Risk factors for low bone mass in premenopausal women with systemic lupus erythematosus
Article Sidebar
Main Article Content
Abstract
Introduction: patients with systemic lupus erythematosus have a high risk of presenting low bone mass. The etiology is multifactorial (traditional risk factors, characteristic of the disease, laboratory, serological, metabolic and those related to treatment).
Objective: to determine the traditional risk factors for low bone mass (sedentary lifestyle, smoking, alcohol, low milk intake, low body mass index), those related to the disease (clinical presentation, laboratory), metabolic and treatment, with the decrease of bone mineral density in premenopausal women with systemic lupus erythematosus.
Methodology: prospective analytical cross-sectional observational study of premenopausal women with systemic lupus erythematosus, who attended the National Hospital in the period October 2017 - October 2019. Bone mineral density was evaluated by DEXA densitometry, and the Z score was used, equal values or lower than -2,0 SD was considered low bone mass. The variables analyzed were: traditional risk factors for low bone mass, related to lupus, laboratory, serological, metabolic and treatment. Statistical analysis: mean and standard deviation for continuous variables were used to describe the variables; and proportions for qualitative ones. The risk factors for low bone mass were established by the Chi square test, considering a p value of ˂0,05 as significant; the Student's t test was used to compare means.
Result: 61 premenopausal women were studied, with a mean age 25,6 ± 7 years, being from the interior of the country 50,8 % and Central 49,18 %. They had secondary studies 54,10 %, tertiary 34,43 %, primary 11,48 %. 40,98 % were sedentary. 21,31 % had a low milk intake and 1,64 % was an active smoker. They were 66,2 % normal weight, 15,25 % overweight, 18,33 % obese, 1,64 % underweight. The mean time of illness was 50,5 ± 56,4 months. The disease activity index (SLEDAI) was 6,5 ± 6,5. 31,5 % had a duration of the disease greater than 5 years. They had lupus nephritis 52,54 %, severe activity 24,5 %, hypocomplementemia 45 %. Mean ANA 995,5 ± 1164, mean anti DNA 274,2 ± 830,8, anti Ro positive 54,7 %, anti Sm positive 24,5 %. Vitamin D normal value 18,5 %, insufficient 50,9 %, deficient 32,6 %. 7 patients had low bone mass, 11,4 %. No association was found between traditional risk factors, those related to the disease (systemic inflammation, laboratory), metabolic and treatment with low bone mass, (p ≥ 0,05).
Conclusion: they had a low bone mass 11,4 %. The traditional risk factors, those related to the disease, laboratory, metabolic and treatment did not present a statistically significant association with low bone mass.
Article Details
This work is licensed under a Creative Commons Attribution 4.0 International License.
References
Bultink IE. Osteoporosis and fractures in systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2012; 64(1):2-8. doi: 10.1002/acr.20568.
Bultink IE, Harvey NC, Lalmohamed A, Cooper C, Lems WF, van Staa TP, et al. Elevated risk of clinical fractures and associated risk factors in patients with systemic lupus erythematosus versus matched controls: a population-based study in the United Kingdom. Osteoporos Int. 2014;25(4):1275-83. doi: 10.1007/s00198-013-2587-z.
Velázquez Franco CJ, Zuluaga M, Lozano Pineda F, Pulgarín Montoya S, Onésimo Vallejo E, Rodríguez Padilla L, et al. Baja masa ósea y osteoporosis en pacientes con lupus eritematoso sistémico. Rev Colomb Reumatol 2017; 24 (1): 4-10
Estévez del Toro H, Chico Capote A, Montes Zavala M, Gutiérrez Rojas AR, Gandara Reyes A, Caballero Pinelo R. Osteoporosis en mujeres premenopáusicas con lupus eritematoso sistémico. Rev Cubana Med. 2007; 46(3):1-12 pant. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-75232007000300007&lng=es.
Bultink IEM, Lems WF. Systemic lupus erythematosus and fractures. RMD Open 2015; (1)e000069. doi:10.1136/rmdopen-2015-000069
Mok Cc, Mak A, Ma Km. Bone mineral density in postmenopausal Chinese patients with systemic lupus erythematosus. Lupus 2005; 14(2): 106–12.
