Osteoporosis y artritis. Las amistades peligrosas

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Las amistades peligrosas" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "9" "paginaFinal" => "12" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Joan M Nolla" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Joan M" "apellidos" => "Nolla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología. IDIBELL-Hospital Universitari de Bellvitge. L'Hospitalet de Llobregat. Barcelona. España." "etiqueta" => "a" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Osteoporosis and arthritis.Dangerous friends" ] ] "textoCompleto" => "IntroducciónEn los últimos años ha aumentado considerablemente el interés por los procesos comórbidos que presentan los pacientes afectos de una artropatía inflamatoria, una vez se ha constatado el notable impacto de las neoplasias, las infecciones, la enfermedad ulcerosa péptica, la arteriosclerosis y la osteoporosis en la salud de estos pacientes1,2.En las artropatías inflamatorias concurren diversas circunstancias que favorecen la aparición de osteoporosis (tabla 1). Sin duda, el abordaje de la etiopatogenia de la pérdida ósea que presentan los pacientes con una artritis crónica debe realizarse desde una óptica multifactorial. Además de considerar el papel de los factores intrínsecos al individuo (edad, sexo y base genética, entre otros), se debe tener en cuenta que habitualmente en un mismo enfermo concurren varios factores extrínsecos que causan pérdida ósea. En este sentido conviene enfatizar que los términos osteoporosis en las artropatías inflamatorias y osteoporosis inducida por glucocorticoides no son términos sinónimos.<img src="273v3nExtra.1-13100412tab01.gif"></img>Se está avanzando a un ritmo vertiginoso en el conocimiento de la relación entre inflamación y pérdida ósea3 y en el análisis de la magnitud del problema de la osteoporosis en los reumatismos inflamatorios más habituales en práctica clínica4.Artritis reumatoideEs la enfermedad de la que se dispone de más información. Está perfectamente establecido que los pacientes con artritis reumatoide (AR) presentan menor densidad mineral ósea (DMO) que la población general5,6 y mayor riesgo de fractura7. Los factores7,8 que parecen tener un mayor peso en el determinismo de la DMO y de las fracturas son la edad, el índice de masa corporal, la actividad y la duración de la enfermedad, el estado funcional y el tratamiento con glucocorticoides.Parece confirmarse la hipótesis9 de que los osteoclastos son las células que causan los tres tipos de lesiones óseas que acontecen en la AR: las erosiones, la pérdida yuxtaarticular y la pérdida generalizada (osteoporosis). Esta circunstancia abre interesantísimas vías de investigación tanto en el ámbito de la etiopatogenia como de la terapéutica de la enfermedad reumatoide10.Se sabe que la remodelación ósea está sometida a complejos factores reguladores11, tanto locales (citocinas, factores de crecimiento y óxido nítrico, entre otros) como sistémicos (hormonas sexuales, vitamina D y paratirina, entre otros), que mantienen un equilibrio entre la destrucción y la formación de tejido. El efector final de la gran mayoría de los mecanismos reguladores es el sistema constituido por la osteoprotegerina (OPG) y el ligando del receptor activador del factor nuclear kappa-B (RANKL)12,13. La OPG es una glucoproteína producida por los osteoblastos y las células estromales cuya función principal es estimular la apoptosis de los osteoclastos y bloquear su formación y activación. El RANKL, producido también por los osteoblastos, tiene funciones antagónicas a las de la OPG, es decir, inhibe la apoptosis de los osteoclastos y estimula su formación y activación, al unirse a los preosteoclastos mediante un receptor denominado RANK.El sistema RANK/RANKL/OPG constituye el componente fundamental