Pedreira et al.

Arthritis Research & Therapy 2011, 13:R16

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RESEARCH ARTICLE Open Access

Bone mineral density and body composition in

postmenopausal women with psoriasis and
psoriatic arthritis
Paulo G Pedreira*, Marcelo M Pinheiro, Vera L Szejnfeld

Abstract
Introduction: The aim of the present study was to compare bone mineral density (BMD) and body composition
(BC) measurements as well as identify risk factors for low BMD and osteoporotic fractures in postmenopausal
women with psoriasis (Ps) and psoriatic arthritis (PsA).
Methods: A cross-sectional study was carried out in 45 PsA women, 52 Ps women and 98 healthy female controls
(HC). Clinical risk factors for low bone density and osteoporotic fracture were evaluated by a specific questionnaire.
An X-ray absorptiometry (DXA) at the lumbar spine, total femur and total body was performed on all patients. Skin
and joint outcomes were measured by specific tools (PASI, HAQ and DAS28). Morphometric vertebral fractures
were evaluated by lumbar and thoracic spine X-ray, according to Genant’s method.
Results: There were no significant differences in age, body mass index (BMI), total lean mass and bone mineral
density among the groups. However, the PsA group had a significantly higher body fat percentage (BF%) than the
Ps and HC groups. Osteoporotic fractures were more frequently observed in PsA and Ps groups than in the HC
group (P = 0.01). Recurrent falls and a longer duration of disease increased the risk of fracture (odds ratio (OR) =
18.3 and 1.08, respectively) in the PsA group (P = 0.02). Disability was the main factor related to osteoporotic
fracture in the Ps group (odds ratio (OR) = 11.1) (P = 0.02).
Conclusions: Ps and PsA patients did not present lower BMD. However, they had a higher prevalence of
osteoporotic fractures and higher risk of metabolic syndrome. Patients with a longer duration of disease, disability
and recurrent falls need preventive measures.

Introduction peripheral blood as well as T cells and fibroblasts in the

Psoriasis (Ps) and psoriatic arthritis (PsA) are chronic, synovial fluid of patients with PsA [6]. Hofbauer et al.
immuno-mediated inflammatory diseases characterized found an increase in serum RANKL in these patients
by abnormal expressions of keratinocytes, with actions and significant reduction of the osteoclastogenesis after
of interferon (IFN)-g, tumor necrosis factor (TNF)-a, treatment with TNF inhibitors [7]. Ng et al., evaluating
TNF-b, transforming growth factor (TGF)-b, interleukin rheumatoid arthritis (RA) and PsA patients before and
(IL)-1, IL-6, IL-8 and IL-17 [1-3] or activation of Th2 after one year of anti-TNF therapy, demonstrated
inflammatory response, releasing TNF-a, IL-1 and IL-6, increased bone density and bone formation markers in
as well as proliferation and neovascularization of the both groups as well as reduction of bone resorption
synovial [4,5]. markers [8]. Nymann et al. found a decrease of spine
According to Colucci et al., there is greater in vitro BMD in patients with palmoplantar pustulosis [9]. How-
expression of TNF-a and receptor activator of nuclear ever, this same correlation was not observed in Ps [10]
factor-kappa ligand (RANKL) in T and B cells of the or PsA patients [11,12].
Higher release of IL-1, IL-2, IL-6, IFN-g and TNF-a is
* Correspondence: [email protected] associated with lean mass loss in patients with AIDS,
Rheumatology Division, Federal University of São Paulo, UNIFESP/Paulista
School of Medicine, EPM. 740, Botucatu Street, 04023-900, São Paulo-SP,
cancer, chronic obstructive pulmonary disease, kidney
Brazil failure, RA, acute myocardial infarction [13,14].
© 2011 Pedreira et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons
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any medium, provided the original work is properly cited.
