS, clin-PMR-AS and imp-CRP-PMR-AS were measured at every visit. The concordance and correlation between these scores were evaluated using kappa correlation coefficients, Bland-Altman correlations, intraclass correlation coefficients (ICCs) and scatter plots.

RESULTS

A total of 101 patients were included in the SEMAPHORE trial, and 100 were analysed in this study. The correlation between the PMR-ASs was excellent, as the ICC and kappa were >0.85 from week 4 until week 24 (CRP-PMR-AS ≤10 or >10). Bland-Altman plots revealed that the differences between the CRP-PMR-AS and the other threescores were low. The cut-off values for the clin-PMR-AS were similar to those for the CRP-PMR-AS 86% of the time.

CONCLUSION

The correlation between all the PMR-ASs was excellent, reflecting the low weight of CRP. In clinical trials using drugs that have an impact on CRP, the derived activity scores can be used.

TRIAL REGISTRATION NUMBER

NTC02908217.

Risk of fracture in women with glucocorticoid requiring diseases is independent from glucocorticoid use: An analysis on a nation-wide database

OBJECTIVE

Glucocorticoid-induced osteoporosis (GIOP) is a common cause of secondary osteoporosis. However, glucocorticoid requiring diseases pose a risk themselves for fracture. The aim of the present study was to determine the risk of fracture associated with variety of glucocorticoid requiring diseases independently from glucocorticoid use and other risk factors for osteoporosis.

METHODS

We conducted a retrospective cross-sectional analysis of a nation-wide cohort (DeFRACalc79 database). We used multivariable regression analysis adjusting for several risk factors for fracture and glucocorticoid intake to estimate the independent role of glucocorticoid requiring illnesses on fracture risk.

RESULTS

We found that patients with rheumatoid arthritis, connective tissue diseases, chronic obstructive pulmonary disease (COPD) and neurological diseases were at greater risk of vertebral or hip fracture (crude ORs 1.31, 1.20, 1.92 and 2.97 respectively). After adjusting for potential confounders COPD and neurological diseases remained significantly associated with an increased risk of vertebral or hip fractures (aORs 1.33, 95 % CI 1.18-1.49 and 2.43, 95 % CI 2.17-2.74). Rheumatoid arthritis, COPD, IBD and neurological diseases also significantly increased the risk of non-vertebral, non-hip fractures (aORs 1.23, 1.42, 1.52 and 1.94 respectively).

CONCLUSION

Some glucocorticoid requiring diseases were independently associated with an increased risk of fractures. COPD and neurological diseases with both vertebral and non-vertebral fracture risk while RA and IBD were independently associated only with non-vertebral, non-hip fractures.

[Trabecular bone score in rheumatology : Are there benefits in comparison to bone densitometry alone?]

Patients with inflammatory rheumatic diseases have an increased risk of fractures due to the inflammatory potential of the disease and also because of the treatment with glucocorticoids that is often necessary. According to the current guidelines of the Governing Body on Osteology (DVO), the fracture risk can be assessed using dual energy X‑ray absorptiometry and can also be supplemented by measuring the trabecular bone score (TBS). The assessment of the TBS offers additional advantages, for example in glucocorticoid-induced osteoporosis and in patients with osteoproliferative changes of the spine (spondylarthritis) and thus optimizes the fracture risk assessment in the rheumatological patient population.

Bisphosphonate use for glucocorticoid-induced osteoporosis in older patients with immune thrombocytopenia: a clinical perspective

Prednisolone, used as a standard initial treatment for immune thrombocytopenia (ITP), is an important risk factor for osteoporosis. Recently, we found that prescription of bisphosphonate during initial loading of prednisolone may prevent reduction in bone mineral density and development of glucocorticoid-induced osteoporosis (GIO) in older patients with ITP receiving prolonged steroid therapy. In this review, I describe the treatment options for older patients with ITP, and present the best practices for screening, evaluating, and diagnosing ITP. I also summarize the literature from 2017 to 2022 on the treatment options for ITP, including discussions on the contraindications and side effects, with an emphasis on GIO, and the relative merits of bisphosphonates as a co-treatment for prevention of GIO. Finally, I present a perspective and an expert recommendation on how older patients with ITP would best be served in the future.

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.

ОСТЕОПОРОЗ У БОЛЬНЫХ РЕВМАТОИДНЫМ АРТРИТОМ: КОМОРБИДНОСТЬ ИЛИ СИСТЕМНЫЕ ПРОЯВЛЕНИЯ?

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Effects of intestinal microbes on rheumatic diseases: A bibliometric analysis

Background

Rheumatic diseases (RD) are a group of multi-system inflammatory autoimmune diseases whose causes are still under study. In the past few decades, researchers have found traces of the association between rheumatic diseases and intestinal microbiota, which can partially explain the pathogenesis of rheumatic diseases. We aimed to describe the research trend and main divisions on how gut flora interreacts with rheumatic diseases, and discussed about the possible clinical applications.

