Ibandronate increases cortical bone density in patients with systemic lupus erythematosus on long-term glucocorticoid.

INTRODUCTION: The purpose of this research is to assess the effects of oral ibandronate on bone microarchitecture by using high-resolution peripheral quantitative computed tomography (HR-pQCT) in patients with systemic lupus erythematosus (SLE) taking a long-term glucocorticoid. METHODS: In this double-blind placebo-controlled study, 40 Chinese female SLE patients taking prednisolone were randomly assigned to receive either monthly oral ibandronate (150 mg) or placebo with daily 1-hydroxycholecalciferol (Alfacalcidol; 1 µg) and calcium supplement for 12 months. Assessments of bone microarchitecture by using HR-pQCT and area bone mineral density (aBMD) of the lumbar spine and hip with dual-energy x-ray absorptiometry (DXA) were performed at baseline and 12 months. RESULTS: No differences in baseline characteristics were found between the two groups. After 12 months, no statistical differences were noted in any of the bone densities, microarchitectural parameters, or percentage changes of these parameters, as measured with HR-pQCT or DXA between the two groups. However, within the active group, the percentage improvement was significant in cortical bone density (P = 0.023) which was absent in the placebo group. Improvement was also seen in the aBMD of both the lumbar spine (P < 0.0001) and the hip (P < 0.005). In the placebo group, the percentage increase in trabecular separation was significant (P = 0.04), and the percentage improvement in aBMD in the spine also was significant (P = 0.049). CONCLUSIONS: Oral ibandronate treatment improves microarchitecture in SLE patients taking long-term glucocorticoid assessed with HR-pQCT, and this new technology may have a role in assessing bony changes in future longitudinal studies in SLE patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00668330.

Bone microarchitecture assessment by high-resolution peripheral quantitative computed tomography in patients with systemic lupus erythematosus taking corticosteroids.

OBJECTIVE: We assessed the relationship between vertebral fracture and bone microarchitecture in patients with systemic lupus erythematosus (SLE) on chronic corticosteroid therapy using high-resolution peripheral quantitative computed tomography (HR-pQCT). METHODS: Fifty-nine Chinese women with SLE taking corticosteroid were selected to participate in a cross-sectional study. Vertebral fracture was confirmed semiquantitatively by lateral radiographs of the thoracic and lumbar spine. Density and microarchitecture at the distal radius were measured with HR-pQCT. Areal bone mineral density (aBMD) at hip and lumbar spine was measured by dual-energy X-ray absorptiometry (DEXA). RESULTS: Twelve patients had vertebral fractures. The aBMD of spine or hip did not differ between those with and without vertebral fractures. Measures by HR-pQCT revealed that patients with vertebral fractures had significantly lower level of average bone density (p = 0.007), cortical bone density (p = 0.029), trabecular bone density (p = 0.024), trabecular bone volume to tissue volume (p = 0.023), and trabecular thickness (p = 0.011) than those without vertebral fractures. Independent explanatory variables associated with higher risk of vertebral fractures were older age (p = 0.013) and lower average cortical bone density (p = 0.029). CONCLUSION: Vertebral fracture in patients with SLE on chronic corticosteroid treatment was associated with alterations of bone density and microarchitectures measured by HR-pQCT and DEXA. However, alterations were more pronounced in measurements by HR-pQCT. Low cortical bone density and old age were significant predictors of vertebral fracture risk.

Socioeconomic burden of psoriatic arthritis in Hong Kong: direct and indirect costs and the influence of disease pattern.

OBJECTIVE: To estimate the direct costs and indirect costs of patients with psoriatic arthritis (PsA) in Hong Kong. METHODS: A retrospective cost-of-illness study was performed on 125 patients with PsA. Participants completed questionnaires on demographics, employment status, and out of pocket expenses. Health resources consumption was recorded by chart review and patient self-report questionnaire. Patients were grouped according to disease pattern, i.e., peripheral and axial disease. Multiple regression was used to determine the predictors of the costs. RESULTS: The average annual direct costs were $4,141 (2006 US dollars) per patient. Costs of inpatient care accounted for 27% of direct costs, followed by costs of visits to healthcare providers (25%). The estimated average indirect costs were $3,127 per patient-year. Forty-eight (42%) patients had no indirect costs. Sixty percent of patients with peripheral disease were still employed, compared to 39% of patients with axial disease. Patients with axial disease had almost twice the indirect costs compared to those with peripheral disease (p = 0.005). Increased pain and poor function were independently associated with increased direct costs. Worse physical health status, determined by indirect costs borne by the patient, and poor function and old age predicted high costs. CONCLUSION: PsA imposes substantial economic burden. Pain and function are significantly associated with costs. Improvements in treatments to reduce pain and restore function are likely to reduce the costs incurred by these patients.

High prevalence of asymptomatic vertebral fractures in Chinese women with systemic lupus erythematosus.

