Monitoring of Osteonecrosis in Systemic Lupus Erythematosus: A Systematic Review and Metaanalysis

Abstract

Objective.Nontraumatic osteonecrosis (ON) is a well-recognized complication causing disability and affecting quality of life in patients with systemic lupus erythematosus (SLE). The aim of this study was to identify the risk factors for ON, and to identify the minimal investigation(s) needed to optimally monitor the risk of ON in patients with SLE.Methods.A systematic review was conducted using MEDLINE and EMBASE. These databases were searched up to January 2016 using the Medical Subject Heading (MeSH) terms “Osteonecrosis,” “Systemic lupus erythematosus,” and synonymous text words. Randomized controlled trials, case control, cohort, and cross-sectional studies were included. Risk factors for ON in patients with SLE were compiled. The quality of each study was assessed using the Newcastle-Ottawa scale for nonrandomized studies. The quality of evidence of each risk factor was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation method.Results.Of the 545 references yielded, 50 met inclusion criteria. Corticosteroid (CS) use may be strongly associated with ON in patients with SLE. Other clinical variables were moderately associated, including hypertension, serositis, renal disease, vasculitis, arthritis, and central nervous system disease. However, the evidence was low to very low in quality.Conclusion.Based on the best evidence available, CS use may be strongly associated with ON in patients with SLE. Results of this review were considered in the development of recommendations for the diagnosis and monitoring of patients with SLE in Canada and will guide clinicians in their assessment of these patients.

Corticosteroid-induced Knee Osteonecrosis and Accompanying Femoral Head Osteonecrosis

“…CS-induced ON tends to be multifocal lesions at multiple joints, as illustrated by studies of patients with SLE who are on long-term CS therapy (2,18,19). Similarly, we found that five of 16 (31.3%) patients with knee joint ON had femoral head ON who were complaining of hip joint pain.…”

Risk of joint replacement surgery in Taiwanese female adults with systemic lupus erythematosus: a population-based cohort study

“…The occurrence of osteonecrosis in patients with SLE could be affected by various factors. The long-term use of corticosteroid is certainly a strong risk factor of osteonecrosis, but neuropsychiatric manifestations of SLE, vasculitis, hypertension, serositis, and renal disease could also increase the risk of osteonecrosis [15]. In addition, it is estimated that more than half of the SLE patients who have osteonecrosis will progress and finally require surgical intervention [16].…”

Canadian Rheumatology Association Recommendations for the Assessment and Monitoring of Systemic Lupus Erythematosus

“…There is very low-to low-quality evidence for a small association of most risk factors with osteonecrosis. In patients with a high suspicion of osteonecrosis owing to clinical symptoms, it is unclear whether laboratory tests such as aPL could be used to evaluate the risk of osteonecrosis 57 . The panel agreed that the accuracy of different imaging modalities would be similar in the general population and in patients with SLE, that radiographs are less expensive than bone scan with SPECT or MRI, and some regions may not have access to the latter.…”