Kleyer A, Finzel S, Rech J, Manger B, Krieter M, Faustini F, et al. Bone loss before the clinical onset of rheumatoid arthritis in subjects with anticitrullinated protein antibodies. Ann Rheum Dis 2014;73(5):854–60
Jacobs J, Korswagen LA, Schilder AM, van Tuyl LH, Dijkmans BA, Lems WF, et al. Six year follow-upstudy of bone mineral density in patients with systemic lupus erythematosus. Osteoporos Int. 2013;24(6):1827-33.
Bultink IE, Baden M, Lems WF. Glucocorticoid-induced osteoporosis: an update on current pharmacotherapy and future directions. Expert Opin Pharmacother. 2013; 14(2): 185-97. doi: 10.1517/14656566.2013.761975.
De Nijs RN. Glucocorticoid-induced osteoporosis: a review on pathophysiology and treatment options. Minerva Med. 2008; 99(1):23-43.
Geusens PP, de Nijs RN, Lems WF, Laan RF, Struijs A, van Staa TP, et al. Prevention of glucocorticoid osteoporosis: a consensus document of the Dutch Society for Rheumatology. Ann Rheum Dis. 2004;63(3):324–325.
Bultink IEM. Bone disease in connective tissue disease/systemic lupus erythematosus. Calcif Tissue Int. 2018; 102(5):571-91
Rees F, Doherty M, Grainge M, Lanyon P, Davenport G, Zhang W. The burden of comorbidity in systemic lupus erythematosus in the United Kingdom 1999–2012. Arthritis Care Res (Hoboken). 2006; 68(6):819–827. doi:10.1002/acr.22751.
Petri M. Musculoskeletal complications of systemic lupus erythematosus in the Hopkins Lupus Cohort: an update. Arthritis Care 1995; 8(3):137–145
Almehed K, Forsblad d’Elia H, Kvist G, Ohlsson C, Carlsten H. Prevalence and risk factors of osteoporosis in female SLE patients: extended report. Rheumatology 2007; 46(7):1185–1190.
Xia J, Luo R, Guo S, Yang Y, Ge Sh, Xu G, et al. Prevalence and risk factors of reduced bone mineral density in systemic lupus erythematosus patients. BioMed Research International. 2019;2019: 1-10. doi.org/10.1155/2019/3731648
Svenungsson E, Fei GZ, Jensen-Urstad K, de Faire U, Hamsten A, Frostegard J.TNF-alpha: a link between hypertriglyceridaemia and inflammation in SLE patients with cardiovascular disease. Lupus 2003; 12(6):454–461.
Frostegard J, Svenungsson E, Wu R, Gunnarsson I, Lundberg IE, Klareskog L, et al. Lipid peroxidation is enhanced in patients with systemic lupus erythematosus and is associated with arterial and renal disease manifestations. Arthritis Rheum. 2005; 52(1):192–200.
Teichmann J, Lange U, Stracke H, Federlin K, Bretzel RG. Bone metabolism and bone mineral density of systemic lupus erythematosus at the time of diagnosis. Rheumatol 1999; 18(4):137–140.
Wang X, Yan S, Liu C, Xu Y, Wan L, Wang Y, et al. Fracture risk and bone mineral density levels in patients with systemic lupus erythematosus: a systematic review and meta-analysis. Osteoporos Int. 2016; 27(4):1413-1423. doi: 10.1007/s00198-015-3449-7.
Zhu TY, Griffith JF, Au SK, Tang XL, Kwok AW, Leung PC, et al. Bone mineral density change in systemic lupus erythematosus: a 5-year followup study. J Rheumatol. 2014; 41(10):1990–1997. doi:10.3899/jrheum.131190
Cameron JS. Lupus nephritis. J Am Soc Nephrol. 1999; 10(2):413–424
Huisman AM, White KP, Algra A, Harth M, Vieth R, Jacobs JW, et al. Vitamin D levels in women with systemic lupus erythematosus and fibromyalgia. J Rheumatol. 2003; 28(11):2535–2539
Borba VZ, Vieira JG, Kasamatsu T, Radominski SC, Sato EI, Lazaretti-Castro M. Vitamin D deficiency in patients with active systemic lupus erythematosus. Osteoporos Int. 2009; 20(3):427–433. doi:10.1007/s00198-008-0676-1
Toloza SM, Cole DE, Gladman DD, Ibañez D. Vitamin D insufficiency in a large female SLE cohort. Lupus 2010; 19(1):13–19. doi:10.1177/0961203309345775
Lakshminarayanan S, Walsh S, Mohanraj M, Rothfield N. Factors associated with low bone mineral density in female patients with systemic lupus erythematosus. J Rheumatol 2001; 28(1):102–108
Carvalho JF, Blank M, Kiss E, Tarr T, Amital H, Shoenfeld Y. Anti-vitamin D, vitamin D in SLE: preliminary results. Ann N Y Acad Sci 2207;1109:550–557.