Methods

We analyzed bibliometric data from the Web of Science core collection (dated 15th May 2022). Biblioshiny R language software packages (bibliometrix) were used to obtain the annual publication and citations, core sources according to Bradford's law, and country collaboration map. We designed and verified the keyword co-occurrence network and strategic diagram with the help of VOSviewer and CiteSpace, subdivided the research topic into several themes and identified research dimensions. The tables of most local cited documents and core sources were processed manually. Furthermore, the Altmetric Attention Score and the annual Altmetric Top 100 were applied to analyze the annual publication and citation.

Results

From a total of 541 documents, we found that the overall trend of annual publication and citation is increasing. The major research method is to compare the intestinal microbial composition of patients with certain rheumatic disease and that of the control group to determine microbial alterations related to the disease's occurrence and development. According to Bradford's law, the core sources are Arthritis and Rheumatology, Annals of the Rheumatic Diseases, Current Opinion in Rheumatology, Nutrients, Rheumatology, and Journal of Rheumatology. Since 1976, 101 countries or regions have participated in studies of rheumatology and intestinal microbes. The United States ranks at the top and has the broadest academic association with other countries. Five themes were identified, including the pivotal role of inflammation caused by intestinal bacteria in the rheumatic pathogenesis, the close relationship between rheumatic diseases and inflammatory bowel disease, immunoregulation mechanism as a mediator of the interaction between rheumatic diseases and gut flora, dysbiosis and decreased diversity in intestine of patients with rheumatic diseases, and the influence of oral flora on rheumatic diseases. Additionally, four research dimensions were identified, including pathology, treatment, disease, and experiments.

Conclusion

Studies on rheumatic diseases and the intestinal microbiota are growing. Attention should be paid to the mechanism of their interaction, such as the microbe-immune-RD crosstalk. Hopefully, the research achievements can be applied to diseases' prevention, diagnosis, and treatment, and our work can contribute to the readers' future research.

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.

Bisphosphonate Use for Glucocorticoid-Induced Osteoporosis in Elderly Patients with Immune Thrombocytopenia Receiving Prolonged Steroid Therapy: A Single Institute Retrospective Study

Prednisolone, used as a standard initial treatment for immune thrombocytopenia (ITP), is an important risk factor for osteoporosis. To investigate the prevention of glucocorticoid-induced osteoporosis (GIO) in elderly ITP patients receiving prolonged steroid therapy, associations between GIO prevention and the real-world data of score changes of a dual-energy X-ray absorptiometry (DXA) scan, FRAX® and the Garvan tool during the initial loading of prednisolone were examined. In our institute, 22 ITP patients aged ≥ 70 years received 0.5−1.0 mg/kg prednisolone for 2−3 weeks as the initial ITP treatment between 2014 and 2021. The femoral neck bone mineral density (BMD) measured by DXA scan was entered into FRAX® to define the risk-adapted approach to bisphosphonate during the initial loading of prednisolone. Bisphosphonate was administered according to <−1.0 femoral neck BMD T-score measured by DXA scan. Worse scores of FRAX® and the Garvan tool were associated with bisphosphonate use for short-term fracture prevention in primary GIO; however, there were no incidents of fracture or significant differences in probabilities determined by FRAX® and the Garvan tool. During the initial loading of prednisolone, prescribing bisphosphonate might prevent the reduction in BMD in elderly patients with ITP receiving prolonged steroid therapy.

Optimising both disease control and glucocorticoid dosing is essential for bone protection in patients with rheumatic disease

OBJECTIVES

Inflammatory rheumatic and musculoskeletal diseases (iRMDs) are associated with increased systemic bone loss that is mediated by chronic inflammation, treatment with glucocorticoids (GCs) and other factors. Our objective was to analyse the impact of variables that influence osteoporosis (OP) in patients with iRMD treated with GC.

METHODS

Rh-GIOP (acronyme) is a prospective observational cohort study investigating bone health in consecutive patients with iRMD and current or prior GC treatment. We present an analysis of the patients' baseline data here. Bone mineral density (BMD) measured by dual X-ray absorptiometry was the primary outcome. Multivariable linear regression models were performed to identify variables associated with BMD.

RESULTS

Data from 1066 patients with iRMD were analysed. GC doses of <5 mg prednisone equivalent per day, cumulative dose and duration of GC therapy were not associated with negative effects on BMD. Dosages of ≥5 mg/day lost their negative association with BMD after adjustment for confounders. When subanalysing patients with exactly 5 mg/day, no negative effect was seen. For patients with rheumatoid arthritis (RA), GC doses of >7.5 mg/day showed a negative association with BMD overall, but this effect seemed to be specific only to patients with moderate or high disease activity (Disease Activity Score 28-C reactive protein >3.2).

CONCLUSIONS

GCs of ≤5 mg/day did not seem to be associated with a reduction of BMD in patients with iRMD and current or prior exposure to GC. This is most likely due to the dampening of inflammation by GC, which exerts a mitigating effect on the risk of OP. In RA, current GC doses of >7.5 mg/day were negatively associated with BMD, but only in patients with moderate to high disease activity.

TRIAL REGISTRATION NUMBER

NCT02719314.