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Inflammatory cytokines activate the muscle proteolytic the manufacturer’s instructions. The US National Health
system, stimulate the release of cortisol and catechola- and Nutrition Examination Survey (NHANES III) data-
mines, induce lipolysis and b-oxidation, as well as higher base was adopted. The right femur was studied in all
synthesis of very low density lipoprotein (VLDL) and tri- individuals, except in those with a hip fracture, prosthe-
glycerides and an increase of fat mass [15]. The growth sis or severe arthritis on this side, in which cases the left
hormone (GH) and type I insulin-like growth factor femur was evaluated. The coefficient of variation at our
(IGF-I) increase the protein synthesis by myocites. Tous- service is 3% for the femur and 2% for the lumbar spine.
sirot et al. found higher serum leptin in RA patients as Total body densitometry was performed to evaluate
well as a positive correlation with fat mass and negative body composition (lean, fat and bone mass). The skele-
association with lean mass. However, the GH concentra- tal muscle mass index (SMMI) was calculated as the
tion was increased and IGF-I did not differ from the ratio of the sum of the lean mass of the arms and legs
control group [16]. Westhovens et al. found a significant (kg) divided by the height squared (m2). The same cal-
reduction of total body BMD and lean mass as well as culation was performed for the skeletal fat mass index
an increase of fat mass in RA patients when compared (kg/m2), considering the fat mass of the arms and legs.
to HC [17]. Marcora et al. demonstrated a significant Sarcopenia was defined by a SMMI below 5.45 [24]. The
decrease of lean mass and muscle strength in men with coefficient of variation for the total body is 3%. In order
ankylosing spondylitis (AS) [18]. Briot et al. verified to differentiate the terms from BMI, the procedure
higher spine and femur BMD and fat mass after treat- described by Giles et al. was adopted, in which a BMI
ment with etanercept and infliximab in AS patients [19]. below 18.50 kg/m 2 is considered underweight; a BMI
Saraceno and Gisondi demonstrated an increase of body between 18.50 and 24.99 kg/m 2 is the ideal weight
weight in Ps and PsA patients treated with etanercept, range; a BMI between 25 and 29.99 kg/m2 is considered
adalimumab and infliximab [20,21]. overweight; and a BMI equal to or greater than 30 kg/
The aim of the present study was to analyze bone m2 is obese [25]. Overfat was defined if total body fat
density and body composition in postmenopausal exceeding 41%, measured by DXA, in White women
women with psoriasis, psoriatic arthritis and in healthy under 60 years old or 43% for women with 60 years or
controls in order to identify risk factors for low bone older [25,26]. Obese sarcopenia was defined as a patient
mass, fractures and changes of body composition. fulfilling overfat and sarcopenia criteria [25].
The Psoriasis Area Severity Index (PASI) was used to
Materials and methods assess the extent and severity of skin involvement in
A cross-sectional study was carried out in 45 PsA patients with Ps and PsA [27]. The Health Assessment
women, 52 Ps women and 98 HC. The diagnosis of PsA Questionnaire (HAQ) was applied to determine the
was defined by the Classification Criteria for Psoriatic degree of temporary or definitive functional impairment
Arthritis (CASPAR) [22]. PsA patients were in treatment [28]. Disease Activity Score 28 (DAS28) and Psoriatic
at the Rheumatology Division of Federal University of Arthritis Response Criteria (PsARC) were used to mea-
São Paulo (UNIFESP)/Paulista School of Medicine sure joint activity in PsA patients [29,30].
(EPM) and Sao Paulo Public Servants’ Hospital. Ps A thoracic and lumbar spine X-ray was performed to
patients were regularly followed-up at the UNIFESP/ identify and classify vertebral deformities or fractures,
EPM Dermatology Outpatient Clinic. The control group accordingly Genant’s criteria [31].
was paired for gender, age, BMI, ethnic background and Secondary osteoporosis, osteoarthritis that could com-
socioeconomic class. The study was approved by the promise the bone mineral density measurements or pre-
Committee of Medical Ethics in Research of UNIFESP/ vious diagnosis of sarcopenia were considered exclusion
EPM. All patients agreed to participate in the study and criteria as well as patients with Steinbroker functional
signed the informed consent form. Clinical risk factors class IV; use of insulin, statins, GH, anabolic agents,
to low bone density and osteoporotic fracture were eval- hormonal therapy, TNF blockers or vitamin D; cognitive
uated by a specific questionnaire based on the European impairment; cancer or active HIV infection.
