目标

评估TNFi对患者骨密度(BMD)的影响和强直性脊柱炎(AS)患者无症状椎骨骨折(VFx)的发病率。

方法

包括持续未使用TNF抑制剂组的强直性脊柱炎(AS)患者(符合修订版的纽约准则)。患者来自于大学医学中心和Reade，接受TNFi治疗已四年。四年后，对患者的髋部和腰椎部骨密度(BMD)进行基线水平测量。据WHO骨质疏松诊断标准5，骨密度评分被归类为"正常骨密度"、"骨量减少"和"骨质疏松症"。无症状椎骨骨折(VFx)的发病率由2位观察员使用Genant方法断定。

结果

总体来说，107名有完整数据集的患者(68.2%的男性)都包括在内。患者平均年龄是42.6岁，患病持续时间(自诊断时算起)为11.0年。使用类固醇或骨质疏松症预防的比例在0.9%和2.8%之间。在基线时，40.1%患者髋部和脊柱的骨密度(BMD)下降，其中27位患者(26%)髋部骨密度(BMD)下降及腰椎骨密度(BMD)下降。经过4年的TNFi治疗后，脊椎和髋部的骨密度改善(表1)。在13位患者中(12.1%)，在脊椎和髋部的基线上发现了14 VFx，经过4年TNFi的治疗后，在21名患者中发现了26VFx。

四年后，21名患者中的4位的VFx≥1，发现了26VFx，髋部和腰椎骨密度(BMD)下降，另外17名患者骨密度(BMD)正常。大部分的VFx都出现在胸椎中部或下部。

结论

髋部和腰椎基线处BMD降低的且较为年轻的AS患者的比重很大(40%)。 经过4年的TNFi治疗，腰椎骨密度在14.9%的患者和髋部密度在8.3%患者中有所改善。 在基线时，12%的患者有椎骨骨折，治疗4年后增加到21%。 在1984名50岁以上正常人群中，骨质疏松性脊柱骨折的患病率为8.9%。如果在疾病早期开始使用TNFi治疗，可能能预防AS骨折的发生。

原 文

Long-term effects of tnf-alpha inhibitors on bone mineral density and the incidence of vertebral fractures in patients with ankylosing spondylitis

Objectives

To evaluate the long-term effect of TNFi on BMD and the incidence of VFx in patients with AS.

Methods

Consecutive TNFi naive AS patients(who fulfilled the Modified New York criteria) were included. Patients were recruited from the VUmc and Reade and were treated with TNFi for 4 years. BMDat hip and lumbar spine (LS) were measured at baseline and after 4 years.T-scores were categorised as‘normal BMD’, ‘osteopenia’and‘osteoporosis’, based on the WHO osteoporosis criteria. 5 The incidence of VFx was determined by two observers using the Genant method.

Results

In total, 107 AS patients with complete datasets (68.2% male) were included. The mean age was 42.6 years andthe disease duration (time since diagnosis) was 11.0 years. The use of steroidsor osteoporosis profylaxis varied respectively between 0.9% and 2.8%. Atbaseline 40.1% of the patients had a decreased BMD of the hip and 40.2% of thespine, of whom 27 patients (26%) had both a decreased hip BMD as well as adecreased lumbar BMD. The BMD of spine and hip improved after 4 years of TNFi treatment (table 1). In 13 patients (12.1%), 14 VFx were observed both atbaseline and after 4 years of TNFi-treatment, 26 VFx were observed in 21 patients.

After 4 years, 4 out of 21 patientswith ≥1VFx had a decreased BMD at hip andlumbar spine whereas the other 17 patients had a normal BMD. The majority of VFx was localised in the mid or lower thoracic spine.

Conclusions

The percentage of relatively young AS patients with a decreased BMD at baseline of the hip and lumbar spine was high (40%). After 4 years of TNFi-treatment, the BMD of the lumbar spine improved in 14.9% of the patients and of the hip in 8.3% of the patients. At baseline, 12% of the patients had vertebral fractures which increased to 21% after 4 years of treatment. A normal population of 1984 individuals above 50 years showed a prevalence of 8.9% osteoporotic spinal fractures.7 Probably, the start of treatment with TNFi at an earlier stage ofthe disease might prevent the onset of fractures in AS.

文章出处：

K. Beek1, M. van der Weijden1, T.Rusman1, W. Lems1, C. van Denderen2, M. Nurmohamed1, I. van der Horst-Bruinsma1.Annals of Rheumoid Arthritis. Saturday, 16 JUNE 2018.https://ard.bmj.com/content/77/Suppl_2/1008.1