Bone Involvement in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by a wide variability of clinical manifestations due to the potential involvement of several tissues and internal organs, with a relapsing and remitting course. Dysregulation of innate and adaptive immune systems, due to genetic, hormonal and environmental factors, may be responsible for a broad spectrum of clinical manifestations, affecting quality of life, morbidity and mortality. Bone involvement represents one of the most common cause of morbidity and disability in SLE. Particularly, an increased incidence of osteoporosis, avascular necrosis of bone and osteomyelitis has been observed in SLE patients compared to the general population. Moreover, due to the improvement in diagnosis and therapy, the survival of SLE patient has improved, increasing long-term morbidities, including osteoporosis and related fractures. This review aims to highlight bone manifestations in SLE patients, deepening underlying etiopathogenetic mechanisms, diagnostic tools and available treatment.

[The DRFZ-a pioneer in research on the interaction between immune and stromal cells during de- and regeneration of the musculoskeletal system]

Rheumatoid arthritis and osteoarthritis are two related chronic diseases of the musculoskeletal system which are particularly pronounced in the region of joints and bones. Their pathogeneses are associated with chronic inflammation, which can disrupt homeostasis in bones and articular cartilage. Degradation products deriving from articular cartilage can contribute to the exacerbation of inflammation in the joint region. Mechanical stimuli and blood vessels also play a central role in both the regulation of bone growth as well as in the regeneration of bone tissue. Not only chronic inflammatory processes but also hormonal changes after menopause or undesired effects of glucocorticoid therapy have an influence on the balance between bone resorption and deposition, by promoting the former and reducing the latter. This results in decreased bone quality and, in some cases, considerable loss of bone or osteoporosis. An in-depth understanding of these processes at the molecular, cellular, and tissue level, as well as of the changes present in chronic inflammatory diseases, has been the focus of research at the German Rheumatism Research Center (Deutsches Rheuma-Forschungszentrum, DRFZ) since its foundation. Based on an improved understanding of these mechanisms, the DRFZ aims to develop improved prevention and treatment strategies with effects even in early disease stages.

Challenges in the diagnosis and management of glucocorticoid-induced osteoporosis in younger and older adults

OBJECTIVE

Glucocorticoids constitute a considerable risk for developing osteoporosis in both younger and older adults. However, currently available bone imaging modalities and fracture-risk assessment tools do not adequately capture the dramatic changes in bone microarchitecture, heterogeneity of glucocorticoid exposure, the impact of chronic disease and other osteoporosis risk factors on the assessment of osteoporosis in these individuals.

DESIGN

A narrative review is presented, following a systematic search of the literature from 2000 to 2021.

RESULTS

Our current appreciation of glucocorticoid-induced osteoporosis (GIO) is focused on older populations, with limited evidence to guide the investigation, risk assessment and treatment in premenopausal women and men less than 50 years. The impact of the underlying chronic disease on secondary osteoporosis in these younger adults is also poorly understood.

CONCLUSION

Through this narrative review, we provide a comprehensive overview of and recommendations for optimising the management of this common cause of secondary osteoporosis younger and older adults.

Retrospective Analysis of Factors Associated with Fracture in 714 Patients with Polymyalgia Rheumatica

Introduction

Polymyalgia rheumatica (PMR) is a disease of the elderly, associated with increased fracture risk due to glucocorticosteroid (GC) treatment with the additional possible influence of chronic inflammation. Risk factors for fracture in PMR have not been extensively studied. Hip structure analysis (HSA) is a way to measure bone morphology in the hip using dual X-ray absorptiometry (DEXA). It has been used as a predictor of fracture in epidemiological settings. HSA has not been studied in PMR before.

Objectives

The object of this retrospective study was to determine if fracture risk in PMR was associated with densitometry data and to determine the influence, if any, of HSA on that association.

Methods

714 patients with PMR referred for a bone density estimate at a district general hospital from June 2004 to October 2010 were studied. Demographic data, GC use, alcohol consumption, smoking status, secondary osteoporosis, and fracture history were recorded. Bone mineral density (BMD), Z score, T score, body composition data, and HSA measurements were collected. These were geometric measurements taken from 2-dimensional DEXA images of the hip. Fracture was modelled as an outcome variable using logistic regression models, adjusted for age and sex. And the fit of the model was assessed by comparing the area under the curve (AUC).

Results

714 patients were studied, 532 (75%) were female, and mean age was 70.5 with SD of 8.8. 703 (98%) had been treated with GCs. Lumbar and femoral BMD models were significantly associated with fracture. Right femur OR 0.062 (0.014-0.285), left femur OR 0.098 (0.023-0.412), right femoral neck 0.078 (0.014-0.43), left femoral neck 0.104 (0.022-0.492), L1 0.192 (0.066-0.56), L2 OR 0.138 (0.053-0.358), L3 0.192 (0.079-0.463), and L4 0.243 (0.108-0.544). Cross-sectional area was the only HSA parameter that was associated with fracture OR 0.988 (0.980–0.997).

Conclusion

L2 association models were strongest. Prospective studies are needed to elucidate whether these factors predict future fracture. GC data were binary, not reflecting dose and duration.

