Karine Briot

Mild prevalent and incident vertebral fractures are risk factors for new fractures

SummaryThis prospective four-year study indicates that post-menopausal osteoporotic women with mild prevalent and incident vertebral fractures have an increased risk of incident fractures.IntroductionMild vertebral fractures are under diagnosed as there is disagreement about their clinical significance. Our aim was to assess the risk of subsequent fractures induced by both prevalent and incident mild vertebral fractures in osteoporotic post-menopausal women.Patients and methodsThree thousand three hundred and fifty-eight patients, aged 74u2009±u20096xa0years, with post-menopausal osteoporosis included in the placebo groups of two clinical trials of strontium ranelate were followed for 4xa0years. A Cox regression model adjusted on age, body mass index and bone mineral density was used to calculate the relative risk (RR) of fracture in subjects with only mild fractures as compared to patients without fracture, and to patients with at least one grade ≥ 2 fracture. These calculations were made for prevalent and then incident fractures.ResultsThe RR of vertebral fracture in 4xa0years was 1.8 (1.3–2.4) pu2009<u20090.001, and 2.7 (2.3–3.3) pu2009<u20090.001 for patients having only mild vertebral fractures and at least one grade ≥ 2 fracture at baseline respectively. The RR of vertebral fracture in the 3rd and 4th years of follow-up was 1.7 (1.1–2.6) pu2009=u20090.01, and 1.9 (1.3–2.6) pu2009<u20090.001 for patients having during the first 2xa0years incident mild fractures only, and for patients having at least one grade ≥ 2 incident fracture respectively. The RR of non-vertebral fracture in 4xa0years was 1.3 (0.9–1.9) pu2009=u20090.15 and 1.7 (1.4–2.1) pu2009<u20090.001 for patients having only mild or at least one grade ≥ 2 vertebral fracture at baseline respectively. For patients aged more than 70xa0years, these RR were 1.45 (0.99–2.11) (pu2009=u20090.06), and 1.72 (1.36–2.18) pu2009<u20090.001 respectively. The RR of non-vertebral fracture in the 3rd and 4th years was 1.68 (1.36–2.09) pu2009<u20090.001 for patients having at least one grade ≥ 2 incident fracture during the 2 first years of follow-up.ConclusionMild vertebral fractures are a risk factor for subsequent vertebral and non-vertebral fracture in postmenopausal women with osteoporosis; 1 out of 4 patients with an incident mild vertebral fracture in 2xa0years will fracture again within the 2 next years.

Vitamin D, bone metabolism and fracture risk

Insufficient serum levels of 25OH vitamin D (25OHD) is a risk factor for osteoporosis. A new paradigm has emerged with the locally synthesized 1,25(OH)2D within osteoblasts and osteoclasts as the essential pathway for the effects of 25OHD in regulating bone remodeling via direct or indirect activation of the specific receptor VDR. Vitamin D has positive effects on fracture risk but these results have been consistently observed whenever daily doses were above 800 UI/d administered to compliant patients together with adequate calcium supplementation and with an achieved biological target of serum 25OHD levels above 30 ng/mL.

THU0414 Trabecular Bone Score: A Tool for Identification of Severe Spinal Osteoporosis