para la regulación de la biología ósea tanto en las situaciones normales como en las enfermedades. La cantidad de RANKL respecto de la de OPG constituye el principal determinante de la actividad de los osteoclastos14,15.Al analizarse la interfaz entre el pannus y el hueso, en las zonas de erosión se observa la presencia de células multinucleadas que corresponden a osteoclastos4, en conjunción con fibroblastos y macrófagos, y se constata expresión de RANKL16. En modelos animales de AR se ha demostrado que los fibroblastos sinoviales expresan RANKL, que induciría la diferenciación de osteoclastos a partir de macrófagos17; en el tejido sinovial normal, por el contrario, no se ha evidenciado la expresión de RANKL3,18. Por otro lado, cabe considerar que los linfocitos T activados tienen capacidad de expresar RANKL y, con ello, contribuir a la destrucción ósea19,20.Especialmente interesante resulta la observación21 de que, en pacientes con AR de inicio, el valor circulante basal de OPG:RANKL y el valor medio de la velocidad de sedimentación globular (VSG) en el primer año actúan como determinantes independientes de la aparición futura (5 años) de erosiones óseas; la progresión de la destrucción radiológica es mayor en los pacientes con valores altos de VSG y bajos de OPG:RANKL.Así pues, la especial propensión de la sinovial inflamada en la AR a inducir resorción ósea probablemente esté relacionada con su capacidad de producir diversos factores que pueden inducir, de forma directa o indirecta, la activación y la diferenciación de los osteoclastos, como la interleucina (IL) 6, la IL-11, la IL-17 y, especialmente, la IL-1, el factor de necrosis tumoral alfa (TNFα) y el RANKL; la sinergia entre estos tres últimos factores resulta especialmente relevante22,23.Con los estudios longitudinales se ha puesto de manifiesto que la pérdida ósea sistémica acontece fundamentalmente en las fases iniciales de la enfermedad y que se relaciona estrechamente con los valores de los reactantes de fase aguda24,25.En la AR, además del fenómeno inflamatorio, se observan alteraciones hormonales26,27, inmovilidad28 y déficit de vitamina D29; estos factores contribuyen, en mayor o menor medida, a la pérdida ósea.El efecto nocivo de los glucocorticoides es incuestionable, especialmente si se administran en dosis medias o altas; no obstante, cabe contemplar también un potencial efecto beneficioso en tanto que su uso contribuye a disminuir la actividad inflamatoria de la enfermedad de base24. En cuanto al metotrexato, parece que puede afirmarse que en dosis bajas no induce pérdida ósea adicional8,30,31.La prevalencia de la osteoporosis, definida a partir de criterios densitométricos, depende de las características de la población estudiada. En un estudio noruego de base poblacional6 en el que se evaluó a mujeres premenopáusicas y posmenopáusicas, la prevalencia de osteoporosis, definida por un T-score < 2,5 desviaciones estándar (DE), fue del 16,8% en columna lumbar y del 14,7% en cuello femoral; en un estudio de nuestro grupo32 en el que se estudió a mujeres posmenopáusicas tratadas con dosis bajas de glucocorticoides, la prevalencia de osteoporosis fue del 38% en columna lumbar y del 34% en cuello femoral. En varones, la frecuencia de osteoporosis es mucho menor5; en un trabajo reciente de nuestro grupo se situó alrededor del 15%33.La prevalencia de las deformidades vertebrales en pacientes tratadas con glucocorticoides a dosis bajas34 se acerca al 25% y la de las fracturas vertebrales clínicas, al 10%. En ocasiones, la fragilidad ósea se traduce en forma de fracturas de ramas isquiopubianas y de tibia o peroné35,36; en estos casos, el diagnóstico diferencial con un brote álgico de la enfermedad de base puede resultar difícil.Cabe considerar que los pacientes con una AR avanzada37 presentan alteraciones sinoviales y musculoligamentosas