Innovative Anti-Inflammatory and Pro-resolving Strategies for Pulmonary Hypertension: High Blood Pressure Research Council of Australia Award 2019

Pulmonary hypertension is a rare, ostensibly incurable, and etiologically diverse disease with an unacceptably high 5-year mortality rate (≈50%), worse than many cancers. Irrespective of pathogenic origin, dysregulated immune processes underlie pulmonary hypertension pathobiology, particularly pertaining to pulmonary vascular remodeling. As such, a variety of proinflammatory pathways have been mooted as novel therapeutic targets. One such pathway involves the family of innate immune regulators known as inflammasomes. In addition, a new and emerging concept is differentiating between anti-inflammatory approaches versus those that promote pro-resolving pathways. This review will briefly introduce inflammasomes and examine recent literature concerning their role in pulmonary hypertension. Moreover, it will explore the difference between inflammation-suppressing and pro-resolution approaches and how this links to inflammasomes. Finally, we will investigate new avenues for targeting inflammation in pulmonary hypertension via more targeted anti-inflammatory or inflammation resolving strategies.

Fracture Risk and Its Prevention Patterns in Korean Patients with Polymyalgia Rheumatica: a Retrospective Cohort Study

BACKGROUND

To evaluate the incidence of fractures and fracture risk factors in Korean patients with polymyalgia rheumatica (PMR).

METHODS

All PMR patients who visited a rheumatology clinic at a tertiary referral hospital between March 2005 and March 2018 were retrospectively assessed. We estimated bone mineral density (BMD) screening rate within 6 months of the first visit and classified the patients according to the performance and results of BMD screening. Incidence rates (IRs) of fractures were calculated in each group and risk factors for fractures were identified using Poisson regression analysis.

RESULTS

A total of 95 PMR patients with median (interquartile range) age of 64.0 (56.0-72.0) years were included. Baseline BMD was assessed in only 55.8% of these patients (n = 53); 24 patients with osteoporosis, 20 with osteopenia, and 9 with normal BMD. During 433.1 person-years (PYs) of observation, 17 fractures occurred in 12 patients (IR, 3.93 [95% confidence interval (CI), 2.46-6.26]/100 PYs); 8.32 (95% CI, 4.09-16.90)/100 PYs in the osteopenia group, 3.40 (95% CI, 1.30-8.90)/100 PYs in the osteoporosis group, and 3.37 (95% CI, 1.53-7.39)/100 PYs in the no BMD test group. Risk factors for fractures were female sex, advanced age (≥ 65 years), longer follow-up duration, initial glucocorticoid dose ≥ 10 mg/day, and higher cumulative glucocorticoid dose over the first 6 months.

CONCLUSION

The incidence rate of fractures in Korean patients with PMR was 3.93/100 PYs. Female sex, advanced age, longer follow-up duration, and increased glucocorticoid dose are risk factors for osteoporotic fracture.

Effects of Denosumab in Japanese Patients With Rheumatoid Arthritis Treated With Conventional Antirheumatic Drugs: 36-month Extension of a Phase III Study

OBJECTIVE

To evaluate the safety and efficacy of long-term denosumab 60 mg every 6 months (Q6M) or every 3 months (Q3M) in patients with rheumatoid arthritis (RA).

METHODS

This 12-month, randomized, double-blind, placebo-controlled, multicenter, phase III trial with an open-label extension period from 12 to 36 months (DESIRABLE) enrolled Japanese patients with RA treated with placebo (P) for 12 months followed by either denosumab Q6M (P/Q6M) or denosumab Q3M (P/Q3M) for 24 months; denosumab Q6M for 36 months (Q6M/Q6M); or denosumab Q3M for 36 months (Q3M/Q3M). Efficacy was assessed by van der Heijde modified total Sharp score (mTSS), bone erosion score (BES), and joint space narrowing ( JSN) score.

RESULTS

Long-term treatment better maintained mTSS and BES suppression in the P/Q3M and Q3M/ Q3M vs P/Q6M and Q6M/Q6M groups; changes from baseline in total mTSS (standard error) at 36 months were 2.8 (0.4) and 1.7 (0.3) vs 3.0 (0.4) and 2.4 (0.3), respectively, and corresponding changes in BES were 1.3 (0.2) and 0.4 (0.2) vs 1.4 (0.2) and 1.1 (0.2), respectively. No JSN effect was observed. Bone mineral density consistently increased in all groups after denosumab initiation, regardless of concomitant glucocorticoid administration. Serum C-terminal telopeptide of type I collagen decreased rapidly at 1 month postdenosumab administration (in both the initial 12-month [Q3M and Q6M groups] and long-term treatment [P/Q3M and P/Q6M groups] phases). Adverse event incidence leading to study drug discontinuation was similar across treatment groups.

CONCLUSION

Denosumab treatment maintained inhibition of progression of joint destruction up to 36 months. Based on effects on BES progression, higher dosing frequency at an earlier treatment stage may be needed to optimize treatment. Denosumab was generally well tolerated. (ClinicalTrials.gov: NCT01973569).

Osteoporotic fractures in rheumatoid arthritis patients in Argentina: a matched retrospective cohort study

BACKGROUND

To compare the incidence of osteoporotic fractures in patients with rheumatoid arthritis (RA) with matched controls from a university hospital.

