Time trend and risk factors of avascular bone necrosis in patients with systemic lupus erythematosus

Abstract

Objectives The objective of this paper is to study the time trend and risk factors of avascular bone necrosis (AVN) in patients with systemic lupus erythematosus (SLE). Methods Between 1999 and 2014, patients who fulfilled the ACR criteria for SLE and developed symptomatic AVN were identified from our cohort database and compared with those without AVN, matched for age, sex and SLE duration. The standardized incidence ratios (SIRs) of AVN in different SLE age groups were calculated from data derived from our hospital registry and population census. Risk factors for AVN were studied by logistic regression, adjusted by a propensity score for ever use of high-dose glucocorticoids (GCs). Results Fifty-five SLE patients with AVN and 220 SLE patients without AVN were studied. There were 104 AVN sites involved, with the hips being most commonly affected (82%). The point prevalence of AVN in our SLE cohort was 7.4%. The SIRs of AVN in our SLE patients were 131 (86.6-199; p < 0.001) and 56.0 (34.3-91.4; p < 0.001), respectively, in the periods 1995-2004 and 2005-2014. In both decades, the age-stratified SIR was highest in the youngest age group (<19 years). AVN patients were more likely to be treated with GCs and had received a significantly higher cumulative dose of prednisolone since SLE diagnosis (16.5 vs 10.7 grams; p = 0.001). The SLE damage score (excluding AVN) was also significantly higher in AVN than non-AVN patients (2.5 vs 0.4; p < 0.001). Logistic regression revealed that preceding septic arthritis of the involved joint (odds ratio (OR) 17.7 (1.5-205); p = 0.02), cushingoid body habitus (OR 2.4 (1.1-5.2); p = 0.04), LDL cholesterol level (OR 1.4 (1.0-1.9); p = 0.04), maximum daily dose of prednisolone (OR 6.4 (1.2-33.3); p = 0.03) and cumulative dose of prednisolone received in the first six months of the first lupus flare (OR 1.3 (1.0-1.8); p = 0.046) were independently associated with AVN. Conclusions AVN is prevalent in SLE, particularly in younger patients. The use of GCs remains the strongest independent risk factor. A trend of reduction in the SIR of AVN in our SLE patients is observed over the past two decades.

Incidence and Risk Factors of Osteonecrosis of Femoral Head in Multiple Myeloma Patients Undergoing Dexamethasone-Based Regimens

“…Due to the retrospective nature of our study, the incidence is a little lower than the previous study (8.9%) [10]. Unlike the lower rates of osteonecrosis in renal allograft recipients (3.4%) [6], our results are comparable to the prevalence of osteonecrosis in other diseases treated with corticosteroids, such as SLE [4,11]. Higher dose of corticosteroid in MM patients and immunosuppressive agents using such as cyclosporin or tacrolimus in renal transplantation may contribute to the result.…”

“…Among them, osteonecrosis of femoral head (ONFH) is a rare adverse event in patients undergoing systemic corticosteroid treatment but one with considerable possibility of disability [3]. While corticosteroid-induced ONFH has been reported extensively in systemic lupus erythematosus, renal transplantation, and leukemia patients [4][5][6], there are few studies to identify the incidence and risk factors for ONFH in MM patients.…”

Synergistic effect of cumulative corticosteroid dose and immunosuppressants on avascular necrosis in patients with systemic lupus erythematosus

“…In fact, it has been found that disease severity of SLE is associated with AVN. 13,14,18,22,23 Especially, several studies have reported that proliferative lupus nephritis was associated with corticosteroid-associated damage such as AVN. 13,23,39,40 Since high-dose steroid use and induction therapy of immunosuppressants (e.g.…”

“…15 Although the reported predictive factors of AVN have varied among different reported studies, corticosteroid use has been widely considered to be one of the important ones. 8,10,[12][13][14][16][17][18] However, AVN can occur in patients who have not used steroids, 19,20 furthermore, the incidence of AVN was found to be higher in SLE patients than in non-SLE patients requiring steroid therapy, 17 supporting the roles of several factors specific to SLE. In addition to corticosteroid use, it has been reported that renal disease, neuropsychiatric manifestation, serositis, arthritis, presence of antiphospholipid antibodies, and use of immunosuppressive agents are associated with AVN in SLE in various studies.…”

Time trend and risk factors of avascular bone necrosis in patients with systemic lupus erythematosus: methodological issues

“…We were interested to read the paper written by Tse and colleagues published in Lupus in 2017. 1 The authors aimed to evaluate the time trend and risk factors of avascular bone necrosis (AVN) in patients with systemic lupus erythematosus (SLE). One of the main findings was that preceding septic arthritis of the involved joint was independently associated with AVN [odds ratio (OR) = 17.7; 95% confidence interval (CI): 1.5–205].…”