de las extremidades que determinan un aumento del riesgo de caída y una disfunción de los mecanismos protectores contra el impacto.Los conocimientos actuales avalan que la abolición de la actividad inflamatoria resulta capital a la hora de abordar el problema de la osteoporosis en los pacientes afectos de AR. En este sentido, en estudios preliminares se ha puesto de manifiesto el efecto beneficioso en el hueso que se deriva de la utilización de las terapias biológicas38-40. Por otro lado parece interesante investigar el potencial de los bisfosfonatos de nueva generación y del denosumab como fármacos inhibidores de la aparición de erosiones3,41-43.Espondilitis anquilosanteEs un modelo clínico especialmente interesante a la hora de evaluar la relación entre inflamación y pérdida ósea, dado que habitualmente no se utilizan los glucocorticoides en el tratamiento del paciente.Clásicamente se aceptaba que la aparición de una fractura constituía un evento excepcional; se asumía que los sindesmofitos actuaban como un factor protector. Actualmente está perfectamente establecido que los enfermos con espondilitis anquilosante presentan un riesgo de fractura vertebral aumentado, como consecuencia, especialmente, de la pérdida ósea en la columna lum-bar44. La prevalencia en estudios recientes se cifra en un 15%45.Las fracturas aparecen fundamentalmente en pacientes con una enfermedad de larga evolución, que suelen presentar sindesmofitos vertebrales. De hecho, la pérdida ósea es más intensa en los enfermos con sindesmo-fitos46.La osteopenia se relaciona con la actividad de la enfermedad47,48 y se observa ya en las fases iniciales del proceso49. Se afectan ambos sexos y se ha evidenciado una correlación entre la DMO y los valores de las hormonas sexuales50,51 y de la OPG50.Respecto a la artritis psoriásica apenas hay información en la literatura. La intensidad de la pérdida ósea parece ser menor que en la espondilitis anquilosante52,53.Lupus eritematoso sistémicoLas mujeres con lupus eritematoso sistémico presentan una DMO menor que la población general54-56 y un riesgo de fractura aumentado57. En varones, estas circunstancias no están aclaradas58.La prevalencia de las fracturas vertebrales oscila entre un 1059 y un 20%56,60. Los factores que se ha invocado61 en la etiopatogenia de la pérdida ósea que se observa en el lupus eritematoso sistémico son el tratamiento glucocorticoideo, el hiperparatiroidismo secundario a la insuficiencia renal, la actividad y la duración de la enfermedad y la hipovitaminosis D.Especialmente relevante resulta que se haya demostra-do62 que en mujeres jóvenes hay relación entre una DMO disminuida y un aumento del índice de placa arteriosclerótica en la arteria carótida; además, una DMO baja parece tener relación con la presencia de calcificaciones en las arterias coronarias. Ello hace posible una línea de investigación especialmente interesante; dos de los más importantes procesos comórbidos que afectan a las pacientes con lupus eritematoso sistémico, la arteriosclerosis y la osteoporosis, podrían tener una etiopatogenia común, la inflamación mantenida.<hr></hr>Correspondencia:Dr. J.M. Nolla.Servicio de Reumatología. Hospital Universitari de Bellvitge. Feixa Llarga, s/n. 08907 L'Hospitalet de Llobregat. Barcelona. 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Osteoporosis and arthritis.Dangerous friends

Joan M Nollaa

a Servicio de Reumatología. IDIBELL-Hospital Universitari de Bellvitge. L'Hospitalet de Llobregat. Barcelona. España.