Vertebral Osteoporosis Study (EVOS) that included
details about anthropometric data, personal and medical Statistical analysis
history, gynecological information, concomitant medica- The descriptive summary is presented in the form of
tions, diet, smoking and physical activity [23]. mean ± standard deviation. Levene’s test was used to
Bone mineral density measurements were performed test the homogeneity of the sampling. The multiple
at lumbar spine and proximal femur, using a dual- comparisons among the groups were done with analysis
energy X-ray densitometer (GE-Lunar Radiation Cor- of variance (ANOVA), Tukey’s post hoc test, Kruskal-
poration, DPX MD + model, Madison, WI, USA). The Wallis test or Mann-Whitney test. Chi-square test or
standard technical procedure was followed according to Fisher’s exact test were used for the qualitative variables.
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BMD and BC measurements were considered as depen- PsA patients had more disability than the Ps group and
dent variables. Pearson’s correlation coefficient was cal- healthy controls (P < 0.001). On average, joint activity
culated between quantitative variables that satisfied the was more severe than skin activity. Besides, there was
conditions of normality, as determined by the Kolmo- no significant difference in years since menopause
gorov-Smirnov test. Otherwise, Spearman’s correlation (Table 1). No patient had undergone hormonal replace-
coefficient was preferred. Logistic regression models ment therapy for longer than three months.
were used for binary categorical variables (low-impact Hypertension was highly prevalent, especially among
fracture). In the multivariate regression, two models PsA and Ps patients. The Ps group had more cases of
were performed for bone density separately (spine and type 2 diabetes mellitus and dyslipidemia, without statis-
femur BMD). Statistical adjustments were done for age tically significant differences between groups.
and weight in all tests. The level of significance was set PsA patients had longer duration of glicocorticoster-
as P < 0.05. The analyses were performed using the Sta- oids use than Ps women (9.6 ± 22.8 and 4.8 ± 13.2
tistical Package for Social Sciences (version 15) (IBM, months, respectively; P = 0.14). There was no statisti-
Chicago, Illinois, USA). cally significant difference in family history of osteo-
porosis or hip fracture between PsA and Ps groups as
Results well as recurrent falls in the last year. However, falls
A total of 195 postmenopausal women were studied (45 were more frequent in the patients than in the control
PsA patients, 52 Ps patients and 98 HC), paired for age group (P < 0.001). PsA patients had more fractures
and BMI (Table 1). (33.3%) than the Ps group (28.8%) (P = 0.018). Fragility
There were no significant differences in the para- fractures were more prevalent among the Ps and PsA
meters related to clinical characteristics of the disease, groups than the HC (P = 0.001). The PsA group had
such as duration of skin condition and PASI. However, more morphometric vertebral fractures than the Ps and
time of disease was two-fold greater in Ps patients. control groups (P = 0.06). Dairy product intake was low,
