DMARDs Increase Likelihood of Osteopenia and Osteoporosis in Scleroderma

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Non-corticosteroid immunosuppressant use and long duration of disease increase the likelihood of patients with systemic scleroderma being diagnosed with osteopenia and osteoporosis, according to researchers reporting at the annual meeting of the American College of Rheumatology on Friday.

The researchers, led by Lorinda Chung, director of the Scleroderma Program at Stanford School of Medicine, found that more than 40% of 348 adult systemic scleroderma patients attending its Rheumatologic Dermatology Clinic from January 2006 to March 2016 had a diagnosis of osteopenia/osteoporosis (41.4%; 95% CI: 36.2%, 46.6%).

Lorinda Chung, M.D., MS

Diane Mar, from Stanford’s Department of Immunology/Rheumatology, said not all the patients had DEXA scans so it was “likely the true prevalence is much higher”.

“Osteopenia and osteoporosis are significant comorbidities in scleroderma.It is likely underrecognized and appears to be associated with scleroderma independent of the traditional risk factors associated with osteopenia and osteoporosis. We should be screening our patients more regularly for this,” she said.

The researchers compared the clinical characteristics, autoantibodies, and treatment of systemic scleroderma patients with a diagnosis of osteopenia/osteoporosis to those without a diagnosis of osteopenia/osteoporosis.

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Patients with a diagnosis of osteopenia/osteoporosis had longer disease duration and were more likely to have sclerodactyly, telangiectasias, interstitial lung disease, and gastroesophageal reflux. They were also more commonly treated with corticosteroids and non-corticosteroids immunosuppressants

Logistic regression models adjusted for common risk factors for osteopenia and osteoporosis, including age, race, gender, smoking history, body mass index, and corticosteroid treatment, showed that longer disease duration and non-corticosteroid immunosuppressant use (odds ratio 2.15; CI 95%: 1.18, 3.93) were significantly associated with a higher odds of diagnosis of osteopenia and osteoporosis.

Dr. Mar said she was surprised by the association of immunosuppressants such as azathioprine and mycophenolate, and the possible protective effect of hydroxychloroquine. “These associations have been reported in inflammatory bowel disease patients, transplant patients and systemic lupus erythematosus patients respectively, but not in scleroderma patients. In these patient populations, some of this effect was thought to be more related to disease activity, so the impact of these immunosuppressants on the bone is not clear.”

Under current guidelines screening for osteopenia/osteoporosis is focused on postmenopausal women older 65. “Many rheumatic diseases, including scleroderma, are often diagnosed in young women as well as in men. The choice to screen in this subset of patients comes down to what other risk factors they possess,” Mar said.

Glucocorticoid use is a well-known risk factor, she added. “This study may suggest additional associated factors to take into consideration when screening scleroderma patients, including disease duration and non-glucocorticoid immunosuppressant use. It would be helpful to expand the guidelines for screening to provide recommendations for specific rheumatic conditions such as scleroderma.”

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REFERENCE

ABSTRACT 0394. “Prevalence of a Diagnosis of Osteopenia/Osteoporosis Amongst Patients with Systemic Sclerosis and Identification of Associated Clinical Factors.” The annual meeting of the American College of Rheumatology. 9:00 AM, Friday, Nov. 6, 2020.