Bone mineral density and body composition in men with systemic lupus erythematosus: A case control study

doi:10.1016/j.bone.2008.04.003

Bone

Volume 43, Issue 2, August 2008, Pages 327-331

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Abstract

Objective

To study the bone mineral density (BMD) and body composition in men with systemic lupus erythematosus (SLE).

Methods

Consecutive male patients who fulfilled ≥ 4 ACR criteria for SLE and age-matched healthy men were recruited for measurement of BMD and body composition by DXA scan. Risk factors for low BMD in SLE patients were evaluated.

Results

40 male SLE patients were studied (age 42.6 ± 12 years; disease duration 84.7 ± 79 months). 34 (85%) patients were treated with long-term glucocorticoids. Compared with 40 controls, SLE patients had a significantly lower BMD at the lumbar spine (0.96 ± 0.16 vs 1.03 ± 0.11 g/cm²; p = 0.02) and the hip (0.87 ± 0.14 vs 0.94 ± 0.12 g/cm²; p = 0.04). At the spine, 12 (30%) SLE patients had Z scores< − 2.0 and 2 (5%) had osteoporotic fractures. At the hip, 3 (7.5%) patients had Z scores< − 2.0 but none had hip fractures. The BMD Z scores at the femoral neck and spine were significantly lower in SLE patients than controls. The total lean body mass was also lower in patients than control subjects (46.4 ± 7.3 vs 50.5 ± 5.9 kg; p = 0.01). Multiple regression revealed increasing age, habitual drinking, lower BMI and use of high-dose prednisolone were unfavorably associated with lower BMD at the spine in SLE patients.

Conclusions

Reduced BMD and lean body mass are prevalent in men with SLE. Appropriate measures against osteoporosis should be undertaken, especially in older patients with low BMI who receive high-dose glucocorticoids.

Introduction

Despite improvement in survival of systemic lupus erythematosus (SLE) [1], [2], morbidities as a result of disease and treatment related complications are still major concerns [3], [4]. Osteoporosis and its related fractures is one of the most prevalent complications in patients with SLE. In addition to chronic glucocorticoid therapy, renal insufficiency, premature ovarian failure, avoidance of sun exposure, disabling arthritis and myopathy, failure to achieve a peak bone mass and the use of other medications such as anticoagulants and anticonvulsants also contribute to osteoporosis [3].

Previous studies have demonstrated that bone mineral density (BMD) in premenopausal women with SLE was significantly lower than that of age and gender matched healthy controls [5], [6], [7]. Osteoporosis occurred in 3–42% of SLE patients, depending on study design, ethnicity, age and proportion of postmenopausal patients in the study cohorts, duration of SLE and corticosteroid treatment [8]. A retrospective study in the United States described an incidence of 12.3% of self-reported fractures in women with SLE [9]. Fracture was nearly 5-fold increase compared with women of similar age in the general population. Another cross-sectional study in the United Kingdom showed that fragility fractures occurred in 9.1% of patients since SLE diagnosis [10].

Few studies of BMD in SLE have focused on men. Bhattoa et al. [11] studied 23 men with SLE and reported that the prevalence of osteoporosis at the lumbar spine was 17.4%. BMD in patients was not significantly lower than that of controls. Another study also failed to show a significant difference in BMD between 20 male SLE patients and controls [12]. None of the patients had osteoporosis and no relationship between BMD and cumulative doses of corticosteroids could be demonstrated.

Body composition is seldom studied in SLE. Kipen et al. studied 82 female SLE patients and reported that reduced fat-free body mass correlated with low BMD and was associated with disease severity, corticosteroid treatment and increasing age [13]. A more recent case control study of 68 childhood-onset SLE patients showed that fat mass was significantly higher whereas lean mass was lower in patients [14].

In this study, we evaluated the body composition and BMD, and their determinants, in a larger group of men with SLE.

