Rheumatoid arthritis and bone health

Association between bone mineral density and vascular health in rheumatoid arthritis

INTRODUCTION

Rheumatoid arthritis (RA) is associated with heightened cardiovascular disease and increased susceptibility to osteoporosis, with shared underlying mechanisms. This study aimed to investigate the association between vascular function and bone mineral density (BMD).

METHODS

We conducted a cross-sectional study of 49 patients with RA at Tan Tock Seng Hospital, Singapore. Endothelial function was measured as reactive hyperaemia index (RHI)-endothelial peripheral arterial tonometry and aortic stiffness as carotid-femoral pulse wave velocity (cf-PWV) using SphygmoCor. Univariable and multivariable linear regression analyses were performed to evaluate the associations between BMD and vascular function. We used natural logarithm RHI (lnRHI) and cf-PWV as response variables, and each BMD as covariate, adjusting for body mass index, positive anti-cyclic citrullinated peptide, cumulative prednisolone dose, hydroxychloroquine use and Systematic COronary Risk Evaluation 2.

RESULTS

We recruited 49 patients (mean age 61.08 ± 8.20 years), of whom 44 (89.80%) were women and 39 (81.25%) were Chinese. Significant associations were found between lnRHI and BMD at the lumbar spine (β = 0.4289, P = 0.037) and total hip (β = 0.7544, P = 0.014) in univariable analyses. Multivariable analyses confirmed these associations, showing that lower BMD at the lumbar spine (β = 0.7303, P = 0.001), femoral neck (β = 0.8694, P = 0.030) and total hip (β = 0.8909, P = 0.010) were significantly associated with worse lnRHI. No significant associations were found between BMD and cf-PWV.

CONCLUSION

Lower BMD is associated with endothelial dysfunction, but not aortic stiffness in patients with RA. Further longitudinal studies are needed to confirm these associations and understand the underlying mechanisms.

Irisin: A Multifaceted Hormone Bridging Exercise and Disease Pathophysiology

The fibronectin domain-containing protein 5 (FNDC5), or irisin, is an adipo-myokine hormone produced during exercise, which shows therapeutic potential for conditions like metabolic disorders, osteoporosis, sarcopenia, obesity, type 2 diabetes, and neurodegenerative diseases, including Alzheimer's disease (AD). This review explores its potential across various pathophysiological processes that are often considered independent. Elevated in healthy states but reduced in diseases, irisin improves muscle-adipose communication, insulin sensitivity, and metabolic balance by enhancing mitochondrial function and reducing oxidative stress. It promotes osteogenesis and mitigates bone loss in osteoporosis and sarcopenia. Irisin exhibits anti-inflammatory effects by inhibiting NF-κB signaling and countering insulin resistance. In the brain, it reduces amyloid-β toxicity, inflammation, and oxidative stress, enhancing brain-derived neurotrophic factor (BDNF) signaling, which improves cognition and synaptic health in AD models. It also regulates dopamine pathways, potentially alleviating neuropsychiatric symptoms like depression and apathy. By linking physical activity to systemic health, irisin emphasizes its role in the muscle-bone-brain axis. Its multifaceted benefits highlight its potential as a therapeutic target for AD and related disorders, with applications in prevention, in treatment, and as a complement to exercise strategies.

Osteoporosis and Rheumatoid Arthritis: A Review of Current Understanding and Practice

This review presents a current perspective on the association between rheumatoid arthritis (RA) and osteoporosis. Many factors contribute to the increased risk of osteoporosis and fracture in RA patients. These factors include advanced age, duration of disease, long-term glucocorticoid use, and poor inflammation control inflammation in RA. This review discusses current guidelines and their limitations in assessing bone health in RA-related osteoporosis. Available anti-osteoporotic treatments, their mechanisms of action, and their potential benefits in managing the interaction between RA and osteoporosis are discussed. We also consider potential advancements, including areas of future development in RA and osteoporosis diagnosis and management.