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    "textoCompleto" => "<p class="elsevierStylePara">Introducci&#243;n</p><p class="elsevierStylePara">En los &#250;ltimos a&#241;os ha aumentado considerablemente el inter&#233;s por los procesos com&#243;rbidos que presentan los pacientes afectos de una artropat&#237;a inflamatoria&#44; una vez se ha constatado el notable impacto de las neoplasias&#44; las infecciones&#44; la enfermedad ulcerosa p&#233;ptica&#44; la arteriosclerosis y la osteoporosis en la salud de estos pacientes<span class="elsevierStyleSup">1&#44;2</span>&#46;</p><p class="elsevierStylePara">En las artropat&#237;as inflamatorias concurren diversas circunstancias que favorecen la aparici&#243;n de osteoporosis &#40;tabla 1&#41;&#46; Sin duda&#44; el abordaje de la etiopatogenia de la p&#233;rdida &#243;sea que presentan los pacientes con una artritis cr&#243;nica debe realizarse desde una &#243;ptica multifactorial&#46; Adem&#225;s de considerar el papel de los factores intr&#237;nsecos al individuo &#40;edad&#44; sexo y base gen&#233;tica&#44; entre otros&#41;&#44; se debe tener en cuenta que habitualmente en un mismo enfermo concurren varios factores extr&#237;nsecos que causan p&#233;rdida &#243;sea&#46; En este sentido conviene enfatizar que los t&#233;rminos osteoporosis en las artropat&#237;as inflamatorias y osteoporosis inducida por glucocorticoides no son t&#233;rminos sin&#243;nimos&#46;</p><p class="elsevierStylePara"><img src="273v3nExtra.1-13100412tab01.gif"></img></p><p class="elsevierStylePara">Se est&#225; avanzando a un ritmo vertiginoso en el conocimiento de la relaci&#243;n entre inflamaci&#243;n y p&#233;rdida &#243;sea<span class="elsevierStyleSup">3</span> y en el an&#225;lisis de la magnitud del problema de la osteoporosis en los reumatismos inflamatorios m&#225;s habituales en pr&#225;ctica cl&#237;nica<span class="elsevierStyleSup">4</span>&#46;</p><p class="elsevierStylePara">Artritis reumatoide</p><p class="elsevierStylePara">Es la enfermedad de la que se dispone de m&#225;s informaci&#243;n&#46; Est&#225; perfectamente establecido que los pacientes con artritis reumatoide &#40;AR&#41; presentan menor densidad mineral &#243;sea &#40;DMO&#41; que la poblaci&#243;n general<span class="elsevierStyleSup">5&#44;6</span> y mayor riesgo de fractura<span class="elsevierStyleSup">7</span>&#46; Los factores<span class="elsevierStyleSup">7&#44;8</span> que parecen tener un mayor peso en el determinismo de la DMO y de las fracturas son la edad&#44; el &#237;ndice de masa corporal&#44; la actividad y la duraci&#243;n de la enfermedad&#44; el estado funcional y el tratamiento con glucocorticoides&#46;</p><p class="elsevierStylePara">Parece confirmarse la hip&#243;tesis<span class="elsevierStyleSup">9</span> de que los osteoclastos son las c&#233;lulas que causan los tres tipos de lesiones &#243;seas que acontecen en la AR&#58; las erosiones&#44; la p&#233;rdida yuxtaarticular y la p&#233;rdida generalizada &#40;osteoporosis&#41;&#46; Esta circunstancia abre interesant&#237;simas v&#237;as de investigaci&#243;n tanto en el &#225;mbito de la etiopatogenia como de la terap&#233;utica de la enfermedad reumatoide<span class="elsevierStyleSup">10</span>&#46;</p><p class="elsevierStylePara">Se sabe que la remodelaci&#243;n &#243;sea est&#225; sometida a complejos factores reguladores<span class="elsevierStyleSup">11</span>&#44; tanto locales &#40;citocinas&#44; factores de crecimiento y &#243;xido n&#237;trico&#44; entre otros&#41; como sist&#233;micos &#40;hormonas sexuales&#44; vitamina D y paratirina&#44; entre otros&#41;&#44; que mantienen un equilibrio entre la destrucci&#243;n y la formaci&#243;n de tejido&#46; El efector final de la gran mayor&#237;a de los mecanismos reguladores es el sistema constituido por la osteoprotegerina &#40;OPG&#41; y el ligando del receptor activador del factor nuclear kappa-B &#40;RANKL&#41;<span class="elsevierStyleSup">12&#44;13</span>&#46; La OPG es una glucoprote&#237;na producida por los osteoblastos y las c&#233;lulas estromales cuya funci&#243;n principal es estimular la apoptosis de los osteoclastos y bloquear su formaci&#243;n y activaci&#243;n&#46; El RANKL&#44; producido