Ungual involvement was more frequent in the PsA but similar, between the three groups. Alcoholic bever-
group (64.4%) than the Ps group (36.5%) (P = 0.006). age consumption was infrequent with no significant

Table 1 Age, anthropometric data and clinical characteristics of the women studied
PsA N = 45 Ps N = 52 Control N = 98 P
Age (years) 60.5 ± 8.7 61.4 ± 9.1 60.1 ± 8.4 0.95
Weight (kg) 69.4 ± 8.9 71.1 ± 14.2 67.8 ± 11.2 0.19
Height (m) 1.50 ± 0.7 1.50 ± 0.6 1.55 ± 0.6 0.97
BMI (kg/m2) 29.1 ± 3.6 26.6 ± 6.2 28.1 ± 4.54 0.19
Within ideal weight range *
N (%) 7 (15.6) 9 (17.3) 25 (25.5) 0.29
Overweight†
N (%) 17 (37.8) 22 (42.3) 40 (40.8) 0.9
Obese‡
N (%) 21 (46.7) 21 (40.4) 33 (33.7) 0.31
Ps Duration (years) 24.8 ± 16.2 21.8 ± 17.8 - 0.39
PsA Duration (years) 11 ± 10.5 - - -
PASI 2.2 ± 3.3 3.2 ± 3.4 - 0.22
HAQ 0.7 ± 0.5§|| 0.2 ± 0.3 0.1 ± 0.2 <0.001
DAS28 3.7 ± 1.4 - - -
PsARC
N° of swollen joints 3.2 ± 2.9 - - -
N° of painful joints 3.5 ± 3.4 - - -
Global evaluation of patient (VAS) 4 ± 2.8 - - -
Global evaluation of physician (VAS) 3.3 ± 2.4 - - -
Years since of menopause 12.7 ± 9.9 15.4 ± 10.9 12.1 ± 8.6 0.22
*BMI 18.50 - 24.99 kg/m2; †BMI 25 - 29.99 kg/m2; ‡BMI ≥ 30 kg/m2.
DAS28, disease activity score 28; HAQ, health assessment questionnaire; PASI, psoriasis area severity index; PsA, psoriatic arthritis; Ps, psoriasis; PsARC, psoriatic
arthritis response criteria; VAS, visual analogue scale.
§
P < 0.001 (PsA vs. Ps).
||
P < 0.001 (PsA vs. control).
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Table 2 Bone density of total body, lumbar spine and Table 4 Correlations between anthropometric data,
proximal femur among the women studied clinical findings and bone density measurements in
PsA Ps Control P patients with psoriatic arthritis
N = 45 N = 52 N = 98 Vertebral Femur TLM TBF
Total Body BMD BMD
BMC (g) 2140 ± 282 2161 ± 287 2207 ± 304 0.40 Age r* -0.05 -0.09 0.11 0.02
BMD (g/cm2) 1.118 ± 0.09 1.118 ± 0.1 1.117 ± 0.08 0.99 (P) (0.76) (0.53) (0.45) (0.86)
Lumbar Spine (g/cm2) 1.058 ± 0.16 1.054 ± 0.13 1.058 ± 0.15 0.98 Weight r* 0.27 0.13 0.63 0.59
Total Femur (g/cm2) 0.934 ± 0.13 0.922 ± 0.13 0.949 ± 0.12 0.46 (P) (0.78) (0.39) (<0.001) (<0.001)
BMC, bone mineral content; BMD, bone mineral density; Ps, psoriasis; PsA, BMI r* 0.16 0.20 0.35 0.63
psoriatic arthritis. (P) (0.30) (0.17) (0.02) (<0.001)
Duration of Ps r* 0.23 0.02 0.13 -0.10
difference between groups. No patient reported the use (P) (0.13) (0.88) (0.37) (0.52)
of illicit drugs. A current smoking habit was more fre- Duration of PsA r† 0.14 0.09 0.14 0.15
quent in Ps patients (21.2%) than in PsA women (11.1%) (P) (0.34) (0.55) (0.35) (0.34)
(P = 0.11). Duration of menopause r† -0.29 -0.14 0.07 -0.04
Total body, spine and femur BMC and BMD measure- (P) (0.04) (0.37) (0.64) (0.79)
ments were not different among the three (Table 2). On HAQ r† 0.04 0.01 -0.27 -0.02
the other hand, the PsA group presented almost signifi- (P) (0.8) (0.93) (0.08) (0.91)
cantly less total lean mass (TLM) than the Ps and HC PASI r† 0.08 -0.13 0.13 -0.15
group (P = 0.06). All groups had a large amount of total (P) (0.6) (0.39) (0.38) (0.31)