Background Vertebral fractures (VFs) are the hallmark of osteoporosis and are more predictive of future fracture than areal Bone Mineral Density (BMD). Number and severity of VFs are related to bone microarchitecture deterioration. Trabecular Bone Score (TBS), derived from the texture of the DXA image, has been shown to be related to bone microarchitecture and fracture risk. Our hypothesis is that TBS measurement could be related to the severity of VFs. Objectives to evaluate performance of TBS, alone or added to aBMD, in the prediction of the presence of VFs and of the severity of these fractures. Methods Patients were selected from the Fracture Liaison Service (FLS) of our department, aiming at providing assessment of osteoporosis to patients over the age of 50 years who had sustained low trauma fractures and who are hospitalized in the Orthopaedic surgery department. aBMD and Vertebral Fracture Assessment (VFA) were performed one week to 3 months after the fracture using DXA. VFs were classified using the Genant’s semiquantitative evaluation and severity was assessed using the spinal deformity index (SDI), i.e. the sum of number and grades of VFs. TBS was obtained after re-analysis of DXA lumbar spine (L2-L4) scans. Performance of TBS, BMD and their combination was assessed using Receiver operator characteristic (ROC) and areas under receiver operating characteristics curves (AUCs). Results Data from 528 patients over 50 years with a non vertebral fragility fracture were examined between February 2009 and October 2012. VFA and TBS were not performed in 166 of them due to technical reasons. 362 patients (77.3% women; mean age 74.3±11.7 years) were analysed; 182 (50.3%) had hip fractures and 49 (13.5%) received an anti-osteoporotic treatment. Prevalence of VFs by VFA was 36.7%; 189 (52.2%) patients were osteoporotic (T score≤-2.5 at at least one site). TBS was lower in the patients with VFs than in patients without VFs in the whole population (1.16 ±0.11 vs 1.23±0.11, p<0.0001) and in non osteoporotic patients (1.19 ±0.12 vs 1.25±0.10, p=0.001). In the whole population, performance of TBS (AUC=0.677) was similar to lumbar spine (LS) BMD (AUC= 0.669) and hip BMD (AUC= 0.692) for the identification of VFs. However combination of TBS and LS BMD improves the discrimination as compared to LS BMD alone (AUC=0.707, p=0.043). In the non osteoporotic population (n=173), AUC of TBS for the discrimination of VFs was higher than AUC of LS BMD (0.67 0vs 0.541, p=0.035). There was a negative correlation between TBS and SDI: r= -0.31 (p<0.0001). Conclusions Our study suggests that about 40% of patients with a non vertebral fracture have vertebral fractures that were not previously diagnosed. TBS is able to discriminate patients with vertebral fractures, and adds information on LS aBMD. TBS is correlated to the number and severity of vertebral fractures evaluated by SDI. TBS measurement may be useful to identify subjects with non vertebral fracture requiring spine imaging. Disclosure of Interest None Declared

FRI0111 Body mass index (BMI) is not a surrogate of rheumatoid cachexia

Background Rheumatoid cachexia (RC) is a metabolic abnormality defined by a low fat-free mass with a normal or high fat mass in patients with Rheumatoid Arthritis (RA). It is predictor of poor health outcomes in RA. Objectives The objectives of this study were to determine the prevalence of rheumatoid cachexia and its determinants in RA patients, and, during a 6-year retrolective follow-up, the body composition changes and its determinants. Data were compared with those of the body mass index (BMI, kg/m²). Methods 133 patients with RA (115 women and 18 men) with a mean age 56.9±12.7 years, who consulted in a tertiary Department of Rheumatology were included; 91 of the patients (75 women and 16 men) were retrolectively followed during 6.3±2.0 years. Demographic data, disease duration, RA activity and severity, RA therapies were collected. Dual Energy X ray Absorptiometry (DXA) was performed for body composition measurement (fat free and fat mass index). We defined RC as fat-free mass index below the 10th percentile together with fat mass index above the 25th percentile (1). Results 106(76.7%), 66(49.6%) and 86(64.7%) of the 133 patients were treated by DMARDs, corticosteroids and biological therapies, respectively at the time of the body composition assessment. Prevalence of rheumatoid cachexia was 45.1% (n=60), higher in men (66.7%) than in women (41.7%) (p=0.048). None of the patients with body mass index (BMI) below 19kg/m2 had RC while prevalence of RC was high (82.4%) in overweight patients (25<BMI≤30). Univariate analysis showed that disease duration and activity disease, use of biological treatments and corticosteroids were not associated with presence of RC. In the retrolective follow-up, 55 patients (59.8%) received continuously biological therapies, 27 (29.3%) intermittently and 9 never received biological therapies. BMI significantly decreased over follow-up (2.8% (±10.3), (p= 0.005). Fat mass index significantly increased from baseline of 7.5% (±21.3) (p= 0.001) in whole population, in patients with continuous biological treatments (8.0 % (±20.4), p=0.005) and a trend was observed in patients without biological treatment (13.1% ±14.3, p=0.055) without any difference between groups. Fat free mass index did not significantly change from baseline. Body composition changes during the retrolective follow-up did not significantly change prevalence of RC. Conclusions This study suggests that rheumatoid cachexia is frequent in RA patients even treated with biological therapies. Fat mass increase in RA can be observed in patients with biological therapies or without. In RA, Body Mass Index (BMI) cannot be used to identify patients with rheumatoid cachexia. References Elkan AC, et al. Rheumatoid cachexia, central obesity and malnutrition in patients with low-active rheumatoid arthritis: feasibility of anthropometry, Mini Nutritional Assessment and body composition techniques. Eur J Nutr 2009; 48:315-22. Disclosure of Interest None Declared