tambi&#233;n por los osteoblastos&#44; tiene funciones antag&#243;nicas a las de la OPG&#44; es decir&#44; inhibe la apoptosis de los osteoclastos y estimula su formaci&#243;n y activaci&#243;n&#44; al unirse a los preosteoclastos mediante un receptor denominado RANK&#46;</p><p class="elsevierStylePara">El sistema RANK&#47;RANKL&#47;OPG constituye el componente fundamental para la regulaci&#243;n de la biolog&#237;a &#243;sea tanto en las situaciones normales como en las enfermedades&#46; La cantidad de RANKL respecto de la de OPG constituye el principal determinante de la actividad de los osteoclastos<span class="elsevierStyleSup">14&#44;15</span>&#46;</p><p class="elsevierStylePara">Al analizarse la interfaz entre el pannus y el hueso&#44; en las zonas de erosi&#243;n se observa la presencia de c&#233;lulas multinucleadas que corresponden a osteoclastos<span class="elsevierStyleSup">4</span>&#44; en conjunci&#243;n con fibroblastos y macr&#243;fagos&#44; y se constata expresi&#243;n de RANKL<span class="elsevierStyleSup">16</span>&#46; En modelos animales de AR se ha demostrado que los fibroblastos sinoviales expresan RANKL&#44; que inducir&#237;a la diferenciaci&#243;n de osteoclastos a partir de macr&#243;fagos<span class="elsevierStyleSup">17</span>&#59; en el tejido sinovial normal&#44; por el contrario&#44; no se ha evidenciado la expresi&#243;n de RANKL<span class="elsevierStyleSup">3&#44;18</span>&#46; Por otro lado&#44; cabe considerar que los linfocitos T activados tienen capacidad de expresar RANKL y&#44; con ello&#44; contribuir a la destrucci&#243;n &#243;sea<span class="elsevierStyleSup">19&#44;20</span>&#46;</p><p class="elsevierStylePara">Especialmente interesante resulta la observaci&#243;n<span class="elsevierStyleSup">21</span> de que&#44; en pacientes con AR de inicio&#44; el valor circulante basal de OPG&#58;RANKL y el valor medio de la velocidad de sedimentaci&#243;n globular &#40;VSG&#41; en el primer a&#241;o act&#250;an como determinantes independientes de la aparici&#243;n futura &#40;5 a&#241;os&#41; de erosiones &#243;seas&#59; la progresi&#243;n de la destrucci&#243;n radiol&#243;gica es mayor en los pacientes con valores altos de VSG y bajos de OPG&#58;RANKL&#46;</p><p class="elsevierStylePara">As&#237; pues&#44; la especial propensi&#243;n de la sinovial inflamada en la AR a inducir resorci&#243;n &#243;sea probablemente est&#233; relacionada con su capacidad de producir diversos factores que pueden inducir&#44; de forma directa o indirecta&#44; la activaci&#243;n y la diferenciaci&#243;n de los osteoclastos&#44; como la interleucina &#40;IL&#41; 6&#44; la IL-11&#44; la IL-17 y&#44; especialmente&#44; la IL-1&#44; el factor de necrosis tumoral alfa &#40;TNF&#945;&#41; y el RANKL&#59; la sinergia entre estos tres &#250;ltimos factores resulta especialmente relevante<span class="elsevierStyleSup">22&#44;23</span>&#46;</p><p class="elsevierStylePara">Con los estudios longitudinales se ha puesto de manifiesto que la p&#233;rdida &#243;sea sist&#233;mica acontece fundamentalmente en las fases iniciales de la enfermedad y que se relaciona estrechamente con los valores de los reactantes de fase aguda<span class="elsevierStyleSup">24&#44;25</span>&#46;</p><p class="elsevierStylePara">En la AR&#44; adem&#225;s del fen&#243;meno inflamatorio&#44; se observan alteraciones hormonales<span class="elsevierStyleSup">26&#44;27</span>&#44; inmovilidad<span class="elsevierStyleSup">28</span> y d&#233;ficit de vitamina D<span class="elsevierStyleSup">29</span>&#59; estos factores contribuyen&#44; en mayor o menor medida&#44; a la p&#233;rdida &#243;sea&#46;</p><p class="elsevierStylePara">El efecto nocivo de los glucocorticoides es incuestionable&#44; especialmente si se administran en dosis medias o altas&#59; no obstante&#44; cabe contemplar tambi&#233;n un potencial efecto beneficioso en