Section snippets

Patients and methods

Consecutive male patients who fulfilled ≥ 4 of the American College of Rheumatology criteria for SLE [15] and were followed in the Lupus clinic of the Department of Medicine, Tuen Mun Hospital, Hong Kong were referred for BMD (lumbar spine, non-dominant hip and whole body) and body composition (fat mass, lean mass) measurement by dual X-ray absorptiometry (DXA) scan. A routine radiological examination of the thoracic and lumbar spine (anteroposterior and lateral views) was also performed to

Clinical characteristics of SLE patients and controls

Forty male SLE patients (mean age 42.6 ± 12 years; disease duration 84.7 ± 79 months) were studied. This comprised 91% of all male SLE patients in our Lupus clinic. Forty age-matched healthy men (mean age 42.6 ± 12 years; p = 0.99) were also studied. All participants were ethnic Chinese. The clinical manifestations of the SLE patients are shown in Table 1. Thirty-four (85%) SLE patients had ever received corticosteroids for at least 6 months. The mean duration of corticosteroid treatment was 56.2 ±

Discussion

That osteoporosis has an equal impact in both men and women is under-recognized. The reasons for this are several: men achieve a higher peak bone mass at skeletal maturity, men experience a lower rate of age-related bone loss because of the lack of a menopausal equivalent, and men have a shorter life expectancy [18]. In addition, although men experience enhanced endocortical bone resorption similar to that of women, periosteal bone formation is greater [19]. This leads to a greater