OBJECTIVE: To investigate the prevalence of vertebral fractures and to identify risk factors associated with vertebral fractures in Chinese women with systemic lupus erythematosus (SLE). METHODS: One hundred fifty-two consecutive patients with SLE were recruited in this cross-sectional study. Bone mineral density (BMD) measurements of the hip and spine were performed using the same dual energy X-ray absorptiometry (DEXA). Lateral radiographs of the spine (T5-L4) were assessed for vertebral fractures using a method described by Genant. Inflammatory and biochemical markers included C-reactive protein, receptor activator of nuclear factor-kappaB ligand, serum ss-CrossLaps assay for C-terminal telopeptides of type 1 collagen, and osteoprotegerin (OPG). RESULTS: Asymptomatic vertebral fractures occurred in 20.4% of patients with SLE. Univariate analyses of variables associated with fractures were older age, higher body mass index (BMI), lower BMD spine, lower BMD hips, higher serum C3 and C4, longer estrogen exposure, higher levels of OPG, and the use of sunscreen. Multivariate analysis showed older age (p = 0.017), higher BMI (p < 0.036), and lower BMD of the spine were significantly associated with vertebral fractures in the thoracic and/or lumbar spine (odds ratio 1.068, 1.166, 0.005; p = 0.018, p = 0.025, p = 0.003, respectively). CONCLUSION: Asymptomatic vertebral fractures occur in 20.4% of patients with SLE and 30% of these patients have normal BMD. The current method using DEXA to predict the presence of vertebral fracture has limited value and there is a need for assessment of bone quality. Vertebral morphometry in patients with SLE is recommended and early therapeutic intervention is necessary to prevent vertebral fractures in patients with SLE.

Is combination rituximab with cyclophosphamide better than rituximab alone in the treatment of lupus nephritis?

OBJECTIVE: To assess if combination rituximab and cyclophosphamide is more effective than rituximab monotherapy as an induction therapy for proliferative lupus nephritis. METHODS: A randomized open-label pilot study in which 9 patients received rituximab alone and 10 patients received two doses rituximab + intravenous cyclophosphamide. The clinical, laboratory and renal histological changes were assessed after 48 weeks of treatment. RESULTS: At week 48, four patients had a complete response, 11 patients achieved partial response, 2 patients remained the same or stable and 2 worsened. There were no statistical differences in the proportion of patients with complete or partial response between the two groups. None of the variables was an independent predictor of response at week 48. Nine patients had significant improvement in activity indices in renal biopsies, but there were no significant differences between the two groups. Overall, 18 out of 19 patients were found to have effective B-cell depletion. The median duration of complete B-cell depletion in all patients was 22 weeks. There were no statistically significant differences in the proportion of patients with complete depletion at weeks 4, 8, 24 and 48 between the two groups except at week 2. CONCLUSIONS: Rituximab monotherapy appears to be effective as induction therapy in lupus nephritis. The addition of cyclophosphamide offers no additional improvement in clinical, laboratory and renal histological assessment or the duration of B-cell depletion at 48 weeks. Large-scale studies with longer duration are needed to confirm these findings.

Subclinical carotid atherosclerosis in patients with psoriatic arthritis.

OBJECTIVE: To examine the prevalence of subclinical atherosclerosis in patients with psoriatic arthritis (PsA) compared with healthy controls, and to identify clinical and biologic markers for atherosclerotic disease in this patient population. METHODS: Subclinical atherosclerosis was defined as the average of intima-media thickness (IMT) measures in the common carotid artery, bifurcation, and internal carotid artery on both sides above the 95th percentile of healthy controls. IMT was measured using carotid ultrasonography in 82 consecutive PsA patients and 82 healthy controls matched on age, sex, and ethnicity. We also ascertained traditional and novel cardiovascular (CV) risk factors, Framingham risk score (FRS), disease severity, treatment, and inflammatory markers in all PsA patients. RESULTS: No PsA patients had clinically overt CV diseases. After adjusting for traditional CV risk factors, PsA patients had a higher prevalence of subclinical atherosclerosis. PsA patients with subclinical atherosclerosis had significantly increased sugar, total triglyceride levels, total cholesterol/high-density cholesterol, white cell count, and patients' global assessment score compared with those without subclinical atherosclerosis. Using logistic regression analysis, independent explanatory variables associated with subclinical atherosclerosis in PsA included increased sugar and total triglyceride levels. The FRS was similar in PsA patients with or without subclinical atherosclerosis. Twenty-six (35%) of 74 patients had subclinical atherosclerosis despite having a low CV risk. CONCLUSION: PsA is associated with subclinical atherosclerosis after adjusting for traditional CV risk factors. Independent explanatory variables associated with subclinical atherosclerosis in PsA included increased sugar and total triglyceride levels. Carotid IMT can identify PsA patients with subclinical atherosclerosis who may benefit from early intervention.

The relationship between neuropsychiatric, clinical, and laboratory variables and quality of life of Chinese patients with systemic lupus erythematosus.

OBJECTIVE: To investigate the role of neuropsychiatric (NP), clinical, and laboratory variables in influencing the health related quality of life (HRQOL) of Chinese patients with systemic lupus erythematosus (SLE). METHODS: The Medical Outcomes Study Short Form-36 was applied in a cohort of 291 patients with SLE. At the time of HRQOL testing all patients underwent a clinical and laboratory evaluation together with measures of disease activity and damage. Patients also submitted to a battery of NP tests. RESULTS: Using multivariate analysis, NP involvement-ever was associated with impairment of the general health subscale. Cerebrovascular disease and mononeuropathy were associated with impairment of the physical function subscale, while the latter was also associated with impairment of the role-emotional subscale. Cognitive impairment was associated with impairment of the mental health subscale. The Hospital Anxiety and Depression (HAD) depression score was associated with impairment of all the 8 subscales, physical, and mental summary scores. The HAD anxiety score was associated with impairment of predominantly mental function. Active arthritis, lower education level, and serum albumin levels were associated with impairment of predominantly physical function. Advancing age and damage were associated with impairment of both physical and mental function. Low hemoglobin level and female sex were associated with impairment of predominantly mental function. CONCLUSION: NP involvement and low-grade inflammation as reflected by low serum albumin and hemoglobin concentrations were associated with impaired HRQOL in patients with SLE, independent of other sociodemographic and clinical variables.