Lahita RG, Bradlow HL, Ginzler E, Pang S, New M. Low plasma androgens in women with systemic lupus erythematosus. Arthritis Rheum 1987; 30(3):241–248
Formiga F, Moga I, Nolla JM, Navarro MA, Bonnin R, Roig-Escofet D. The association of dehydroepiandrosterone sulphate levels with bone mineral density in systemic lupus erythematosus. Clin Exp Rheumatol 1997; 15(4):387–392.
Jacobs J, Voskuyl AE, Korswagen LA, Theunissen R, Cohen Tervaert JW, Bultink IE. The association between FOK-I vitamin D receptor gene polymorphisms and bone mineral density in patients with systemic lupus erythematosus. Clin Exp Rheumatol. 2015; 33(5):765
Sosa Henríquez M, Gómez de Tejada Romero MJ. Osteoporosis. Medicine. 2018;12(60):3499-505
Hawkins Carranza F, Martínez Díaz-Guerra G, Guadalix Iglesias S. Factores de riesgo de osteoporosis y fracturas. Quiénes deben de ser estudiados. Estimación de probabilidad del riesgo de fracturas. Medicine. 2010; 10(60):4128-34.
Martínez Morillo M, Grados D, Holgado S. Osteoporosis premenopaúsica: ¿Cómo tratarla?. Reumatolg clin 2012; 8(2): 93-97
Grossman JM, Gordon R, Ranganath VK, Deal C, Caplan L, Chen W, et al. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken). 2010 62(11):1515–1526.
Fangtham M, Petri M. 2013 Update: Hopkins lupus cohort. Curr Rheumatol Rep. 2013; 15(9):360. doi:10.1007/s11926-013-0360-0
Mok CC. Vitamin D and systemic lupus erythematosus: an update. Expert Rev Clin Immunol. 2013;9(5):453–463. doi:10.1586/eci.13.19
Mosca M, Tani C, Aringer M, Bombardieri S, Boumpas D, Brey R, et al. European League Against Rheumatism recommendations for monitoring patients with systemic lupus erythematosus in clinical practice and in observational studies. Ann Rheum Dis 2010; 69(7):1269–1274. doi:10. 1136/ard.2009.117200
Bultink I, Lems W, Kostense P. Prevalence of and risk factors for low bone mineral density and vertebral fractures in patients with Systemic Lupus Erythematosus. Arthritis & Rheumatism. 2005; 54, (7): 2044–2050. Doi 10.1002/art.21110.
Schur PH, Wallace DJ. Musculoskeletal manifestations of systemic lupus erythematosus. Waltham, MA: UpToDate Inc. 2019. Disponible en: https://www.uptodate.com/contents/musculoskeletal-manifestations-of-systemic-lupus-erythematosus
Rosen H, Saag K. Prevention and treatment of glucococorticoid induced osteoporosis. 2019; Waltham, MA: UpToDate Inc. 2019: Disponible en: https://www.uptodate.com/contents/prevention-and-treatment-of-glucocorticoid-induced-osteoporosis 41. Medina Y. Evaluando la masa ósea en pacientes con lupus eritematoso sistémico. Rev Colomb Reumat. 2017;24(1):1-3.
Alele JD, Kamen DL. The importance of inflammation and vitamin D status in SLE-associated osteoporosis. Autoimmunity Reviews. 2010;9(3): 137–139.
Ekblom-Kullberg S, Kautiainen H, Alha P, Julkunen H. Frequency of and risk factors for symptomatic bone fractures in patients with systemic lupus erythematosus. Scand J Rheumatol. 2013;42(5): 390-3. 10.3109/03009742.2013.775331
Cramarossa G, Urowitz MB, Su J, Gladman D, Touma Z. Prevalence and associated factors of low bone mass in adults with systemic lupus erythematosus. Lupus. 2017; 26(4):365-372.
