Prevalence and predictors of fragility fractures in systemic lupus erythematosus

Abstract

Objective: To establish the prevalence of reduced bone mineral density (BMD) and fractures, and risk factors for fractures, in a cross sectional study of a large cohort of patients with systemic lupus erythematosus (SLE). Methods: All SLE patients willing to take part in the study had bone densitometry in 1999/2000 and completed a questionnaire on risk factors for osteoporosis and on drugs used. Accumulated damage was scored using the SLICC/ACR damage index (SDI). Only fractures occurring since the onset of SLE and unrelated to trauma were included, and the SDI score was modified to exclude osteoporotic fractures. Statistical analysis was by x 2 test, Fisher's exact test, and binary logistic regression. Results: 242 patients were studied, median age 39.9 years (range 18 to 80), median disease duration 7.0 years (range 0 to 42). Of these, 123 (50.8%) had reduced BMD (T score ,21.0) and 25 (10.3%) were in the osteoporotic range (T score ,-2.5). Fragility fractures had occurred in 22 patients (9.1%) since diagnosis of SLE. Of these, two (9.1%) had normal BMD and 20 (90.9%) had reduced BMD, while seven (31.8%) were within the osteoporotic range. Non-Afro-Caribbean race and exposure to prednisolone .10 mg daily were significantly associated with reduced BMD, while age and menopause were associated with osteoporosis. The risk factors for fractures were reduced BMD and age. Conclusions: Reduced BMD, osteoporosis, and fragility fractures appear to be prevalent in patients with SLE. Steroids were not an independent risk factor for fractures, although their effect could be mediated through reduced bone mineral density.

Notable Difference between the Development of Vertebral Fracture and Osteonecrosis of the Femoral Head in Patients Treated with High-dose Glucocorticoids for Systemic Rheumatic Diseases

“…(1,3,4,6,7,(26)(27)(28)(29) (15,(32)(33)(34)(35)(36)(37) (Fig. 1) as previously reported (38), probably because the lateral view of DEXA more accurately estimates trabecular bone mass compared with the AP view (39).…”

Osteoporosis and fractures in systemic lupus erythematosus

“…The combined risk for hip and vertebral fractures was increased with an odds ratio (OR) of 2.9 in a Swedish study (43). Symptomatic fractures since lupus diagnosis occur in 6 -12.5% of patients (7,13,42,44), and the hip/femur, vertebra, rib, foot, ankle, and arm are the most frequent sites of fractures (7,42,44). Age (7,13,42), postmenopausal status (7), smoking (17), disease duration (44), renal insufficiency (17), Raynaud's syndrome (17), lupus anticoagulant (17), and reduced BMD (13) are reported as risk factors for symptomatic fractures in SLE patients.…”

“…Smoking is not reported as a risk factor for bone loss in SLE (5,8,10,13,16), but has been identified as a risk factor for osteoporotic fractures in a large study from the Hopkins Lupus Cohort (17), while the percentage of current smokers among SLE patients is not different from healthy controls (10,18). Alcohol use was associated with bone loss in male lupus patients in Hong Kong (10).…”

“…Symptomatic fractures since lupus diagnosis occur in 6 -12.5% of patients (7,13,42,44), and the hip/femur, vertebra, rib, foot, ankle, and arm are the most frequent sites of fractures (7,42,44). Age (7,13,42), postmenopausal status (7), smoking (17), disease duration (44), renal insufficiency (17), Raynaud's syndrome (17), lupus anticoagulant (17), and reduced BMD (13) are reported as risk factors for symptomatic fractures in SLE patients. In addition, GC treatment (both cumulative and highest dose [7,45]) is a predictor of osteoporotic fractures, and longer use of GCs is associated with time from lupus diagnosis to fracture (42).…”

Orthopedic surgery and its complication in systemic lupus erythematosus

“…It has been estimated that the mortality rate in the first year after fracture is up to 20%-30% [12] . Osteoporotic vertebral fractures, which are clinically silent in two thirds of cases, are also common, with reported prevalence between 9% and 20% [13,14] . An important point of note is, back pain per se is not a manifestation of lupus and uncomplicated osteoporosis.…”