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J Bone Miner Res. 2019 Jan 28. doi: 10.1002/jbmr.3684. [Epub ahead of print]

Long-term Treatment with TNF-alpha Inhibitors Improves Bone Mineral Density But Not Vertebral Fracture Progression in Ankylosing Spondylitis.

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Dep Rheumatology, Amsterdam Rheumatology and immunology Centre, Amsterdam, the Netherlands.
Department of Rheumatology, Groene hart ziekenhuis, Gouda, the Netherlands.
VUmc and Reade, Amsterdam, the Netherlands.
Department of Rheumatology, Veterans Administration Hospital (NIMTS), Athens, Greece.


Objectives The aim of this cohort study was to evaluate the long term effects of TNF-inhibitors (TNFi) on Bone Mineral Density (BMD) and the incidence of Vertebral Fractures (VFx) in patients with Ankylosing Spondylitis (AS). Method Consecutive patients with active AS with a TNFi treatment duration up to 4 years, with available DXA scans and spine X-rays, were included. BMD (classified according to the WHO criteria for osteoporosis) of hip and lumbar spine, the VFx (classified as a Genant-score > 1/> 20% height loss) and radiological progression (modified stoke ankylosing spondylitis spinal score; mSASSS) scores were performed at baseline and 4 years of TNFi treatment. Results Overall, 135 AS patients were included. At baseline, 40.1% of the patients had a low BMD of the hip and 40.2% of the lumbar spine. This decreased respectively to 38.1% (p = 0.03) with a low hip BMD and 25.3% (p < 0.001) for the lumbar spine after 4 years of TNFi treatment. VFx were present at baseline in 11.1% of the 131 patients, which increased to 19.6% after 4 years of TNFi treatment. A Genant score ≥ 2, was found at baseline in, 3 out of 14 VFx (21.4%) which increased to 7 out of 27 VFx (25.9%) after 4 years. All disease activity parameters, The Ankylosing Spondylitis Disease Activity Scale (ASDAS, both CRP and ESR), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), C-reactive protein and erythrocyte sedimentation rate decreased all significantly (p <0.001). The mean radiological progression (n = 80) increased significantly from a median mSASSS-score of 4.0 (1.5-16.0) at baseline to 6.5 (2.1-22.9) after 4 years of TNFi treatment (p < 0.001). Conclusion Despite the improvement of BMD and well-known decrease in disease activity, we still found new VFx, increase in severity in the number and grade of VFx and radiographic progression during 4 years of treatment with TNFi in AS patients with a long disease duration.




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