METHODS

Consecutive RA patients (n = 100) were matched (age and sex) with controls (1:2). The follow-up period began at the index date, defined as the date of diagnosis for RA patients and the date of the first medical claim at the Health Management Organization (HMO) for non-RA patients. Fracture incidence rates per 1000 persons-years (PY) for distinct types of fractures were calculated. Multivariate cox regression analysis was performed to identify factors associated with fractures.

RESULTS

One hundred RA patients were followed for a total of 975.1 patients-years and 200 controls for 1485.7 patients-years. No difference was found in the overall fracture incidence rate per 1000 PY between RA and controls (19.5, 95% CI 12.7-28.6 vs 12.1, 95% CI 7.7-18.7, p = 0.07). In the Cox regression analysis, only age (HR 1.06, 95% CI 1.02-1.11, p = 0.006) and history of a prior fracture (HR 9.85, 95% CI 2.97-32.64, p <  0.001) were associated with fractures after the index date. The stratified analysis of the fractures by location showed that only the vertebral fractures were more frequent in RA patients compared with controls (12.9 per 1000 PY, 95% CI 8.9-25.8, vs. 3.4, 95% CI 1.4-8.1, respectively, p = 0.01).

CONCLUSION

Patients with RA didn't show an overall increased risk of osteoporotic fractures compared with matched controls, but vertebral fractures were more frequently observed in patients with RA.

Glucocorticoid-Induced Osteoporosis: The Potential Role of Romosozumab

Glucocorticoid (GC)-induced osteoporosis (GIOP) is a major problem in patients with rheumatic diseases. The deleterious effect of GC on bone turnover is rapid and dose-dependent, with a predilection on the trabecular bone, resulting in vertebral fractures. Early recognition and prompt treatment of GIOP helps prevent bone loss and reduce fractures. There are pitfalls in current assessment tools for GIOP by dual-energy X-ray absorptiometry (DXA) and fracture risk assessment tool (FRAX) estimation formula. In this review, we evaluate different assessment methods for GIOP and summarize current therapies of GIOP, including the antiresorptive and anabolic agents. The potential role of newer anti-osteoporosis agent romosozumab, an anti-sclerostin monoclonal antibody, is also discussed.

Effects of glucocorticoids on osteoporosis in rheumatoid arthritis: a systematic review and meta-analysis

We evaluated the effects of glucocorticoids on bone mineral density (BMD), and prevalence of osteoporosis and fracture in rheumatoid arthritis (RA) by meta-analysis. Until June 26, 2019, we conducted a systematic literature search in EMBASE, Web of science, PubMed, and Cochrane Library to obtain BMD and the prevalence of osteoporosis and fracture in glucocorticoid-treated subjects with RA. The BMD of the treatment and control groups were analyzed by meta-analysis (Stata. version 15), and the 95% confidence interval (CI) was calculated. We identified 15 observational studies, including 46,711 RA subjects and 857 healthy controls. The BMD of the lumbar spine (- 0.038 g/cm²; CI, - 0.052, - 0.024) and femoral neck (- 0.017 g/cm²; - 0.030, - 0.003) in RA treated with glucocorticoids were significantly lower than those in RA controls. Compared with healthy control group, the BMD of the lumbar spine (- 0.094 g/cm²; - 0.126, - 0.061) and femoral neck (- 0.097 g/cm², - 0.109, - 0.085) of RA treated with glucocorticoids decreased more significantly. The prevalence of osteoporosis in whole body, spine, and femur was 38.6% (0.305, 0.466), 32.9% (0.277, 0.381), and 21.7% (0.106, 0.328), respectively. And the prevalence of vertebral fracture was 13.0% (0.058, 0.203). Glucocorticoids may lead to a decline in skeletal health in subjects with RA, especially in vertebral and femoral BMD, compared with normal people or RA without glucocorticoid therapy. Meanwhile, osteoporosis and fractures were also common. Therapeutic measures should be targeted at individuals, which needs further study. Through meta-analysis, we found that glucocorticoids have some negative effects on the bone health of subjects with rheumatoid arthritis. Therefore, when using glucocorticoids to treat rheumatoid arthritis, we should take strategic measures to prevent the decline of bone quality.

Reference values of 25-hydroxyvitamin D revisited: a position statement from the Brazilian Society of Endocrinology and Metabolism (SBEM) and the Brazilian Society of Clinical Pathology/Laboratory Medicine (SBPC)

Hypovitaminosis D is a common condition with a negative impact on health. This statement, prepared by experts from the Brazilian Society of Endocrinology and Metabolism and the Brazilian Society of Clinical Pathology/Laboratory Medicine, includes methodological aspects and limitations of the measurement of 25-hydroxyvitamin D [25(OH)D] for identification of vitamin D status, and identifies individuals at increased risk for deficiency of this vitamin in whom 25(OH)D measurement is recommended. For the general population, 25(OH)D levels between 20 and 60 ng/mL are considered normal, while individuals with levels below 20 ng/mL are considered to be vitamin D deficient. This statement identifies potential benefits of maintaining 25(OH)D levels > 30 ng/mL in specific conditions, including patients aged > 65 years or pregnant, those with recurrent falls, fragility fractures, osteoporosis, secondary hyperparathyroidism, chronic kidney disease, or cancer, and individuals using drugs with the potential to affect the vitamin D metabolism. This statement also calls attention to the risk of vitamin D intoxication, a life-threatening condition that occurs at 25(OH)D levels above 100 ng/mL.

