Prevalência e fatores de risco para fraturas por fragilidade em pacientes com artrite reumatoide estabelecida
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Data
2024-04-24
Autores
Ramos, Fernanda Pulcheri [UNIFESP]
Orientadores
Castro, Charlles Heldan de Moura [UNIFESP]
Tipo
Dissertação de mestrado
Título da Revista
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Resumo
Justificativa/Objetivo: O impacto negativo da artrite reumatoide (AR) sobre a saúde óssea é frequentemente negligenciado. O objetivo do presente estudo é determinar a prevalência e os fatores de risco para fraturas por fragilidade em pacientes com AR estabelecida seguidos em centro de saúde terciário em São Paulo, Brasil.
Métodos: Pacientes com AR em seguimento clínico realizaram medidas da densidade mineral óssea (DMO) por DXA (GE Lunar DPX MD+) e radiografia da coluna vertebral. Análise morfométrica foi realizada pelo método de Genant e presença e gravidade das fraturas vertebrais foi mensurada pelo índice de deformidade vertebral (IDV). Associações entre dados demográficos, características da doença, uso de medicamentos modificadores do curso de doença (MMCD), glicocorticoides (GC, dose atual e cumulativa em 5 anos) e atividade da doença com os desfechos da saúde óssea foram avaliadas por análise de regressão logística e linear.
Resultados: Um total de 179 mulheres e 21 homens com AR (média de idade 65±9,6 anos; FR positivo 71,9%) participaram do estudo. Atividade de doença moderada a alta foi observada em 45,5% e 31% dos pacientes no momento do estudo e na média acumulada em 5 anos, respectivamente. Os pacientes estavam em uso atual de GC (28,5%, dose diária média 2,1±4,5 mg de prednisona), MMCDsc (93,5%) e MMCDb/sae (60%) e 33 (16,5%) tinham AR difícil de tratar. Osteoporose densitométrica e fraturas por fragilidade foram observados em 44% e 28% dos pacientes, respectivamente. As fraturas mais frequentes foram vertebrais (23,5%), do antebraço (5,5%) e fêmur (2,5%). Nas mulheres, o IMC (OR=0,916; IC95%=0,854 - 0,983; P=0,015) e a carga tabágica (OR=1,023; IC95%=1,002 - 1,044; P=0,032) foram associados ao risco de osteoporose densitométrica, a atividade de doença nos últimos 5 anos (OR=3,474; IC95%=1,557 - 7,751; P=0,002) e o T-score do fêmur total (OR=0,646; IC95%=0,436 - 0,956; P=0,029) foram previsores significativos de fraturas, enquanto a dose atual de GC (β=0,125; t=2,800; P=0,006) e T-score do colo do fêmur (β=-0,523; t=-2,807; P=0,006) foram previsoras significativas do IDV (R2=0,108; P<0,001). Nos homens, a idade foi previsora significativa de fraturas (OR=1,214; IC95% 1,015 - 1,453; P=0,034).
Conclusão: Altas taxas de osteoporose densitométrica e fraturas foram observadas em pacientes com AR estabelecida de longa duração. Mais de 40% das fraturas ocorreram em pacientes sem osteoporose densitométrica. Baixo IMC e a elevada carga tabágica associaram-se a maior risco de osteoporose densitométrica, enquanto atividade de doença moderada a alta ao longo do tempo, dose maiores de GC e valores menores de DMO no fêmur proximal são varáveis associados a maior risco de fraturas. A densitometria óssea combinada com a morfometria vertebral são complementares para identificação da fragilidade óssea em pacientes com AR.
