Bone mineral density in patients with early axial spondyloarthritis

Objective: to study bone mineral density (BMD) of the lumbar spine (LS) and femoral neck (FN) in patients with early axial spondyloarthritis (SpA) and to reveal its association with inflammatory disease activity.

Subjects and methods. Seventy-three patients aged 18–45 years with inflammatory back pain lasting at least 3 months and not more than 5 years were examined. Axial SpA was diagnosed according to the 2009 ASAS criteria. BASDAI and ASDAS C-reactive protein (CRP) values were used to estimate disease activity; BASFI was employed to evaluate functional status. The examination encompassed determination of HLA-B27, X-ray of the pelvis and LS, magnetic resonance imaging (MRI) of sacroiliac joints, LS, and hip joints (in the presence of clinical signs of their injuries), densitometry of LS (LI-IV) and FN. By taking into account the young age of patients, the Z-score was applied to measure BMD. The latter is considered lower if the Z-score is 1–2 standard deviations (SD) in at least one of the segments under study.

Results. The median Z-score was -0.7 (-1.3; -0.3) SD for FN and 0.9 (-1.6; -0.5) SD for LS. Reduced BMD in at least one of the segments under study was detected in 13 (17.8%) patients: that in LS and FN in 11 (15.1%) and 5 (6.8%) patients, respectively. Lower BMD was observed in two segments in 3 (4.1%) patients. No association was found between lower BMD and age, gender, disease activity (BASDAI, ASDAS), and laboratory inflammatory markers (erythrocyte sedimentation rate (ESR) and CRP). A relationship was established between inflammatory changes according to the data of MRI of LS (MRI spondylitis) and reduced BMD in the same segment. MRI spondylitis was detected in 8 patients. Five and 3 patients with spondylitis of LS were found to have lower and normal BMD in this segment, respectively. Six out of 65 patients without MRI spondylitis in LS had its reduced BMD and the remaining (n=59) patients had its normal BMD (p=0.0014).

Conclusion. There was an association between the active inflammatory changes as evidenced by LS MRI and the reduced BMD in this segment of the axial skeleton. Our data validate the hypothesis that in early axial SpA, bone is lost in the vertebral bodies due to local inflammation.

1. NIH Consensus Development Conference on Osteoporosis: Prevention, Diagnosis and Therapy. JAMA. 2001 Feb 14;285(6):785–95.

2. Bessant R, Keat A. How shoud clinicans manage osteoporosis in ankylosing spondylitis? J Rheumatol. 2002 Jul;29(7):1511–9.

3. El Maghraoui A. Osteoporosis and ankylosing spondylitis. Joint Bone Spine. 2004 Jul;71(4):291–5.

4. Пирогова ОА, Раскина ТА, Летаева МВ. Низкая минеральная плотность кости как фактор риска развития остеопороза у мужчин, страдающих анкилозирующим спондилитом, и способы ее коррекции. Современная ревматология. 2014;(3):45–50. [Pirogova OA, Raskina TA, Letaeva MV. Low bone mineral density as a risk factor for osteoporosis and ways of its correction in male patients with ankylosing spondylosis. Sovremennaya revmatologiya = Modern Rheumatology Journal. 2014;(3):45–50. (In Russ.)]. DOI: http://dx.doi.org/10.14412/1996-7012-2014-3-45-50

5. Wendling D. Bone Loss in Ankylosing Spondylitis: Can We Put the Puzzle Together? J Rheumatol. 2005 Jul;32(7):1184–5.

6. Мясоутова ЛИ, Лапшина СА, Салихов ИГ, Васильева АГ. Изменения минеральной плотности костной ткани у больных анкилозирующим спондилитом. Остеопороз и остеопатии. 2011;(3):14–8. [Myasoutova LI, Lapshina SA, Salikhov IG, Vasil'eva AG. Changes in mineral density of bone tissue in patients with ankylosing spondylitis. Osteoporoz i osteopatii. 2011;(3):14–8. (In Russ.)].