body fat, especially patients with PsA (P = 0.04). Total DAS 28 r* -0.13 -0.19 -0.12 0.12
body fat (TBF) above expected values for individuals of (P) (0.39) (0.2) (0.41) (0.43)
the same gender and age occurred in the majority of PsARC for swollen joints r† 0.13 -0.16 -0.01 0.02
PsA (84.4%) and Ps (65.4%) patients (P = 0.02). Overfat (P) (0.41) (0.29) (0.94) (0.88)
was significantly more identified in the PsA group than PsARC for painful joints r† -0.13 -0.03 0.07 0.01
in the other two groups (P = 0.04), mainly with android (P) (0.38) (0.86) (0.63) (0.93)
distribution. Moreover, all patients with PsA and sarco- PsARC (VAS) - patient r† 0.05 -0.01 -0.15 0.08
penia were obese (Table 3). (P) (0.74) (0.91) (0.32) (0.57)
In the PsA group, spine BMD was negatively corre- PsARC (VAS) - physician r† 0.01 0.01 -0.62 0.05
lated with years since menopause. TLM and TBF were (P) (0.93) (0.94) (0.69) (0.75)
positively correlated with weight and BMI (Table 4). In TLM r* 0.19 0.15 1 -0.22
the Ps group, spine BMD had positive correlation with (P) (0.2) (0.33) (0.15)
weight and TLM. Femur BMD presented a positive TBF r* 0.11 -0.006 -0.22 1
(P) (0.48) (0.97) (0.15)
r*, Pearson’s correlation; r†, Spearman’s correlation.
Table 3 Body composition, overfat and sarcopenia
according to the body fat normality curves measured by
DXA correlation with weight, BMI and TLM and inverse cor-
PsA Ps Control P relation with age. TLM and TBF were positively corre-
N = 45 N = 52 N = 98 lated with weight and BMI (Table 5).
TLM (kg) 35.28 ± 3.96 37.45 ± 5.32 35.93 ± 4.81 0.06 In the PsA group, the final logistic regression model
TBF (%) 46 ± 5.7* 43.8 ± 6.2 43.4 ± 5.5 0.04 revealed an 8% increase in the risk of fragility fracture
Within normality (%) 15.6†‡ 34.6 37.8 0.02 for each year of joint disease. Furthermore, the number
Above normality (%) 84.4†‡ 65.4 62.2 0.02 of falls increased from 2- to 18-fold the risk of fracture
Overfat (%) 86.7 || § 61.5 58.2 0.03 in patients with recurring events. In the Ps group, there
Sarcopenia (%) 11.1 5.8 6.1 0.50 was an 11-fold increase in the risk for each lower unit
Obesity-sarcopenia (%) 11.1 3.8 4.1 0.19 of functional capacity (Table 6).
DXA, dual X-ray absorptiometry; Ps, psoriasis; PsA,: psoriatic arthritis; TBF, total The final multivariate regression model showed a
body fat; TLM, total lean mass. reduction of 0.01 g/cm 2 in spine BMD for each year
*P = 0.03 (PsA vs. control).
†
since menopause to PsA patients. However, none of the
P < 0.05(PsA vs Ps).
‡
P < 0.05 (PsA vs control).
variables studied were significantly associated with
§
P < 0.01 (PsA vs. Ps). femur BMD. In the Ps group, there was an increase of
||
P < 0.01 (PsA vs. control). spine and femur BMD for each one-gram increase in
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Table 5 Correlations between anthropometric data, et al. [11], Dheda et al. [32], Millard et al. [10] and Gri-
clinical findings and bone density measurements in sar et al. [33]. However, these authors studied small,
patients with psoriasis non-homogeneous (men, pre- and postmenopausal
Vertebral Femur TLM TBF women) populations and had no adequate control
BMD BMD group.
