Prediction of Vertebral Fractures by Trabecular Bone Score in Patients With Ankylosing Spondylitis

Ankylosing spondylarthritis (AS) is associated falsely increased lumbar spine bone mineral density (BMD). New tool for discrimination of subjects at fracture risk is needed. Vertebral fracture (VF) prediction of routine methods for osteoporosis assessment, BMD and trabecular bone score (TBS), in patients with AS. Cross-sectional study of all AS patients regularly followed at the rheumatology outpatient clinics of two centers. All subjects undergone BMD measurement at lumbar spine (LS), total hip (TH) and femoral neck (FN) using Hologic® Horizon device. TBS at L1-4 in all subjects by TBS InSight® software were assessed. Vertebral fracture assessment (VFA) was performed using the lateral spine imaging IVA™ and graded using Genant semi-quantitative approach. 119 AS subjects (90 males/29 females), mean age 47.6 years were included in the study. In 20 patients 34 VFs were detected, from whom 7 patients had multiple fractures. Subjects with VF were older and had lower FN BMD, TBS in comparison to non-VF subjects. No differences in LS BMD, FN BMD or BASDAI between groups were observed. Among patients with VF only 3 had T-score less than -2.5 but 7 has TBS less than 1.23 which means highly degraded microarchitecture. AS patients with VF have lower TBS and FN BMD in comparison to non-VF subjects. In addition, TBS was able to detect 20 % more VFs than BMD. Therefore, TBS seems promising in VF discrimination among patients with AS.

A Randomized Placebo-Controlled Trial of Primary Prophylaxis with Weekly Alendronate Against Glucocorticoid-Induced Osteoporosis in Lymphoma Patients Treated with Steroid-Containing Chemotherapy.

Introduction: Many lymphoma patients receive high doses of glucocorticoids as part of standard therapy, and several recent observational studies have highlighted a possible risk of glucocorticoid-induced osteoporosis (GIO) and excess bone fracture risk. As a substantial fraction of lymphoma patients become long-term survivors, studies that focus on mitigating the negative effects of treatment toxicities on survivorship are important. The objective of the SIESTA trial was to determine if primary prophylaxis with oral alendronate (ALN) is safe and effective against (GIO) in lymphoma patients. Methods: SIESTA was a single-center randomized and double-blinded phase 2 study performed at the Department of Hematology, Aalborg University Hospital, Denmark, enrolling lymphoma patients that were planned for glucocorticoid-containing chemotherapy regimens such as (R-)CVP and all variants of (R)-CHOP. Patients were randomized to weekly oral ALN 70mg or placebo with a treatment duration of 52 weeks. Study assessments included bone mineral density (BMD) measurements at baseline, after completion of chemotherapy at 4-6 months (EOT), and after 12 months, as well as vertebral fracture assessment (VFA) at baseline and at 12 months. The primary study endpoint was change in lumbar spine T-score from baseline to 12 months. Key secondary endpoints were change in T-score from baseline to 12 months at total hip and femoral neck levels, vertebral compression fractures and early T-score changes. Biomarker analyses were exploratory. The target recruitment was 60 patients in a three-year period. Results: A total of 59 patients (36 Diffuse large B-cell lymphoma, 15 follicular lymphoma, 8 other) were enrolled with 22 of 30 patients in the ALN arm and 23 of 29 patients in the placebo arm completing the study (efficacy group). Patient characteristics in the two arms were balanced with exception of more advanced stage diseases (Ann Arbor stage III-IV) in the ALN arm (70·0% vs 41·4%), and a lower median baseline T-score at the lumbar spine in the ALN arm (median T-score -0·6 vs 1·0). Patients in the ALN group received a median of 3,291 mg prednisone versus 3,398 mg for the placebo group. Median change in T-score from baseline to 12 months at the lumbar spine level (primary endpoint) was +0·2 for the ALN arm and -0·2 for the placebo arm (P=0·013) (figure 1), with stronger effect for female patients (median change; ALN +0·25; placebo -0·25) (figure 2). ALN had no effect on BMD for total hip (P=0·30) and femoral neck (P=0·58) at 12 months (figure 1). ALN had no significant early effects on BMD for any measured sites (4-6 months). No new fractures were observed. Nine patients experienced AEs related to the upper gastro-intestinal (GI) system (7 grade 1-2, 2 grade 3-4) with 5 AEs being assessed as related to the study treatment (3 in the ALN group and 2 in the placebo group). One patient (placebo group) discontinued study treatment due to upper GI AE (bleeding ulcer). Biomarker analyses (C-terminal telopeptide cross links (CTX) as marker of bone resorption and N-terminal propeptides of collagen type 1 (P1NP) as marker for bone formation) showed reduced bone resorption for ALN treated patients opposed to the placebo treated patients. From baseline to EOT the mean change in CTX was -0.17 in the ALN group and 0.10 in the placebo group respectively (P<0.001). From baseline to 12 months the mean change in CTX was -0.19 in the ALN group and 0.00 in the placebo group respectively (P=0.002). Interpretation: ALN was a safe and effective primary prophylaxis against GIO in lymphoma patients planned for glucocorticoid-containing chemotherapy regimens. The treatment effects were clinically meaningful across all patient subgroups, but the largest effect size was observed in females. Biomarker analyses supported reduced bone resorption for ALN treated patients. Figure 1 Figure 1. Disclosures Vestergaard: Novo Nordisk Foundation: Other: Head of Research at Steno Diabetes Center North Jutland funded by the Novo Nordisk Foundation, Research Funding. El-Galaly: Abbvie: Other: Speakers fee; ROCHE Ltd: Ended employment in the past 24 months.