Thong B, Olsen N. The SLE review series: working for a better standard of care. Systemic lupus erythematosus diagnosis and management. Rheumatology. 2017; 56(Suppl 1):3-13.
Apostolopoulos D, Morand E. The SLE review series: working for a better standard of care. It hasn’t gone away: the problem of glucocorticoid. Use in lupus remains. Rheumatology 2017; 56:114-122.
Garcia-Carrasco M, Mendoza-Pinto C, Escarcega M, Jiménez-Hernández M, Etchegaray Morales I, Munguía Realpozo P, et al. Osteoporosis in Patients with Systemic Lupus Erythematosus. IMAJ. 2009: 11(8): 486-491.
Mendoza-Pinto C, García-Carrasco M, Sandoval-Cruz H, Escárcega RO, Jiménez-Hernández M, Etchegaray-Morales I, et al. Risks factors for low bone mineral density in pre-menopausal Mexican women with systemic lupus erythematosus. Clinical Rheumatology. 2009;28(1):65–70.
Abrego D, Cabiedes J, Cabral AR. Anti-citrullinated peptide antibodies in lupus patients with or without deforming arthropathy. Lupus. 2008; 17(4): 300–304.
Kamen Dl, Cooper Gs, Bovali H, Shaftman SR, Hollis BW, Gilkeson GS. Vitamin D. deficiency in systemic lupus erythematosus. Autoimmun Rev. 2006;5(2):114 -7
Pazirandeh S, Burns D. Overview of vitamin D. 2019. Waltham, MA: UpToDate Inc. 2019: Disponible en: https://www.uptodate.com/contents/overview-of-vitamin-d
Sun YN, Feng XY, He L, Zeng LX, Hao ZM, Lv XH, et al. Prevalence and Possible Risk Factors of Low Bone Mineral Density in Untreated Female Patients with Systemic Lupus Erythematosus. Biomed Res Int. 2015;2015:510514.
Formiga F, Moga I, Nolla JM, Pac M, Mitjavila F, Roig-Escofet D. Loss of bone mineral density in premenopausal women with systemic lupus erythematosus. Ann Rheum Dis. 1995;54(4): 274-276.
Ramírez Villada J, León Ariza H. Revisión sistemática sobre la importancia de la actividad física para la prevención y tratamiento de la osteoporosis. Archivos de Medicina. 2013;(1-3):9 1-9.
Fernández Fernández E, Martínez Hernández J, Martínez Suarez V, Moreno Villares JM, Collado Yurrita LR, Hernández Cabria M, et al. Documento de consenso: Importancia nutricional y metabólica de la leche. Nutri Hosp.2015;31 (1):92-101.
Petri M, Orbai AM, Alarcon G, Gordon C, Merrill JT, Fortin PR, et al. Derivation and Validation of the Systemic Lupus International Collaborating Clinics Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheum. 2012;64(8):2677–2686.
Rodriguez J, Mas F, Silva F, Frühbeck Martínez G. Obesidad. Concepto. Clasificación. Implicaciones fisiopatológicas. Complicaciones asociadas. Medicine 2004; 9(19): 1167-1175.
Organización Mundial de la Salud. Actividad física en los adultos: niveles recomendados de actividad física para la salud de 18 a 64 años. 2019. Ginebra: OMS. Disponible en: https://www.who.int/dietphysicalactivity/factsheet_adults/es/
Centros para el Control y Prevención de Enfermedades. Consumo de alcohol. 2016. EEUU: CDC. Disponible en: https://www.cdc.gov/alcohol/spanish/hojas-informativas/consumo-alcohol-salud.html
Miniño M. Indice de actividad lúpica y tratamiento del lupus eritematoso en dermatología. Dermatologia Rev. Mex 2008; 52 (1):20-28.
Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357(3): 266–281.
Hulley S, Cummings S, Browner W, Grady D, Newman T. Diseño de investigaciones clínicas. 3ª ed. Barcelona: Wolter Kluwer Health Lippincott Williams & Wilkins. 2008.
Arboleya L. Trastorno mineral y óseo asociado a la enfermedad renal crónica. Reumatol Clin. 2011:7(S2):18-21.