Age r* -0.21 -0.32 -0.07 0.15 There was also no significant difference among the
(P) (0.13) (0.02) (0.64) (0.3) three groups when applying the 1994 World Health
Weight r† 0.29 0.45 0.72 0.76 Organization (WHO) criteria for osteoporosis [34]. On
(P) (0.04) (<0.001) (<0.001) (<0.001) the other hand, Frediani et al. found a reduction of
BMI r† 0.16 0.43 0.55 0.74 BMD in two-thirds of PsA patients when compared to
(P) (0.26) (<0.001) (<0.001) (<0.001) HC [35]. Potentially, PsA and Ps patients have higher
Duration of Ps r† -0.22 0.07 0.00 -0.09 bone resorption markers and bone loss related to
(P) (0.12) (0.96) (0.97) (0.53) inflammatory process and disability [33]. Similarly,
Duration of menopause r† -0.08 -0.2f -0.18 -0.06 Heim et al. observed higher remodeling rates, without
(P) (0.55) (0.09) (0.19) (0.96) trabecular bone loss, in PsA and Ps patients [36]. The
HAQ r† -0.08 0.09 0.1 0.21 authors believe that the same hyperproliferation that
(P) (0.55) (0.48) (0.48) (0.14) occurs in the skin may also occur in bone tissue,
PASI r† 0.06 0.05 0.05 -0.87 thereby causing latent bone disease. Besides, they sug-
(P) (0.68) (0.72) (0.73) (0.54) gest that Ps patients have partial resistance to the action
TLM r† 0.28 0.56 1 0.19 of vitamin D on dermic fibroblasts. If the same situation
(P) (0.04) (<0.001) (0.18) occurs in bone tissue, this could explain the accelerated
TBF r† 0.06 0.14 0.19 1 bone remodeling. In the present study, no assessment of
(P) (0.65) (0.33) (0.18) bone remodeling markers or of bone biopsies was done.
r*, Pearson’s correlation; r†, Spearman’s correlation. Other aspects may have also played a protective role
regarding the bone density values found in the present
study, such as an overweight condition as well as
the TLM. Moreover, femur BMD was reduced by 0.005 decreased smoking and lower alcohol intake. Dairy pro-
g/cm2 for every year of increasing age. duct intake was low or inadequate in all groups, and
The total hip or total femur BMD showed better per- similar to that reported by Pinheiro et al. in the Brazi-
formance than the femoral neck in the final model of lian population [37]. This point demonstrates that cal-
multivariate regression in both groups (Ps and PsA). cium intake did not play a relevant role in bone mass of
Therefore, it was chosen as the most significant. these subjects. Furthermore, few patients were taking
glucocorticosteroids or had used them for short periods
Discussion of time and in low dosages.
Our results did not demonstrate any significant differ- Although joint activity among PsA patients has been
ence in spine or femur BMD in PsA or Ps patients and considered moderate to severe, the skin condition was
healthy controls. Lean mass was similar in PsA, Ps and considered mild in both groups. Moreover, dermatologi-
HC groups, although PsA patients had a trend to a cal recommendations for psoriasis, such as exposure to
lower lean mass than Ps patients. PsA patients had a sunlight and ultra-violet light baths, play a beneficial
greater percentage of fat mass than Ps women and HC. role on bone metabolism due to vitamin D synthesis
These results are similar to those described by Borman [38].
Among all the risk factors investigated, only age and
years since menopause were determinant of the BMD.
Table 6 Final logistic regression model for low-impact Age for femur BMD in Ps patients and years since
fraction among patients with psoriatic arthritis and menopause for spine BMD in PsA postmenopausal
psoriasis women are similar to those reported by Frediani et al.
Group OR 95% CI p [35].