Radiographic Vertebral Fracture Assessment of Vertebral Fracture by the Three-Line Method

Purpose: To evaluate the value of the three-line (TL) method in the diagnosis of vertebral fractures. Methods: 286 patients over 50 years old who received thoracolumbar X-ray examination in our hospital from 2013 to 2019 were selected and divided into three groups according to their age. The incidence and severity of vertebral fractures were measured by the TL method and Genant semi-quantitative technique by the same observer. Eight vertebrae were measured in each patient, ranging from T10 to L5. Results: The TL method was consistent with the Genant semi-quantitative method when evaluating whether patients had vertebral fractures (k >0.75), and the McNemar-bowker test showed no difference in the diagnosis between the two methods (P >0.05). However, Wilcoxon rank sum test found a difference between the two methods in assessing the severity of fractured vertebrae (P < 0.05), and the TL method was more sensitive. Conclusion: The two methods can be substituted for each other in the diagnosis of vertebral fractures. However, TL method is more sensitive in the diagnosis of the severity of spinal fractures. And the TL method is more quantitative and easier for beginners to master.

Vertebral Fractures in Ireland: A Sub-analysis of the DXA HIP Project

Osteoporosis is an important global health problem resulting in fragility fractures. The vertebrae are the commonest site of fracture resulting in extreme illness burden, and having the highest associated mortality. International studies show that vertebral fractures (VF) increase in prevalence with age, similarly in men and women, but differ across different regions of the world. Ireland has one of the highest rates of hip fracture in the world but data on vertebral fractures are limited. In this study we examined the prevalence of VF and associated major risk factors, using a sample of subjects who underwent vertebral fracture assessment (VFA) performed on 2 dual-energy X-ray absorptiometry (DXA) machines. A total of 1296 subjects aged 40 years and older had a valid VFA report and DXA information available, including 254 men and 1042 women. Subjects had a mean age of 70 years, 805 (62%) had prior fractures, mean spine T-score was − 1.4 and mean total hip T-scores was − 1.2, while mean FRAX scores were 15.4% and 4.8% for major osteoporotic fracture and hip fracture, respectively. Although 95 (7%) had a known VF prior to scanning, 283 (22%) patients had at least 1 VF on their scan: 161 had 1, 61 had 2, and 61 had 3 or more. The prevalence of VF increased with age from 11.5% in those aged 40–49 years to > 33% among those aged ≥ 80 years. Both men and women with VF had significantly lower BMD at each measured site, and significantly higher FRAX scores, P < 0.01. These data suggest VF are common in high risk populations, particularly older men and women with low BMD, previous fractures, and at high risk of fracture. Urgent attention is needed to examine effective ways to identify those at risk and to reduce the burden of VF.

AB0620 MODIFICATION OF THE DECISION OF THE ANTI-OSTEOPOROSIS TREATMENT AFTER PERFORMING THE VFA

Background:Spinal fractures are the most common of all osteoporotic fractures. Its diagnosis is essential, because the discovery of a vertebral fracture testifies the gravity of osteoporosis and modifies the therapeutic intervention threshold by justifying a specific anti-osteoporosis treatment. The evolution of densitometers now makes it possible to take a true X-ray image using software called “Vertebral Fracture Assessment” or VFA.Objectives:To assess the impact of VFA results on therapeutic decision-making after measuring bone mineral density.Methods:We conducted a retrospective and descriptive study in the rheumatology department.We included all patient followed at the consultation for bone pathologies, in whom a measurement of bone mineral density and a supplementation of VFA were performed. Clinical data, BMD, VFA and the therapeutic decision by anti-osteoporosis treatment before and after VFA were collected.Results:Sixty-one patients were included. The mean age was 62.8 years [38 - 85 years]. Sex ratio (female / male) was 19.3. At BMD level, patients with osteoporosis and osteopenia were 49% and 51% respectively. VFA objectified at least one spinal fracture in 64% of patients. Prior to VFA, anti-osteoporosis therapy was indicated to 49% of patients, based on clinical data and BMD. After performing VFA, the prescription of anti-osteoporosis therapy was indicated to 80% of patients.Conclusion:Patients who had no indication for osteoporosis treatment based on BMD data, VFA was able to modify their therapeutic treatment by detecting vertebral fractures in patients who had back pain.Disclosure of Interests:None declared.