Pathogenesis, Diagnosis and Management of Polymyalgia Rheumatica

Polymyalgia rheumatica is an inflammatory rheumatic disease of the elderly characterised by pain and stiffness in the neck and pelvic girdle, and is the second most common inflammatory rheumatic condition in this age group, after rheumatoid arthritis. Polymyalgia rheumatica can occur independently or in association with giant cell arteritis, which is the most common form of primary vasculitis. The diagnosis of polymyalgia rheumatica is usually based on clinical presentation and increase of inflammatory markers. There are no pathognomonic findings that can confirm the diagnosis. However, different imaging techniques, especially ultrasonography, can assist in the identification of polymyalgia rheumatica. Glucocorticoids are the cornerstone of the treatment of polymyalgia rheumatica, but they might be associated with different adverse events. A subgroup of patients presents with a refractory disease course and, in these cases, adding methotrexate as a steroid-sparing agent could be useful. In this review, we summarise the latest findings regarding the pathogenesis, diagnosis and management of polymyalgia rheumatica and try to highlight the possible pitfalls, especially in elderly patients.

Diabetes Mellitus and Osteoporosis Correlation: Challenges and Hopes

Diabetes and osteoporosis are two common diseases with different complications. Despite different therapeutic strategies, managing these diseases and reducing their burden have not been satisfactory, especially when they appear one after the other. In this review, we aimed to clarify the similarity, common etiology and possible common adjunctive therapies of these two major diseases and designate the known molecular pattern observed in them. Based on different experimental findings, we want to illuminate that interestingly similar pathways lead to diabetes and osteoporosis. Meanwhile, there are a few drugs involved in the treatment of both diseases, which most of the time act in the same line but sometimes with opposing results. Considering the correlation between diabetes and osteoporosis, more efficient management of both diseases, in conditions of concomitant incidence or cause and effect condition, is required.

Initiation of anti-osteoporotic drugs in high-risk female patients starting glucocorticoid treatment: a population study in Norway

Glucocorticoid use is a risk factor for osteoporosis and fractures. We studied whether women initiating glucocorticoid treatment also started anti-osteoporotic treatment, according to clinical guidelines. Women with versus without previous fracture were twice as likely to start anti-osteoporotic treatment within 1 year after initiating glucocorticoid treatment, but the cumulative incidences were low 9.1% vs. 4.6%, respectively.

PURPOSE

Use of glucocorticoids (GC) is a risk factor for osteoporosis and fractures, and clinical guidelines suggest that preventive treatment with anti-osteoporotic drugs (AOD) should be considered when starting GC. Women with high risk of osteoporosis comprise those with previous fractures or a known inflammatory rheumatic disease, for whom the indication of AOD is even stronger. The purpose of these analyses was to investigate whether women initiating GC treatment also started AOD, especially those with high risk of osteoporosis.

METHODS

We used data from the Norwegian Prescription Database to identify all women 55 years and older initiating GC treatment in Norway during 2010-2016 and to obtain information on use of AOD. Data from the Norwegian Patient Registry were used to obtain information on previous fractures and diagnoses.

RESULTS

Among 105,477 women initiating GC treatment during 2010-2016, 3256 had started AOD and 79,638 had discontinued GC treatment after 1-year follow-up. Cumulative incidence of starting AOD after 1 year was 9.1% (95% CI: 7.9, 10.4) for women with vs. 4.6% (95% CI: 4.4%, 4.8%) for women without a previous fracture. Women with rheumatoid arthritis or another inflammatory rheumatic disease were more likely to start AOD than women with other indications. For the whole cohort, the probability of starting AOD treatment within 1 year after initiating GC increased on average 3% per year (HR = 1.03, CI: 1.01, 1.05) from 2010 to 2016.

CONCLUSIONS

Having had a previous fracture or an inflammatory rheumatic disease increased the probability of treatment with AOD. However, the proportions starting AOD were much lower than clinically indicated.

Denosumab in the treatment of glucocorticoid-induced osteoporosis: a systematic review and meta-analysis

Objective

Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary osteoporosis. In May 2018, denosumab was approved for the treatment of GIOP in men and women at high risk of fracture. We undertook a systematic review and meta-analysis to summarize the efficacy and safety of denosumab in the prevention and treatment of GIOP.

Methods

We searched PubMed, CINAHL, American College of Rheumatology and American Society for Bone and Mineral Research meeting abstracts for relevant studies. We included studies in which subjects were taking systemic glucocorticoid therapy and were assigned to take denosumab or control therapy, and assessed the effect of treatment on areal bone mineral density (BMD), fractures and/or safety.