Proinflammatory Cytokines Enhance the Mineralization, Proliferation, and Metabolic Activity of Primary Human Osteoblast-like Cells

Osteoporosis is a progressive metabolic bone disease characterized by decreased bone density and microarchitectural deterioration, leading to an increased risk of fracture, particularly in postmenopausal women and the elderly. Increasing evidence suggests that inflammatory processes play a key role in the pathogenesis of osteoporosis and are strongly associated with the activation of osteoclasts, the cells responsible for bone resorption. In the present study, we investigated, for the first time, the influence of proinflammatory cytokines on the osteogenic differentiation, proliferation, and metabolic activity of primary human osteoblast-like cells (OBs) derived from the femoral heads of elderly patients. We found that all the proinflammatory cytokines, IL-1β, TNF-α, IL-6, and IL-8, enhanced the extracellular matrix mineralization of OBs under differentiation-induced cell culture conditions. In the cases of IL-1β and TNF-α, increased mineralization was correlated with increased osteoblast proliferation. Additionally, IL-1β- and TNF-α-increased osteogenesis was accompanied by a rise in energy metabolism due to improved glycolysis or mitochondrial respiration. In conclusion, we show here, for the first time, that, in contrast to findings obtained with cell lines, mesenchymal stem cells, or animal models, human OBs obtained from patients exhibited significantly enhanced osteogenesis upon exposure to proinflammatory cytokines, probably in part via a mechanism involving enhanced cellular energy metabolism. This study significantly contributes to the field of osteoimmunology by examining a clinically relevant cell model that can help to develop treatments for inflammation-related metabolic bone diseases.

Beyond the Surface: Uncovering Secondary Causes of Osteoporosis for Optimal Management

Osteoporosis (OP), a condition marked by reduced bone mineral density and increased fracture risk, can arise either as a primary disorder or secondary to other diseases and medications. While primary OP typically relates to age-related or postmenopausal changes, secondary OP results from underlying conditions or drug exposures, complicating diagnosis and management. This review explores the pathophysiology, prevalence, and treatment approaches for secondary OP arising from endocrine, renal, gastrointestinal, hematological, and autoimmune disorders, as well as medication side effects. The findings highlight that secondary OP is frequently undiagnosed, particularly in premenopausal women and men, with conditions such as chronic kidney disease, glucocorticoid use, and diabetes among the primary contributors. Management strategies must be tailored to address the underlying conditions to effectively reduce fracture risk and improve outcomes. Ultimately, this review underscores the necessity for increased clinical awareness and more targeted interventions for optimal management of secondary OP.

Patient-Reported Outcome Measures After Direct Anterior Total Hip Arthroplasty Are Comparable Between Patients With Rheumatoid Arthritis and Osteoarthritis: A Propensity-Matched Analysis

INTRODUCTION

It is currently unclear whether patients with rheumatoid arthritis have similar functional outcomes after total hip arthroplasty (THA) as those with osteoarthritis, particularly given that rheumatoid arthritis may have systemic manifestations in terms of pain and function. The purpose of this study was to compare patient-reported outcome measures between patients with rheumatoid arthritis and matched control patients with osteoarthritis who underwent direct anterior THA.

METHODS

All patients who underwent direct anterior THA from 2010 to 2022 at a single academic institution were retrospectively reviewed. Hips with rheumatoid arthritis were propensity matched to hips with osteoarthritis on a 1:4 basis. Patient-reported outcome measures, including visual analog scale (VAS) pain at rest and with use, Hip Disability and Osteoarthritis Outcome Score Pain, and Forgotten Joint Score-12, were obtained at follow-up. In addition, modified Harris Hip Scores (mHHS) were obtained both preoperatively and at the final follow-up.

RESULTS

Forty-six hips with rheumatoid arthritis and 184 hips with osteoarthritis were followed for a mean of 6.3 ± 3.6 years. Both cohorts demonstrated notable preoperative to postoperative improvements in mHHS (P < 0.001). No differences were observed at the final follow-up between cohorts for VAS at rest (0.8 vs. 0.5, P = 0.333), VAS with use (1.3 vs. 0.9, P = 0.234), Hip Disability and Osteoarthritis Outcome Score Pain (90.4 vs. 93.6, P = 0.113), Forgotten Joint Score-12 (80.3 vs. 82.8, P = 0.529), and mHHS (86.9 vs. 89.0, P = 0.335). One patient with rheumatoid arthritis had an intraoperative periprosthetic calcar fracture, whereas none underwent subsequent revision THA.