POS1110 RELIABILITY OF VERTEBRAL FRACTURE ASSESSMENT ON DUAL-ENERGY X-RAY ABSORPTIOMETRY

Background:Vertebral Fracture Assessment (VFA) is a new feature available on modern densitometers. Yet, the assessment of vertebral fracture (VF) status has not become standard practice.Objectives:Our study aimed to evaluate the reliability of VFA as assessed by a rheumatologist and a radiology technician.Methods:We conducted a cross-sectional study assessing the performance of low-radiation single energy x-ray absorptiometry VFA for the detection of VF. We selected patients who were assessed for osteoporosis according to screening protocols. Bone mineral densitometry was measured using standard methods over the lumbar spine L1-L4, the total proximal femur, and results were expressed as T-scores. All VFA were independently evaluated by 2 experienced readers: a rheumatologist and a radiology technician for the identification of VF (T4-L4). VF was classified according to the Genant grading system: grade 1 for an anterior, mid or posterior reduction of 20–25% in vertebral height; grade 2 for a reduction of 25– 40% and grade 3 for a reduction of more than 40% in vertebral height. A score for the inter-rater reliability between the readers was expressed using the kappa statistic.Results:One hundred patients were included with a mean age of 66.9 ± 9.5 years [46.7-83] years. There was a female predominance (91%). Nearly half of patients had osteopenia (48.9%), 27.7% had osteoporosis and 23.4% had a normal bone mineral density. On VFA scans, the non-visible vertebra was mostly located in the upper thoracic spine (60%). The mean number of VF was 1.2 [0-3] for both readers. According to the doctor’s evaluation, 25% of patients had at least one VF, of which 75.9% had a Genant grade 1, 17.2% had a Genant 2, and 6.9% had a VF grade 3. According to the technician evaluation, at least one VF was found in 36% of patients. A grade 1 was assessed in 91.7% of cases, a grade 2 in 8.3% of patients but no VF grade 3 was assessed. A kappa score for the inter-rater reliability between the readers for VFA was 0.545 (p=0.000). The overall agreement by grade between the readers was 0.785 (p=0,000). The exclusion of non-visible vertebra resulted in a better agreement (k=0.853). Further analysis excluding vertebra T4 to D10, revealed a very good agreement (k=0.9).Conclusion:Our study showed a low agreement between the readers on VFA and a better agreement when non-visible vertebrae were excluded. Thus, caution should be advocated when relying exclusively on this device.Disclosure of Interests:None declared.

AB0614 DENSITOMETRIC VERTEBRAL FRACTURE ASSESSMENT: FACTORS LIMITING GOOD VISIBILITY OF THE VERTEBRA

Background:The radiograph of the spine is the gold standard for identifying vertebral fractures (VF). Vertebral Fracture Assessment (VFA) is a new feature available on modern densitometers that could assess VF. This technique offers the advantage of low irradiation over standard radiography but at the cost of lower image quality.Objectives:The aim of this study was to assess factors associated with good vertebra visibility when using VFA.Methods:This is a cross-sectional study including patients referred by their physicians for bone mineral density (BMD) measurement. Anthropometric data were recorded. BMD was measured using standard methods over the lumbar spine L1-L4, the total proximal femur. Results were expressed as T-scores using Dual-energy X-ray absorptiometry (DEXA). The screening for VF was performed by VFA. A professional operator analyses VFA scans and assessed the good visibility of the vertebra.Results:The study included 100 patients. The mean age was 61.7 ±12.6 years [18-83].The average body mass index (BMI) was 28.9 ± 24.2 kg/m2 [14.2-45.3]. The mean T-score at the vertebral site was -1.5 DS [-4.9-1.5] with a mean mass of 0.95g/cm2 [0.58-1.371]. Osteoporosis was found in 27.7 % of patients. A vertebral fracture was diagnosed in 25% of cases. The visualization of the vertebra was impaired in the upper thoracic region in 60% of cases. Poor visibility was observed in 19% of cases in the mid-thoracic spine and only in 2% of cases in the lumbar spine. No statistically significant correlation was found between good vertebral visibility and age (p=0.2), weight (p=0.5), or BMI (p=0.7). However, good visibility of the vertebra was associated with a lower height (1.7 m vs 1.5 m, p=0.03). A better vertebrae visualization was correlated neither to the BMD of the right hip (0.84 vs 0.87, p=0.4) nor to the left hip (0.85 vs 0.89, p= 0.3). Similarly, the absence of vertebral osteoporosis was not correlated with a better vertebral visualization (p=0.6).Conclusion:Visibility of the vertebra on VFA does not appear to be altered by the BMD and vertebral osteoporosis, suggesting safe use in the elderly. However, precautions may be taken when interpreting VFA in patients with high heights.Disclosure of Interests:None declared.