Chronic Rheumatic Diseases And Their Effect On Bone Density During Adolescence And On Peak Bone Mass

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The effects of chronic illnesses such as the rheumatic disorders on bone density are well known. Failure to develop adequate bone mineralization is common in children with chronic arthritis. (For a comprehensive review, see Reference 24). Juxta-articular osteopenia can be evident in plain radiographs even in early disease, whereas diffuse osteopenia or osteoporosis can develop later and lead to the risk of vertebral collapse and long-bone fractures after minimal trauma. Multiple risk factors are known to be associated with decreased bone mass, and active arthritis has an osteopenic effect both around affected joints and systemically, by means of a complex and still partly unknown network of proinflammatory cytokines. For example, Henderson and coworkers have studied predictors of BMD in prepubertal patients never treated with glucocorticoids. Almost 30% of mild to moderately ill patients had low total body BMD; parameters of disease severity (number of swollen joints, articular severity score, ESR) exerted a negative effect on bone mineralization. In another study from the same group, approximately 30% of postpubertal females who had never received systemic glucocorticoids demonstrated low bone mass (25,26).

Of particular importance when dealing with adolescents is the fact that chronic disorders are frequently accompanied by pubertal delay. A complex network of endocrine (i.e., the GH-IGF1-IGFBP system) and nutritional factors is usually responsible for this complication. In recent years, several studies have demonstrated that adult subjects with a past history of juvenile arthritis had a lower bone mass than matched controls (27-29). Zak et al. (27) have assessed BMD of the hip and spine in 65 young adults with a history of juvenile chronic arthritis (JCA). They found that BMD was significantly lower (and the frequency of osteopenia and osteoporosis was higher) in patients than in age-, sex-, height- and weight-matched healthy controls. Factors associated with a lower BMD included active disease at the time of the study, baseline erosions, higher Steinbrocker functional class, polyarticular course and chronic corticosteroid treatment. The presence of JCA by itself explained about 20% of BMD variation. The persistence of active inflammation in adulthood—estimated to occur in a third of the patients—is accompanied by a lower BMD than in healthy controls of the same sex and age. In another recent study (28) the impact of disease activity on peak bone mass was assessed in 229 young adults with juvenile arthritis in their mid-twenties, 15 years on average after disease onset. Patients with persistent disease had a significantly lower BMD than did healthy subjects, while patients whose disease was in remission had a normal bone mass overall. However, even in women with only a history of arthritis, BMD was significantly lower in the total body (but not in the lumbar spine or the radius). Moreover, almost half of the patients who were in remission had a history of oligoarthritis. This subtype of disease is more frequent and more benign than the other childhood arthritides and could partly explain the discrepancies between the results of this study and that by Zak et al. where the percentage of patients with oligoarticular disease was lower. Therefore, according to these authors, even the full remission of the disease is not able to completely normalize bone mass at all skeletal sites. Finally, French et al. (29) found osteopenia at spine or femoral neck in 41% of a cohort of adults with a history of juvenile rheumatoid arthritis. This observation is particularly striking given the predominance of patients with pauciarticular JRA in their population based group. Several variables present during adolescence were associated with later low bone density, the most important being a higher Steinbrocker functional class, reduced physical activity, tobacco use and lower calcium intake. These observations, if confirmed by larger studies, are extremely important, since they indicate that there is an increased risk of osteoporosis and fragility fractures in the adult population who suffered from a chronic inflammatory disease many decades before, during childhood and adolescence.

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Arthritis Relief and Prevention

Arthritis Relief and Prevention

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