Results

Three eligible studies were included in the primary meta-analysis. Denosumab significantly increased lumbar spine BMD (2.32%, 95% CI 1.73%, 2.91%, P<0.0001) and hip BMD (1.52%, 95% CI 1.1%,1.94%, P<0.0001) compared to bisphosphonates. Adverse events, serious adverse events and fractures were similar between denosumab and bisphosphonate arms.

Conclusion

Results suggest that denosumab is superior to bisphosphonates in its effects on lumbar spine and total hip BMD in patients with GIOP. There was no difference in the incidence of infections, adverse events or serious adverse events. Studies were underpowered to detect differences in the risk of fracture. Denosumab is a reasonable option for treatment of GIOP. However, further studies are needed to guide transitions off denosumab.

Incidence and Mortality of Osteoporotic Fracture in Rheumatoid Arthritis in South Korea Using Nationwide Claims Data

Background

To investigate incidence and mortaltiy of osteoporotic fractures (including hip, spine, distal radius, and proximal humerus) in rheumatoid arthritis (RA) patients and compare them with those in the genearal population.

Methods

Data provided by National Health Insurance Service were used to identify osteoporotic fractures in patients aged >50 years between 2010 and 2012. Patients with RA were identified by the diagnostic code for seropositive RA. Standardized mortality ratios (SMRs; observed/expected deaths) of osteoporotic fractures were calculated based on age and gender-specific rates in the entire Korean population. Incidence, mortality, and SMR of osteoporotic fractures in RA patients and the general population were calculated and compared.

Results

Osteopororic fractures in the general population and RA patients were increased by 11.6% and 17.4% over 3 years (195,271 and 1,356 in 2010; 217,985 and 1,592 in 2012), respectively. Mean age-specific incidence of osteoporotic fracture in women and men with RA increased from 932.1/100,000 and 306.1/100,000 for aged 50 to 59 year to 9,377.0/100,000 and 3,700.9/100,000 for aged ≥80 years, respectively. Cumulative mortality rate in the first year after osteoporotic fracture in patients with RA was higher than that in the general population (7.8% in RA and 6.6% in the general population). SMR of osteoporotic fracture in RA patients was 1.4 times higher in men and 1.3 times higher in women than that for the general population.

Conclusions

This study demonstated that incidence, 1-year mortality, and SMR of osteoporotic fracture in RA patients aged 50 years and older were higher than those in the general papulation.

Osteoporosis: a clinical and pharmacological update

Osteoporosis is characterized by the loss of bone mass, deterioration of the bone microarchitecture, and an increased risk of fractures; these later complications are associated with significant morbidity and mortality. The asymptomatic and progressive nature of osteoporosis underscores the importance of identifying this entity in early stages. Despite the various treatments available, the prevention of the disease represents the most important aspect of management. An adequate intake of calcium and vitamin D as well as a healthy lifestyle is the basis for maintaining bone health. When osteoporosis is diagnosed, the choice of medications must be individualized considering characteristics of the patient and the risk of fractures. In this article, we review the main causes of osteoporosis, when and how to start treatment, and appropriate therapy and monitoring.

Permanent Discontinuation of Glucocorticoids in Polymyalgia Rheumatica Is Uncommon but May Be Enhanced by Amino Bisphosphonates

OBJECTIVE

The duration of treatment with glucocorticoids (GC) in polymyalgia rheumatica (PMR) is often longterm. Amino bisphosphonates (N-BP) are used in PMR for the prevention of GC-induced osteoporosis, but they coulsd also have immunomodulatory properties. Whether they can be effective as an adjuvant treatment in PMR is unknown. We aimed to establish whether the use of N-BP in our PMR cohort may be associated with GC discontinuation.

METHODS

We conducted a retrospective review of all patients diagnosed with PMR recorded in our electronic medical notes. Cox regression analyses were used to examine the association between the use of N-BP and discontinuation of GC.

RESULTS

Data were retrieved for 385 patients (mean age 71 ± 10 yrs, 64% females, mean initial prednisone dose 19 ± 9 mg/day). The median followup time was 38 months (range 9-57); more than 60% of patients were exposed to N-BP. GC were discontinued in 47% of patients after a median time of 20 months (range 14-27), but subsequently restarted in 39%. Overall, 276/385 patients (72%) were actively treated at their last available evaluation (mean prednisone dose 4.9 ± 5.5 mg/day), while 123/205 (60%) were still receiving GC after 24 months of followup. The use of N-BP was associated with the discontinuation of GC (adjusted HR 0.66, 95% CI 0.50-0.88), independent of age, initial GC dose, and osteoporosis.

CONCLUSION

Unlike current guidelines, longterm treatment with GC is often necessary. These preliminary data suggest that N-BP may be involved in the management of PMR.