SAT0083 Abdominal Aortic Calcifications are Associated with Cardiovascular Diseases and Vertebral Fractures in Patients with Rheumatoid Arthritis.

Background Cardiovascular disease and osteoporosis are two major causes of morbidity in rheumatoid arthritis (RA) patients. Vertebral fracture assessment (VFA) by dual-energy X ray absorptiometry (DXA) is a validated tool for the diagnosis of vertebral fracture. Studies show that lateral VFA image is an accurate method for the diagnosis of abdominal aortic calcifications (AAC), which is a relevant risk factor for cardiovascular disease. Studies in postmenopausal women are conflicting about the association between AAC and presence of vertebral fractures (VFs) and there is no study in RA. Objectives The aim of the study was to assess the prevalence of AAC in RA patients and the relationships between AAC, cardiovascular diseases and bone status (osteoporosis, VFs). Methods This study was performed in 132 patients who consulted for a bone mineral density (BMD) measurement in a tertiary department of Rheumatology. Demographic data, disease duration, activity and severity, RA therapies, cardiovascular risk factors and diseases, low trauma fractures and presence of osteoporosis (T score≤-2.5 at either lumbar spine and/or hip) were assessed. Diagnosis of VF was performed using the Genant semiquantitative analysis on VFA and severity of VF was quantified from grades 1 to 3. AAC were assessed on lateral VFA images of spine by two readers experts in this field, using a 24 and 8 point scale for scored AAC (1) with a good Inter-observer reliability (ICC) (0.845 (95% CI 0.702-0.923) and 0.882 (95% CI 0.769-0.942) for the 24 and 8-AAC scores, respectively). Univariate and multivariate analyses were performed to investigate associations between presence of AAC and disease-related factors. The accuracy of the multivariate model was measured by the area under the curve (AUC). Results 132 RA patients (114 women, mean age of 56.6±12.7) with a mean duration of RA of 15.1±9.1 years were included in the study. 107 (83.0%), 66 (51.2%) and 85 (64.4%) received DMARDs, corticosteroids and biological therapies respectively. Presence of AAC was observed in 32 (24.2%) patients. AAC were significantly associated with the presence of hypertension (p=0.043) and coronaropathy (p=0.0045). 35 patients (26.5%) were osteoporotic and 20 (15.2%) had at least one VF. There was a significant association between presence of AAC and osteoporosis (p=0.003), and between AAC and prevalent VF (p=0.019). Severity of AAC is correlated with VF severity (r= 0.27, p=0.003 and r= 0.23, p=0.011, for the 24 and 8-AAC scores, respectively) Age, male gender, menopause, calcium intake were significantly associated with presence of AAC in univariate analysis (p≤0.05). In multivariate analysis, age was the single variable associated with the presence of AAC (OR=1.24, CI 95% 1.1-1.4, p=0.0004) and calcium intake had a protective effect (0R=0.02, IC 95%0.0001-0.33, p=0.007) (AUC= 0.915). Conclusions This study conducted in severe RA patients suggests that presence of AAC is associated with cardiovascular diseases and vertebral fractures. RA patients with VF should have a systematic cardiovascular assessment. References Schousboe JT, et Al. Detection of aortic calcification during vertebral fracture assessment (VFA) compared to digital radiography. PLoS One.2007;2:e715 Disclosure of Interest None Declared