7. Kim HR, Lee SH, Kim HY. Elevated serum levels of soluble receptor activator of nuclear factors-jB ligand (sRANKL) and reduced bone mineral density in patients with ankylosing spondylitis (AS). Rheumatology (Oxford). 2006 Oct;45(10):1197–200. Epub 2006 Mar 27.

8. Klingberg E. Clinical study on osteoporosis in ankylosing spondylitis. [Dissertation]. Gothenburg: Centre for bone and arthritis research department of rheumatology and inflammation research Sahlgrenska Academy at University of Gothenburg; 2013.

9. Mei Y, Pan F, Gao J, et al. Increased serum IL-17 and IL-23 in the patient with ankylosing spondylitis. Clin Rheumatol. 2011 Feb;30(2):269–73. doi: 10.1007/s10067-010-1647-4. Epub 2010 Dec 17.

10. Allali F, Breban M, Porcher R, et al. Increase in bone mineral density of patients with spondyloarthropathy treated with antitumor necrosis factor α. Ann Rheum Dis. 2003 Apr;62(4):347–9.

11. Раскина ТА, Пирогова ОА. Влияние терапии инфликсимабом на минеральную плотность кости у больных анкилозирующим спондилитом. Остеопороз и остеопатии. 2013;(3):13–6. [Raskina TA, Pirogova OA. The effect of treatment with infliximab on bone mineral density in patients with ankylosing spondylitis. Osteoporoz i osteopatii. 2013;(3):13–6. (In Russ.)].

12. Marzo-Ortega H, McGonagle D, Haugeberg G, et al. Bone mineral density improvement in spondyloarthropathy after treatment with etanercept. Ann Rheum Dis. 2003 Oct;62(10):1020–1.

13. Haugeberg G, Bennett AN, McGonagle D, et al. Bone loss in very early inflammatory back pain in undifferentiated spondyloarthropathy: a1-year observational study. Ann Rheum Dis. 2010 Jul;69(7):1364–6. doi: 10.1136/ard.2009.124982. Epub 2010 May 6.

14. Briot K, Paternotte S, Miceli-Richard C, et al. Use of nonsteroidal anti-inflammatory drugs and high body mass index prevent bone loss in patients with early inflammatory back pain: results from the DESIR cohort. Ann Rheum Dis. 2013;72:Suppl.3:667.

15. Rudwaleit M, Landewe R, van der Heijde D, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal. Ann Rheum Dis. 2009 Jun;68(6):770–6. doi: 10.1136/ard.2009.108217. Epub 2009 Mar 17.

16. Губарь ЕЕ, Бочкова АГ, Дубинина ТВ и др. Клиническая характеристика больных ранним аксиальным спондилоартритом (российская когорта пациентов). Научно-практическая ревматология. 2014;52(5):507-12. [Gubar' EE, Bochkova AG, Dubinina TV, et al. Clinical profile of patients with early axial spondyloarthritis (Russian cohort of patients). Nauchno-prakticheskaya revmatologiya = Rheumatology Science and Practice. 2014;52(5):507–12. (In Russ.)]. doi: http://dx.doi.org/10.14412/1995-4484-2014-507-512

17. Sieper J, Ruadwaleit M, Baraliakos X, et al. The Assesment of Spondyloarthritis international Society (ASAS) Handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009 Jun;68 Suppl 2:ii1-44. doi: 10.1136/ard.2008.104018.

18. Official Positions of the International Society for Clinical Densitometry, copyright ISCD, October 2007, Supersedes all prior «Official Positions» publications.

19. Chavassieux P, Seeman E, Delmas PD. Insights into material and structural basis of bone fragility from diseases associated with fractures: how determinants of the biomechanical properties of bone are compromised by disease. Endocr Rev. 2007 Apr;28(2):151–64. Epub 2006 Dec 19.