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Osteoporosis and osteonecrosis in systemic lupus erythematosus
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Citation Excerpt :
Men with SLE and low bone mass may be associated with abnormal sex hormones. One small study of 40 men with SLE showed that reduced lumbar spine BMD was associated with age, habitual alcohol use, low BMI, and high doses of GCs.8 Osteonecrosis.
Half of the patients with systemic lupus erythematosus (SLE) will have a reduced bone density and more than one in ten will develop osteoporosis (OP) prematurely. Multiple risk factors have been related to loss of bone mass, but just a few are modifiable, such as adequate vitamin D and calcium intakes, weight bearing exercise, controlling SLE activity and limiting the use of glucocorticoids (GC). GC have also been strongly associated to osteonecrosis or avascular necrosis (AVN). The main consequences of OP and AVN are fractures, which lead to significant functional limitation, loss of quality of life and increased morbidity. OP-related fractures can be reduced by performing appropriate screening with bone densitometries and providing prophylactic treatment when long-term or high dose GC are needed. No formal screening is available for AVN; but diagnosis is made by imaging (X-ray, bone scan or advanced imaging where appropriate). Aiming for the lowest dose possible of GC in combination with immunosuppression as well as an early recognition of the symptoms will prevent further complications. This manuscript is a practical review of the epidemiology, pathophysiology, and management of OP and AVN in patients with SLE, based on the available evidence and guidelines.
La mitad de los pacientes con lupus eritematoso sistémico (LES) tendrá una densidad ósea disminuida, y más de uno de cada 10 desarrollará osteoporosis (OP) prematuramente. Son múltiples los factores de riesgo que se han relacionado con la pérdida de la masa ósea, pero solo unos pocos son modificables, tales como la ingesta de niveles adecuados de vitamina D y de calcio, ejercicio con pesas, controlar la actividad del LES, y limitar el uso de glucocorticoides (GC). También se ha encontrado una estrecha relación entre el uso de GC y osteonecrosis o a necrosis avascular (NAV). Las principales consecuencias de la OP y de la NAV son fracturas, que generan una limitación funcional importante, pérdida de la calidad de vida y aumento de la morbilidad. Las fracturas por osteoporosis se pueden reducir mediante un tamizaje adecuado con densitometría ósea y administrando tratamiento profiláctico cuando se requieren GC de largo plazo o a altas dosis. No existe un tamizaje formal para la NAV, pero su diagnóstico se realiza con imágenes (radiografía, gammagrafía ósea o imágenes avanzadas cuando corresponda). El apuntar a la menor dosis posible de GC, en combinación con inmunosupresión, además de la temprana identificación de los síntomas, ayudará a prevenir otras complicaciones. El presente artículo es una revisión práctica de la epidemiología, la fisiopatología y el manejo de la OP y la NAV en pacientes con LES, en función de la evidencia y de las guías disponibles.
The musculoskeletal system in SLE
2020, Systemic Lupus Erythematosus: Basic, Applied and Clinical Aspects
Along with cutaneous disease, musculoskeletal manifestations predominate in SLE with large series observing more than a 90% cumulative involvement, whereas some musculoskeletal complications, such as myositis and arthritis, reflect disease activity, others, such as osteonecrosis and osteoporosis, are typically adverse effects of treatment. In this chapter, we review common musculoskeletal manifestations that affect patients with SLE.
Impact of obesity on autoimmune arthritis and its cardiovascular complications
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Others have made the distinction between fat and fat-free or lean body mass and have observed a more nuanced change in body composition in SLE patients [250]. These patients may have a lower lean body mass, which correlates with reduced bone mineral density and in turn negatively correlates with disease severity [251]. SLE patients often present dyslipidemia [252].
Obesity can instigate and sustain a systemic low-grade inflammatory environment that can amplify autoimmune disorders and their associated comorbidities. Metabolic changes and inflammatory factors produced by the adipose tissue have been reported to aggravate autoimmunity and predispose the patient to cardiovascular disease (CVD) and metabolic comorbidities. Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are autoimmune arthritic diseases, often linked with altered body mass index (BMI). Severe joint inflammation and bone destruction have a debilitating impact on the patient's life; there is also a staggering risk of cardiovascular morbidity and mortality. Furthermore, these patients are at risk of developing metabolic symptoms, including insulin resistance resulting in type 2 diabetes mellitus (T2DM). In addition, arthritis severity, progression and response to therapy can be markedly affected by the patient's BMI. Hence, a complex integrative pathogenesis interconnects autoimmunity with metabolic and cardiovascular disorders. This review aims to shed light on the network that connects obesity with RA, PsA, systemic lupus erythematosus and Sjӧgren's syndrome. We have focused on clarifying the mechanism by which obesity affects different cell types, inflammatory factors and traditional therapies in these autoimmune disorders. We conclude that to further optimize arthritis therapy and to prevent CVD, it is imperative to uncover the intricate relation between obesity and arthritis pathology.
Assessment of the risk of low bone mineral density in premenopausal Japanese female patients with systemic lupus erythematosus
2018, Journal of Orthopaedics
Citation Excerpt :
However, some studies have found no apparent association between disease activity parameters and generalized bone loss.23,24 Some previous studies have reported that low body weight, short stature and low BMI were associated with low BMD in patients with SLE.25,26 In this study we hypothesized that BMD was negatively correlated with age, disease duration, C3 and C4 values, dsDNA antibody and creatinine levels, current dose of glucocorticoid and high-dose glucocorticoid usage, and was positively associated with BMI, regardless of bisphosphonate treatment.
The aim of this study was to assess the relationships between clinical parameters and bone mineral density (BMD) in Japanese female patients with systemic lupus erythematosus (SLE).
A total of female 136 SLE patients without menopause were retrospectively assessed to identify associations between age, disease duration, body mass index (BMI), glucocorticoid usage and disease activity and BMD based on the treatment with or without bisphosphonate. There were 71 patients treated with bisphosphonate (bisphosphonate group) and 65 patients without (non-bisphosphonate group). We evaluated the impact of age, disease duration, BMI, serologic SLE markers, glucocorticoid use on BMD of the anterior-posterior (AP) and lateral lumbar spine, total hip and femoral neck using univariate and multivariate linear regression analyses of both bisphosphonate and non-bisphosphonate groups.
Multivariate linear regression analyses showed that in non-bisphosphonate group disease duration was negatively associated with BMD of AP spine and femoral neck, whereas in bisphosphonate group these negative associations were not present. However, multivariate linear regression analyses showed a significant relationship between BMI and BMD of the AP spine, femoral neck and total hip, regardless of bisphosphonate treatment.
Bisphosphonate treatment eliminated the negative relationships between disease duration and the BMD of the spine and hip. AP spine and hip BMD in patients with SLE depend on BMI, regardless of bisphosphonate use. SLE serologic markers and glucocorticoid use were not negatively associated with generalized bone loss. SLE patients with low BMI have a high risk of generalized bone loss, and should be assessed and treated to prevent osteoporosis even before menopause.
Bone mineral density and vitamin D status in systemic lupus erythematosus (SLE): A systematic review
2017, Autoimmunity Reviews
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Previous studies have suggested possible bone loss and fracture risk in patients with SLE [3,10]. Reduced bone mass in SLE male [11] and female [12] patients has been shown to be more prevalent compared to age-matched healthy controls. Osteoporosis is defined as a systemic skeletal disease characterized by decreased bone mineral density (BMD) [13] and an increase in the susceptibility to bone fractures.
Despite the improvement in the quality of life of patients with SLE due to scientific and technological advances, SLE remains a disease that over the years may produce irreversible damage to patients. Osteoporosis and secondary bone fractures are two of the major causes of irreparable injury in patients with SLE. Vitamin D insufficiency may play a vital role both in reduced bone mineral density (BMD) and in the appearance of fractures, although its mechanisms of action are still unclear. We performed a systematic review of the literature in order to determine the prevalence and predictors of reduced vitamin D plasma levels, bone loss and the presence of fractures in SLE patients. Our review encompassed all English-language publications using Medline and EMBase electronic databases from their inception (1966 and 1980, respectively) to December 2016. We included all intervention studies and observational studies in which vitamin D plasma levels, BMD and bone loss were measured and applied to patients with SLE. Previous studies suggested an increase in bone loss and fracture in patients with SLE compared with general population and although there is a high prevalence of vitamin D insufficiency in the general population, previous studies had demonstrated lower vitamin D levels in patients with SLE compared to age-matched controls. The etiology of reduced bone mass and reduced vitamin D plasma levels in SLE is multifactorial and includes a variety of intrinsic factors related to the disease itself and treatment side effects. SLE patients are at risk for developing these two comorbidities (reduced vitamin D plasma levels and low BMD) and it is therefore essential to study, monitor, prevent and treat bone metabolism disorders in SLE patients.
The Musculoskeletal System in Systemic Lupus Erythematosus
2016, Systemic Lupus Erythematosus: Basic, Applied and Clinical Aspects
Along with cutaneous disease, musculoskeletal manifestations are quite prevalent in systemic lupus erythematosus (SLE). Whereas some musculoskeletal complications, such as myositis and arthritis, reflect disease activity, others, such as osteonecrosis and osteoporosis, are typically adverse effects of treatment. In this chapter, we review the most common musculoskeletal manifestations that affect patients with SLE.