tanto que su uso contribuye a disminuir la actividad inflamatoria de la enfermedad de base<span class="elsevierStyleSup">24</span>&#46; En cuanto al metotrexato&#44; parece que puede afirmarse que en dosis bajas no induce p&#233;rdida &#243;sea adicional<span class="elsevierStyleSup">8&#44;30&#44;31</span>&#46;</p><p class="elsevierStylePara">La prevalencia de la osteoporosis&#44; definida a partir de criterios densitom&#233;tricos&#44; depende de las caracter&#237;sticas de la poblaci&#243;n estudiada&#46; En un estudio noruego de base poblacional<span class="elsevierStyleSup">6</span> en el que se evalu&#243; a mujeres premenop&#225;usicas y posmenop&#225;usicas&#44; la prevalencia de osteoporosis&#44; definida por un T-score &#60; &#173;2&#44;5 desviaciones est&#225;ndar &#40;DE&#41;&#44; fue del 16&#44;8&#37; en columna lumbar y del 14&#44;7&#37; en cuello femoral&#59; en un estudio de nuestro grupo<span class="elsevierStyleSup">32</span> en el que se estudi&#243; a mujeres posmenop&#225;usicas tratadas con dosis bajas de glucocorticoides&#44; la prevalencia de osteoporosis fue del 38&#37; en columna lumbar y del 34&#37; en cuello femoral&#46; En varones&#44; la frecuencia de osteoporosis es mucho menor<span class="elsevierStyleSup">5</span>&#59; en un trabajo reciente de nuestro grupo se situ&#243; alrededor del 15&#37;<span class="elsevierStyleSup">33</span>&#46;</p><p class="elsevierStylePara">La prevalencia de las deformidades vertebrales en pacientes tratadas con glucocorticoides a dosis bajas<span class="elsevierStyleSup">34</span> se acerca al 25&#37; y la de las fracturas vertebrales cl&#237;nicas&#44; al 10&#37;&#46; En ocasiones&#44; la fragilidad &#243;sea se traduce en forma de fracturas de ramas isquiopubianas y de tibia o peron&#233;<span class="elsevierStyleSup">35&#44;36</span>&#59; en estos casos&#44; el diagn&#243;stico diferencial con un brote &#225;lgico de la enfermedad de base puede resultar dif&#237;cil&#46;</p><p class="elsevierStylePara">Cabe considerar que los pacientes con una AR avanzada<span class="elsevierStyleSup">37</span> presentan alteraciones sinoviales y musculoligamentosas de las extremidades que determinan un aumento del riesgo de ca&#237;da y una disfunci&#243;n de los mecanismos protectores contra el impacto&#46;</p><p class="elsevierStylePara">Los conocimientos actuales avalan que la abolici&#243;n de la actividad inflamatoria resulta capital a la hora de abordar el problema de la osteoporosis en los pacientes afectos de AR&#46; En este sentido&#44; en estudios preliminares se ha puesto de manifiesto el efecto beneficioso en el hueso que se deriva de la utilizaci&#243;n de las terapias biol&#243;gicas<span class="elsevierStyleSup">38-40</span>&#46; Por otro lado parece interesante investigar el potencial de los bisfosfonatos de nueva generaci&#243;n y del denosumab como f&#225;rmacos inhibidores de la aparici&#243;n de erosiones<span class="elsevierStyleSup">3&#44;41-43</span>&#46;</p><p class="elsevierStylePara">Espondilitis anquilosante</p><p class="elsevierStylePara">Es un modelo cl&#237;nico especialmente interesante a la hora de evaluar la relaci&#243;n entre inflamaci&#243;n y p&#233;rdida &#243;sea&#44; dado que habitualmente no se utilizan los glucocorticoides en el tratamiento del paciente&#46;</p><p class="elsevierStylePara">Cl&#225;sicamente se aceptaba que la aparici&#243;n de una fractura constitu&#237;a un evento excepcional&#59; se asum&#237;a que los sindesmofitos actuaban como un factor protector&#46; Actualmente est&#225; perfectamente establecido que los enfermos con espondilitis anquilosante presentan un riesgo de fractura vertebral aumentado&#44; como consecuencia&#44; especialmente&#44; de la p&#233;rdida &#243;sea en la columna lum-bar<span class="elsevierStyleSup">44</span>&#46; La prevalencia en estudios recientes se cifra en un 