CONCLUSION

Patients with rheumatoid arthritis and osteoarthritis who underwent direct anterior THA achieved comparable outcomes in this propensity-matched analysis. Although patients with rheumatoid arthritis may be at an increased risk of complications and revision surgery, patients can expect reduced pain and improved functional outcomes similar to those with osteoarthritis following primary THA.

Protocol for rheumatoid arthritis complicated with cardiovascular damage treated with Guanxining tablet with a randomized controlled trial

Background

Cardiovascular disease (CVD) is the main cause of death in patients with rheumatoid arthritis (RA). Apart from traditional cardiovascular risk factors, immune dysfunction and chronic inflammation of RA are also risk factors for complex cardiovascular damage. Although methotrexate (MTX) is beneficial to CVD in RA patients by inhibiting inflammation, its adverse effects limit its clinical application. Therefore, it is essential to seek safer and more effective drugs.

Objective

We aimed to assess the efficacy of Guanxining Tablet (GXNT) for rheumatoid arthritis complicated with cardiovascular damage.

Methods

We will conduct a prospective single-center randomized trial. We will randomly divide 56 eligible patients into two groups. The treatment group will take GXNT and MTX treatment, and the control group will receive MTX and the placebo. The primary outcome measure will be aortic distensibility (AD). Secondary outcome measures will be Cardiac function which will contain right ventricular outflow tract diameter (RVOTD), aortic diameter (AOD), left atrium diameter (LAD), right ventricular end diastolic diameter (RVDD), left ventricular end diastolic diameter (LVDD), ejection fraction (EF%), fractional shortening (FS%), stroke volume (SV). Adverse events will be closely monitored during the entire trial period.

Discussion

This trial is intended to determine whether the addition of GXNT will improve the prognosis of patients with rheumatoid arthritis and cardiovascular damage without severe adverse reactions. Completing this clinical trial might provide these patients with a novel and effective drug while avoiding adverse reactions similar to methotrexate.

Trial registration

ChiCTR2000030247.

Association of alcohol and bone mineral density dependent on type of alcohol consumed

INTRODUCTION

Osteoporosis prevalence will increase in coming decades, with significant financial and economic implications. Whilst alcohol excess has significant detrimental impacts on bone mineral density (BMD), knowledge of low-volume consumption is inconsistent. Type of alcohol may mediate impact on BMD and warrants further investigation.

MATERIALS AND METHODS

Participants were drawn from the Florey Adelaide Male Aging Study, a cohort of community dwelling men from Adelaide, Australia (n = 1195). The final cohort (n = 693) provided information regarding alcohol consumption and undertook BMD scan at wave one (2002-2005) and wave two (2007-2010). Cross-sectional and longitudinal multivariable regression was performed for whole-body and spine BMD. To assess change in exposure over time, change in BMD was compared to change in covariates between waves.

RESULTS

Cross-sectionally, whole-body BMD was positively associated with obesity (p < 0.001), exercise (p = 0.009), prior smoking (p = 0.001), oestrogen concentration (p = 0.001), rheumatoid arthritis (p = 0.013) and grip strength (p < 0.001). No association was identified with volume of differing types of alcohol consumed. Spinal BMD was inversely associated with low-strength beer consumption (p = 0.003). The volume of alcohol consumed at Wave 1 did not predict change in whole-body or spinal BMD; however, increases in full-strength beer consumption between waves were associated with reduced spinal BMD (p = 0.031).

CONCLUSION

When consumed at quantities in the usual social range, alcohol was not associated with whole-body BMD. However, low-strength beer consumption was inversely related to spinal BMD.

The causal relationship between autoimmune diseases and osteoporosis: a study based on Mendelian randomization

Objective

The relationship between different autoimmune diseases and bone mineral density (BMD) and fractures has been reported in epidemiological studies. This study aimed to explore the causal relationship between autoimmune diseases and BMD, falls, and fractures using Mendelian randomization (MR).

Methods

The instrumental variables were selected from the aggregated statistical data of these diseases from the largest genome-wide association study in Europe. Specifically, 12 common autoimmune diseases were selected as exposure. Outcome variables included BMD, falls, and fractures. Multiple analysis methods were utilized to comprehensively evaluate the causal relationship between autoimmune diseases and BMD, falls, and fractures. Additionally, sensitivity analyses, including Cochran's Q test, MR-Egger intercept test, and one analysis, were conducted to verify the result's reliability.