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Bone mineral density and body composition in men with systemic lupus erythematosus: A case control study

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Clinical characteristics of SLE patients and controls

Discussion

Rheum Dis Clin North Am

Lancet

Semin Arthritis Rheum

Cytokine

Long-term survival of southern Chinese patients with systemic lupus erythematosus: a prospective study of all age-groups.

Medicine (Baltimore)

Systemic lupus erythematosus in North American Indians: a population based study

J Rheumatol

Therapy insight: osteoporosis and osteonecrosis in systemic lupus erythematosus

Nat Clin Pract Rheumatol

Accelerated atherosclerosis, arterial thromboembolism, and preventive strategies in systemic lupus erythematosus

Scand J Rheumatol

Loss of bone mineral density in Chinese pre-menopausal women with systemic lupus erythematosus treated with corticosteroids

Br J Rheumatol

The effect of systemic lupus erythematosus and long-term steroid therapy on bone mass in pre-menopausal women

Br J Rheumatol

Loss of bone mineral density in premenopausal women with systemic lupus erythematosus

Ann Rheum Dis

Frequency of fractures in women with systemic lupus erythematosus: comparison with United States population data

Arthritis Rheum.

Prevalence and predictors of fragility fractures in systemic lupus erythematosus

Ann Rheum Dis

Bone mineral density, biochemical markers of bone turnover, and hormonal status in men with systemic lupus erythematosus

Rheumatol Int

Bone mineral density and hormonal status in men with systemic lupus erythematosus

Lupus

Body composition in systemic lupus erythematosus

Br J Rheumatol