15&#37;<span class="elsevierStyleSup">45</span>&#46;</p><p class="elsevierStylePara">Las fracturas aparecen fundamentalmente en pacientes con una enfermedad de larga evoluci&#243;n&#44; que suelen presentar sindesmofitos vertebrales&#46; De hecho&#44; la p&#233;rdida &#243;sea es m&#225;s intensa en los enfermos con sindesmo-fitos<span class="elsevierStyleSup">46</span>&#46;</p><p class="elsevierStylePara">La osteopenia se relaciona con la actividad de la enfermedad<span class="elsevierStyleSup">47&#44;48</span> y se observa ya en las fases iniciales del proceso<span class="elsevierStyleSup">49</span>&#46; Se afectan ambos sexos y se ha evidenciado una correlaci&#243;n entre la DMO y los valores de las hormonas sexuales<span class="elsevierStyleSup">50&#44;51</span> y de la OPG<span class="elsevierStyleSup">50</span>&#46;</p><p class="elsevierStylePara">Respecto a la artritis psori&#225;sica apenas hay informaci&#243;n en la literatura&#46; La intensidad de la p&#233;rdida &#243;sea parece ser menor que en la espondilitis anquilosante<span class="elsevierStyleSup">52&#44;53</span>&#46;</p><p class="elsevierStylePara">Lupus eritematoso sist&#233;mico</p><p class="elsevierStylePara">Las mujeres con lupus eritematoso sist&#233;mico presentan una DMO menor que la poblaci&#243;n general<span class="elsevierStyleSup">54-56</span> y un riesgo de fractura aumentado<span class="elsevierStyleSup">57</span>&#46; En varones&#44; estas circunstancias no est&#225;n aclaradas<span class="elsevierStyleSup">58</span>&#46;</p><p class="elsevierStylePara">La prevalencia de las fracturas vertebrales oscila entre un 10<span class="elsevierStyleSup">59</span> y un 20&#37;<span class="elsevierStyleSup">56&#44;60</span>&#46; Los factores que se ha invocado<span class="elsevierStyleSup">61</span> en la etiopatogenia de la p&#233;rdida &#243;sea que se observa en el lupus eritematoso sist&#233;mico son el tratamiento glucocorticoideo&#44; el hiperparatiroidismo secundario a la insuficiencia renal&#44; la actividad y la duraci&#243;n de la enfermedad y la hipovitaminosis D&#46;</p><p class="elsevierStylePara">Especialmente relevante resulta que se haya demostra-do<span class="elsevierStyleSup">62</span> que en mujeres j&#243;venes hay relaci&#243;n entre una DMO disminuida y un aumento del &#237;ndice de placa arterioscler&#243;tica en la arteria car&#243;tida&#59; adem&#225;s&#44; una DMO baja parece tener relaci&#243;n con la presencia de calcificaciones en las arterias coronarias&#46; Ello hace posible una l&#237;nea de investigaci&#243;n especialmente interesante&#59; dos de los m&#225;s importantes procesos com&#243;rbidos que afectan a las pacientes con lupus eritematoso sist&#233;mico&#44; la arteriosclerosis y la osteoporosis&#44; podr&#237;an tener una etiopatogenia com&#250;n&#44; la inflamaci&#243;n mantenida&#46;</p><hr></hr><p class="elsevierStylePara">Correspondencia&#58;</p><p class="elsevierStylePara">Dr&#46; J&#46;M&#46; Nolla&#46;</p><p class="elsevierStylePara">Servicio de Reumatolog&#237;a&#46; Hospital Universitari de Bellvitge&#46;<br></br> Feixa Llarga&#44; s&#47;n&#46; 08907 L&#39;Hospitalet de Llobregat&#46; Barcelona&#46; Espa&#241;a&#46;</p><p class="elsevierStylePara">Correo electr&#243;nico&#58; <a href="mailto&#58;jm&#46;nolla&#64;csub&#46;scs&#46;es" class="elsevierStyleCrossRefs">jm&#46;nolla&#64;csub&#46;scs&#46;es</a></p>"
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                    0 => array:3 [
                      "titulo" => "Osteoporotic vertebral fracture in clinical practice&#46; 669 patients diagnosed over a 10 year period&#46;"
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                            2 => "Romera M"
                            3 => "Roig-Vilaseca D"
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                            5 => "Mateo L"