Results

Strong evidence was provided in the results of the negatively association of ulcerative colitis (UC) with forearm BMD. UC also had a negatively association with the total body BMD, while inflammatory bowel disease (IBD) depicted a negatively association with the total body BMD at the age of 45-60 years. Horizontal pleiotropy or heterogeneity was not detected through sensitivity analysis, indicating that the causal estimation was reliable.

Conclusion

This study shows a negative causal relationship between UC and forearm and total body BMD, and between IBD and total body BMD at the age of 45-60 years. These results should be considered in future research and when public health measures and osteoporosis prevention strategies are formulated.

Frequency of osteoporosis in Chinese patients with rheumatoid arthritis: a meta-analysis

OBJECTIVE

To evaluate the current frequency of osteoporosis (OP) in Chinese patients with rheumatoid arthritis (RA) through meta-analysis.

METHODS

The databases of PubMed, Web of Science, Cochrane Library, CNKI, Wan Fang, CBM, and VIP were searched for relevant literature regarding the occurrence of OP in Chinese patients with RA from January 1, 2000, to September 15, 2022. The literature was screened using inclusion and exclusion criteria, and qualifying articles were subjected to data extraction, quality evaluation, and meta-analysis using Stata 17.0 software.

RESULTS

Altogether, 44 publications were included in this study, with a total sample size of 12,264 RA cases and 4532 patients with OP. Meta-analysis revealed that the frequency of OP in patients with RA was 37.67% [95% CI: 34.38%, 40.97%], while subgroup analysis showed that the frequency in South China was 49.43% [95% CI: 40.53%, 58.32%]. Also, the frequency in men was 29.29% [95% CI: 22.42%, 36.16%], which was significantly lower than in women (41.89% [95% CI: 36.87%, 46.90%]). The incidence rate in pre-menopausal women was only 15.19% [95% CI: 8.79%, 21.59%], much lower than the figure of 54.29% [95% CI: 45.28%, 63.30%] for post-menopausal women. Additionally, the frequency rates in the low, intermediate, and high disease activity groups were 24.52% [95% CI: 11.52%, 37.52%)], 27.67% [95% CI: 13.50%, 41.85%], and 57.96% [95% CI: 37.35%, 78.56%], respectively.

CONCLUSION

The frequency of OP in the Chinese RA population is higher than the world average, and patients with RA should receive standardized anti-RA therapy at an early stage, with emphasis on bone health in postmenopausal women, patients with high disease activity or longer disease duration.

Cardiovascular disease and bone health in aging female rheumatic disease populations: A review

Rheumatic diseases cover a wide spectrum of conditions, including primary and secondary degenerative joint diseases and autoimmune inflammatory rheumatic diseases. The risks of cardiovascular disease and osteoporosis and resultant fractures in aging female rheumatic disease populations, especially those with autoimmune rheumatic diseases, are increased. Changes in the immune system in aging populations need to be considered especially among patients with autoimmune rheumatic diseases. Immunosenescence is closely aligned to reduced adaptive immunity and increased non-specific innate immunity leading to chronic inflammation of inflammaging. The effective use of disease-modifying antirheumatic drugs to control autoimmune rheumatic diseases may also mitigate factors leading to cardiovascular disease and osteoporosis. Rheumatic diseases, which largely manifest as arthritis, predispose patients to premature joint degeneration and poor bone health and therefore have a higher risk of developing end-stage arthritis requiring joint arthroplasties sooner or more often than other patients without rheumatic disease.

IL-27 regulates autophagy in rheumatoid arthritis fibroblast-like synoviocytes via STAT3 signaling