Denosumab in the treatment of glucocorticoid-induced osteoporosis

Glucocorticoid therapy is the number one cause of secondary osteoporosis particularly effecting young individuals. Possessing an increased risk for fractures, glucocorticoid-induced osteoporosis might interfere with patients' well-being and quality of life. Therefore, proper treatment of bone loss and prevention from fractures are of great importance. There are a limited number of therapeutic and preventative options for glucocorticoid-induced osteoporosis. Denosumab, with its high anti-resorptive potential, has been studied several times among patients on glucocorticoid therapy. However, a comprehensive look analysing the current data is lacking. Thus, the objective of the current article is to evaluate the current evidence on the efficacy, as well as the safety profile of denosumab in glucocorticoid-induced osteoporosis. Pubmed/MEDLINE, Scopus and Web of Science databases were searched for the terms denosumab, glucocorticoid-induced osteoporosis, steroid-induced osteoporosis, glucocorticoids and osteoporosis. Relevant data regarding the efficacy and safety of denosumab among patients with glucocorticoid-induced osteoporosis was analysed. Denosumab contributes to increased bone mineral density and decreased bone-turnover marker levels among glucocorticoid users. It is an effective therapeutic option with a favourable safety profile in glucocorticoid-induced osteoporosis.

THE RISK OF OSTEOPOROTIC FRACTURES IN PATIENTS WITH RHEUMATOID ARTHRITIS: RESULTS OF THE PROGRAM «OSTEOSCREENING RUSSIA»

Rheumatoid arthritis (RA) and the use of glucocorticoids (GCs) are proven risk factors for osteoporosis (OP) and osteoporotic fractures (OPF). There are also other reasons for increased fracture risk in RA.

Objective: to determine the rate of RA in an epidemiological sample of persons aged 50 years and older and to identify those in need of antiosteoporotic therapy among the patients with RA in order to prevent OPF.

Subjects and methods. The epidemiological sample included 18,018 people aged 50 years and older (13,941 women and 4,077 men; mean age, 62±10 years). The survey consisted of a unified questionnaire, measurement of daily dietary calcium intake, and calculation of a 10-year fracture risk using the FRAX® algorithm.

Results and discussion. The prevalence of RA in the epidemiological population sample aged 50 years and older was 1.7% (1.9% in women and 1.2% in men; p=0.0047). The mean FRAX® values for major OPF in RA patients were significantly higher than those in non-RA individuals: 18.4±10 and 13.2±7.9%, respectively (p=0.0001) for women and 8.9±6.4 and 6.2±3.7%, respectively (p=0.0001) for men. 42% of the patients with RA were at high risk for OPF. Thus, 48% of the women with RA had FRAX® values above the therapeutic intervention threshold; and the non-RA group needed antiosteoporotic therapy significantly less (31%; p=0.00001). At the same time, the detection rate of high-risk OPF in men with and without RA did not differ significantly (8 and 5%, respectively; p>0.05). The most common risk factors (RFs) for OP and OPF in RA patients included previous fractures (33%), secondary causes of OP (30%), GC use (18%), and, additionally, smoking (33%) in male patients with RA. The female patients with RA significantly more frequently took GCs (17%) and had other secondary causes of OP and OPF (33%) than those without RA (7.7% (p=0.0001) and 23% (p=0.0004, respectively). The male patients with RA versus to the population-based control showed significant differences when they only used GCs (20 and 5%, respectively; p = 0.0001); the remaining RFs were encountered at the same frequency. Less than half of the normal daily calcium intake was observed in 20% of men and 16% of women (p=0.53).

Conclusion. 42% of the RA patients aged 50 years and older were at high risk for OPF and needed antiosteoporotic therapy. Every third woman with RA had at least one other comorbidity or condition associated with the increased risk of OPF. In the male patients with RA, the FRAX® algorithm could reveal only 8% of persons at high risk for fractures, while 58% of them had two or more additional RFs that can negatively affect bone mineral density and increase the risk of fracture. To identify those who require prevention and treatment of OP and OPF, it is preferable to perform bone densitometry of the axial skeleton among male patients with RA. 

Risk of fracture among patients with polymyalgia rheumatica and giant cell arteritis: a population-based study

BACKGROUND

Glucocorticoids are associated with increased fracture risk and are the mainstay of treatment in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). However, fracture risk in these conditions has not been previously quantified. The aim of this study was to quantify the risk of fracture among patients with PMR and GCA.

METHODS

A retrospective cohort study was conducted using primary care records from the UK-based Clinical Practice Research Datalink. Individuals aged 40 years and over, with incident diagnoses of PMR or GCA were separately identified from 1990-2004 and followed up until 2015. For each exposed individual, four age-, sex- and practice-matched controls were randomly selected. Incidence rates of fracture per 10,000 person-years were calculated for each disease group and hazard rates were compared to the unexposed using Cox regression models.

RESULTS

Overall, 12,136 and 2673 cases of PMR and GCA, respectively, were identified. The incidence rate of fracture was 148.05 (95% CI 141.16-155.28) in PMR and 147.15 (132.91-162.91) in GCA per 10,000 person-years. Risk of fracture was increased by 63% in PMR (adjusted hazard ratio 1.63, 95% CI 1.54-1.73) and 67% in GCA (1.67, 1.49-1.88) compared to the control populations. Fewer than 13% of glucocorticoid-treated cases were prescribed bisphosphonates.

CONCLUSIONS

This study reports, for the first time, a similar increase in fracture risk for patients with PMR and GCA. More needs to be done to improve adherence to guidelines to co-prescribe bisphosphonates. Further research needs to identify whether lower glucocorticoid starting doses and/or aggressive dose reduction reduces fracture risk.