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                    0 => array:3 [
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ISSN: 1699258X
Idioma original: Español

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año/Mes	Html	Pdf	Total

2024 Noviembre	110	13	123
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2022 Diciembre	298	35	333
2022 Noviembre	688	38	726
2022 Octubre	705	70	775
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2022 Mayo	422	44	466
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2022 Enero	378	35	413
2021 Diciembre	360	40	400
2021 Noviembre	433	61	494
2021 Octubre	479	62	541
2021 Septiembre	373	48	421
2021 Agosto	296	43	339
2021 Julio	279	44	323
2021 Junio	323	49	372
2021 Mayo	364	38	402
2021 Abril	653	47	700
2021 Marzo	459	48	507
2021 Febrero	282	34	316
2021 Enero	274	35	309
2020 Diciembre	252	23	275
2020 Noviembre	405	53	458
2020 Octubre	414	21	435
2020 Septiembre	375	22	397
2020 Agosto	308	18	326
2020 Julio	322	27	349
2020 Junio	329	39	368
2020 Mayo	319	29	348
2020 Abril	225	34	259
2020 Marzo	269	16	285
2020 Febrero	300	32	332
2020 Enero	291	26	317
2019 Diciembre	232	20	252
2019 Noviembre	335	24	359
2019 Octubre	322	48	370
2019 Septiembre	323	29	352
2019 Agosto	266	34	300
2019 Julio	347	25	372
2019 Junio	647	45	692
2019 Mayo	417	68	485
2019 Abril	361	75	436
2019 Marzo	319	50	369
2019 Febrero	276	29	305
2019 Enero	202	45	247
2018 Diciembre	199	65	264
2018 Noviembre	234	21	255
2018 Octubre	256	26	282
2018 Septiembre	182	17	199
2018 Agosto	181	16	197
2018 Julio	88	24	112
2018 Junio	22	4	26
2018 Mayo	191	27	218
2018 Abril	155	17	172
2018 Marzo	132	20	152
2018 Febrero	133	14	147
2018 Enero	112	12	124
2017 Diciembre	105	20	125
2017 Noviembre	168	32	200
2017 Octubre	197	25	222
2017 Septiembre	157	27	184
2017 Agosto	129	19	148
2017 Julio	111	23	134
2017 Junio	168	18	186
2017 Mayo	192	52	244
2017 Abril	221	12	233
2017 Marzo	287	19	306
2017 Febrero	390	17	407
2017 Enero	127	9	136
2016 Diciembre	166	25	191
2016 Noviembre	227	18	245
2016 Octubre	241	19	260
2016 Septiembre	285	14	299
2016 Agosto	180	15	195
2016 Julio	73	11	84
2016 Mayo	1	15	16
2016 Abril	0	9	9
2016 Marzo	0	17	17
2016 Enero	0	15	15
2015 Diciembre	0	14	14
2015 Noviembre	0	35	35
2015 Octubre	0	27	27
2015 Septiembre	4	0	4
2015 Agosto	0	18	18
2015 Julio	59	6	65
2015 Junio	54	4	58
2015 Mayo	110	13	123
2015 Abril	51	7	58
2015 Marzo	65	7	72
2015 Febrero	43	7	50
2015 Enero	60	11	71
2014 Diciembre	48	11	59
2014 Noviembre	76	12	88
2014 Octubre	90	12	102
2014 Septiembre	51	6	57
2014 Agosto	61	9	70
2014 Julio	50	11	61
2014 Junio	46	8	54
2014 Mayo	51	7	58
2014 Abril	33	6	39
2014 Marzo	36	9	45
2014 Febrero	31	8	39
2014 Enero	27	9	36
2013 Diciembre	26	6	32
2013 Noviembre	42	5	47
2013 Octubre	40	8	48
2013 Septiembre	33	10	43
2013 Agosto	26	6	32
2013 Julio	43	4	47
2013 Junio	21	6	27
2013 Mayo	35	4	39
2013 Abril	30	9	39
2013 Marzo	29	6	35
2013 Febrero	20	4	24
2013 Enero	15	2	17
2012 Diciembre	11	2	13
2012 Noviembre	5	7	12
2012 Octubre	7	2	9
2012 Septiembre	4	3	7
2012 Junio	1	0	1
2012 Mayo	2	0	2
2012 Marzo	1	0	1
2012 Enero	2	0	2
2011 Noviembre	2	0	2
2011 Agosto	1	0	1
2011 Julio	1	0	1
2011 Junio	3	0	3
2011 Mayo	6	0	6
2011 Abril	8	0	8
2011 Marzo	17	0	17
2011 Febrero	30	0	30
2011 Enero	5	0	5
2010 Diciembre	6	0	6
2010 Noviembre	11	0	11
2010 Octubre	52	0	52
2010 Agosto	8	0	8
2010 Julio	31	0	31
2010 Junio	1	0	1
2010 Mayo	2	0	2
2010 Abril	2	0	2
2010 Marzo	7	0	7
2010 Febrero	3	0	3
2010 Enero	5	0	5
2009 Diciembre	2	0	2
2009 Noviembre	8	0	8
2009 Octubre	4	0	4
2009 Septiembre	3	0	3
2009 Agosto	4	0	4
2009 Julio	6	0	6
2009 Junio	9	0	9
2009 Mayo	7	0	7
2009 Abril	7	0	7
2009 Marzo	2	0	2
2009 Febrero	6	0	6
2009 Enero	2	0	2
2008 Noviembre	7	0	7
2008 Octubre	3	0	3
2008 Septiembre	2	0	2
2008 Agosto	1	0	1
2008 Julio	1	0	1
2008 Junio	3	0	3
2008 Mayo	3	0	3
2008 Abril	2	0	2
2008 Marzo	5	0	5

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