Objective: The negative impact of rheumatoid arthritis (RA) on bone health is often neglected. The aim of the present study is to determine the prevalence and risk factors for fragility fractures in patients with established RA followed at a tertiary health center in São Paulo, Brazil. Methods: Patients with RA under clinical follow-up underwent bone mineral density (BMD) measurements by DXA (GE Lunar DPX MD+) and spine conventional radiography. Morphometric analysis was performed using the Genant method and the presence and severity of vertebral fractures was measured using the spinal deformity index (SDI). Associations between demographics, disease characteristics, use of Disease-Modifying Antirheumatic Drugs (DMARD), glucocorticoids (GC, current and cumulative dose in 5 years), and disease activity with bone health outcomes were assessed by logistic and linear regression analysis. Results: A total of 179 women and 21 men with RA (mean age 65±9.6 years; positive rheumatoid factor 71.9%) participated in the study. Moderate to high disease activity was observed in 45.5% and 31% of the patients at the time of the study and at the 5-year cumulative mean, respectively. Patients were on current GC (28.5%, mean daily dose 2.1±4.5 mg prednisone), csDMARDs (93.5%), and b/tsDMARDs (60%), and 33 (16.5%) filled difficult-to-treat RA criteria. Densitometric osteoporosis and fragility fractures were observed in 44% and 28% of patients, respectively. The most frequent fractures were vertebral (23.5%), forearm (5.5%) and femoral (2.5%). In women, BMI (OR=0.916; CI95%=0.854 - 0.983; P=0.015) and smoking load (OR=1.023; CI95%=1.002 - 1.044; P=0.032) were associated with the risk of densitometric osteoporosis, disease activity in the last 5 years (OR=3.474; CI95%=1.557 - 7.751; P=0.002) and total femoral T-score (OR=0.646; CI95%=0.436 - 0.956; P=0.029) were significant predictors of fractures, while current GC dose (β=0.125; t=2.800; P=0.006) and femoral neck T-score (β=-0.523; t=-2.807; P=0.006) were significant predictors of the SDI (R2=0.108; P<0.001). In men, age was a significant predictor of fractures (OR=1.214; 95%=CI 1.015 - 1.453; P=0.034). Conclusion: High rates of densitometric osteoporosis and fragility fractures were observed in patients with long-standing established RA. More than 40% of fractures occurred in patients without densitometric osteoporosis. Low BMI and high smoking load were associated with higher risk of densitometric osteoporosis, while moderate to high disease activity over time, higher GC doses, and lower BMD values in the proximal femur are associated with higher risk of fractures. Bone densitometry combined with vertebral morphometry are complementary for the identification of bone fragility in patients with RA.
Objective: The negative impact of rheumatoid arthritis (RA) on bone health is often neglected. The aim of the present study is to determine the prevalence and risk factors for fragility fractures in patients with established RA followed at a tertiary health center in São Paulo, Brazil. Methods: Patients with RA under clinical follow-up underwent bone mineral density (BMD) measurements by DXA (GE Lunar DPX MD+) and spine conventional radiography. Morphometric analysis was performed using the Genant method and the presence and severity of vertebral fractures was measured using the spinal deformity index (SDI). Associations between demographics, disease characteristics, use of Disease-Modifying Antirheumatic Drugs (DMARD), glucocorticoids (GC, current and cumulative dose in 5 years), and disease activity with bone health outcomes were assessed by logistic and linear regression analysis. Results: A total of 179 women and 21 men with RA (mean age 65±9.6 years; positive rheumatoid factor 71.9%) participated in the study. Moderate to high disease activity was observed in 45.5% and 31% of the patients at the time of the study and at the 5-year cumulative mean, respectively. Patients were on current GC (28.5%, mean daily dose 2.1±4.5 mg prednisone), csDMARDs (93.5%), and b/tsDMARDs (60%), and 33 (16.5%) filled difficult-to-treat RA criteria. Densitometric osteoporosis and fragility fractures were observed in 44% and 28% of patients, respectively. The most frequent fractures were vertebral (23.5%), forearm (5.5%) and femoral (2.5%). In women, BMI (OR=0.916; CI95%=0.854 - 0.983; P=0.015) and smoking load (OR=1.023; CI95%=1.002 - 1.044; P=0.032) were associated with the risk of densitometric osteoporosis, disease activity in the last 5 years (OR=3.474; CI95%=1.557 - 7.751; P=0.002) and total femoral T-score (OR=0.646; CI95%=0.436 - 0.956; P=0.029) were significant predictors of fractures, while current GC dose (β=0.125; t=2.800; P=0.006) and femoral neck T-score (β=-0.523; t=-2.807; P=0.006) were significant predictors of the SDI (R2=0.108; P<0.001). In men, age was a significant predictor of fractures (OR=1.214; 95%=CI 1.015 - 1.453; P=0.034). Conclusion: High rates of densitometric osteoporosis and fragility fractures were observed in patients with long-standing established RA. More than 40% of fractures occurred in patients without densitometric osteoporosis. Low BMI and high smoking load were associated with higher risk of densitometric osteoporosis, while moderate to high disease activity over time, higher GC doses, and lower BMD values in the proximal femur are associated with higher risk of fractures. Bone densitometry combined with vertebral morphometry are complementary for the identification of bone fragility in patients with RA.
Descrição
Citação
RAMOS, Fernanda Pulcheri. Prevalência e fatores de risco para fraturas por fragilidade em pacientes com artrite reumatoide estabelecida. 2024. 69 f. Dissertação (Mestrado em Reunatologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP). 2024.