Rheumatoid arthritis (RA) is a highly prevalent autoimmune condition associated with pronounced synovial inflammation. The majority of RA patients required long-term treatment to control disease progression, thus imposing a significant financial burden on affected individuals. The development of RA is critically influenced by fibroblast-like synoviocytes (FLSs) within the synovial lining. IL-27 is an IL-6/IL-12 family cytokine that has recently been shown to play varied pro-inflammatory or protective roles in particular autoimmune diseases. However, the effects of IL-27 on FLSs in the context of RA have yet to be clarified and warrant further research. This study was developed to evaluate the impact of IL-27 treatment on apoptotic and autophagic activity in RA-associated FLSs, with a particular focus on the role of the STAT3 pathway in this regulatory context. Through these experiments, we found that IL-27 was able to suppress FLS proliferation and autophagic activity, with a high dose of this cytokine (100 ng/mL) markedly suppressing autophagy while simultaneously inducing some level of cellular apoptosis. The STAT3 inhibitor STA21 was found to reverse the IL-27-mediated suppression of autophagic activity in these RA-associated FLSs. Imbalanced cellular proliferation and apoptosis is of critical importance in the context of RA progression, and we found that IL-27 was able to regulate such imbalance and to enhance the apoptotic activity of RA FLSs by inhibiting rapamycin-activated autophagy. Together, these results indicate that IL-27 can regulate autophagic activity within RA-associated FLSs via the STAT3 signaling pathway, leading to inhibition of cellular proliferation.

Multinucleated Giant Cells: Current Insights in Phenotype, Biological Activities, and Mechanism of Formation

Monocytes and macrophages are innate immune cells with diverse functions ranging from phagocytosis of microorganisms to forming a bridge with the adaptive immune system. A lesser-known attribute of macrophages is their ability to fuse with each other to form multinucleated giant cells. Based on their morphology and functional characteristics, there are in general three types of multinucleated giant cells including osteoclasts, foreign body giant cells and Langhans giant cells. Osteoclasts are bone resorbing cells and under physiological conditions they participate in bone remodeling. However, under pathological conditions such as rheumatoid arthritis and osteoporosis, osteoclasts are responsible for bone destruction and bone loss. Foreign body giant cells and Langhans giant cells appear only under pathological conditions. While foreign body giant cells are found in immune reactions against foreign material, including implants, Langhans giant cells are associated with granulomas in infectious and non-infectious diseases. The functionality and fusion mechanism of osteoclasts are being elucidated, however, our knowledge on the functions of foreign body giant cells and Langhans giant cells is limited. In this review, we describe and compare the phenotypic aspects, biological and functional activities of the three types of multinucleated giant cells. Furthermore, we provide an overview of the multinucleation process and highlight key molecules in the different phases of macrophage fusion.

Inter‐alpha‐trypsin inhibitor heavy chain 4: A serologic marker relating to disease risk, activity, and treatment outcomes of rheumatoid arthritis

Objective

Inter‐alpha‐trypsin inhibitor heavy chain 4 (ITIH4) regulates immunity and inflammation, but its clinical role in rheumatoid arthritis (RA) patients remains unclear. Hence, this study was conducted to explore the association of circulating ITIH4 with disease risk, clinical features, inflammatory cytokines, and treatment outcomes of RA.

Methods

After the enrollment of 93 active RA patients and 50 health controls (HCs), their serum ITIH4 level was analyzed by enzyme‐linked immunosorbent assay (ELISA). For RA patients only, serum ITIH4 level at week (W) 6 and W12 after treatment was also analyzed. Besides, serum tumor necrosis factor‐alpha (TNF‐α), interleukin (IL)‐1β, IL‐6, and IL‐17A at baseline of RA patients were also detected by ELISA.

Results

ITIH4 was downregulated in RA patients (151.1 (interquartile range (IQR): 106.2–213.5) ng/mL) than in HCs (306.8 (IQR: 238.9–435.1) ng/mL) (p < 0.001). Furthermore, ITIH4 was negatively related to C‐reactive protein (CRP) (r_s = −0.358, p < 0.001) and 28‐joint disease activity score using erythrocyte sedimentation rate (DAS28‐ESR) (r_s = −0.253, p = 0.014) in RA patients, but not correlated with other clinical features (all p > 0.05). Besides, ITIH4 was negatively linked with TNF‐α (r_s = −0.337, p = 0.001), IL‐6 (r_s = −0.221, p = 0.033), and IL‐17A (r_s = −0.368, p < 0.001) in RA patients, but not correlated with IL‐1β (r_s = −0.195, p = 0.061). Moreover, ITIH4 was gradually elevated in RA patients from baseline to W12 after treatment (p < 0.001). Additionally, the increment of ITIH4 at W6 and W12 was linked with treatment response and remission in RA patients (all p < 0.05).

Conclusion

Circulating ITIH4 possesses clinical utility in monitoring disease risk, inflammation, disease activity, and treatment outcomes of RA.