Duration of PsA PsA 1.08 1.01 to 1.16 0.01 Studies on body composition in inflammatory disease
N° of falls PsA are more frequent in RA or AS than is PsA patients. In
1 to 3 2.5 0.5 to 12.4 0.02 general, these studies have shown greater lean mass loss,
especially in those with higher activity of disease and
>3 18.3 1.5 to 217.7 0.02 disability. The present study demonstrates that the PsA
HAQ Ps 11.1 15.5 to 84.2 0.02 group had a tendency to lower lean mass than Ps
HAQ, health assessment questionnaire; Ps, psoriasis; PsA, psoriatic arthritis. women or HC.
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There was a positive correlation between lean mass Vertebral and non-vertebral fractures were signifi-
and femur and spine BMD in Ps patients. In the final cantly more prevalent in PsA and Ps patients than in
multivariate regression model, TLM was the most the HC and Brazilian population over 40 years old [42].
important aspect related to femur BMD, suggesting that Sinigaglia et al. found an association among fracture
exercise and higher strength musculature could be rele- and advanced age, disability, more prolonged disease
vant strategies for increase bone mass in these patients. and more severe disease activity in RA and AS patients
This correlation was not found in PsA patients. [43]. Yes, the sentence is correct. In the present study,
We observed a high percentage of total body fat in all longer disease duration and recurrent falls were predic-
three groups, especially in the PsA group (P = 0.04). tors of low-impact fractures in PsA patients, while dis-
Giles et al. pointed out that RA patients with an overfat ability was predictive of fragility fracture in Ps patients.
phenotype had a greater degree of joint deformity and As bone mass measurements did not reflect the bone
disability, as well as higher C-reactive protein (CRP) status in Ps and PsA patients, the evaluation of fractures
levels. Also, these patients are more sarcopenic and sar- is important. Bone neoformation may be another expla-
copenic-obese [25]. Although it was not significant, in nation for the absence of densitometric osteoporosis in
the present study, there was a higher percentage of sarco- PsA patients. However, none of our subjects have had
penia in PsA and Ps groups. Surprisingly, all PsA patients clinical or radiographic axial involvement.
with sarcopenia were obese. Both Ps and PsA group had
a higher frequency of android fat distribution, which is Conclusions
traditionally associated with a greater risk of cardiovascu- PsA and Ps patients have higher risk of fragility fracture
lar disease, metabolic syndrome and diabetes mellitus. and it seems that they also have a higher risk of devel-
Our findings are similar to those described in rheumatoid oping metabolic disease, especially those patients with
patients [17]. A psoriasic chronic inflammatory process longer disease duration, disability and recurrent falls.
causes an increase of type II insulin-like growth factor
(IGF-II), which is responsible for epidermal cell prolifera-
tion and is also implicated in atherogenesis and adipo- Abbreviations
AIDS: acquired immune deficiency syndrome; ANOVA: analysis of variance;
genesis, as well as an increase in vascular endothelial ApoE: apolipoprotein E; AS: ankylosing spondylitis; BC: body composition; BF:
growth factor (VEGF), which may be associated with body fat; BMD: bone mineral density; CASPAR: Classification Criteria for
angiogenesis and hyperinsulinemic states [39]. Psoriatic Arthritis; CDKAL1: cyclin-dependent kinase 5 regulatory subunit
associated protein 1-like 1; CRP: C-reactive protein; DAS28: Disease Activity
Genes associated with Ps and PsA may also be present Score 28; DXA: dual x-ray absorptiometry; EPM: Paulista School of Medicine;
in patients with metabolic disorders. The psoriasis sus- EVOS: European Vertebral Osteoporosis Study; GH: growth hormone; HC:
ceptibility (PSORS) loci PSORS2, PSORS3 and PSORS4 healthy controls; HAQ: Health Assessment Questionnaire; HIV: human
immunodeficiency virus; IFN: interferon; IGF: insulin-like growth factor; IL:
are associated with susceptibility loci to metabolic syn- interleukin; NHANES III: National Health and Nutrition Examination Survey;
drome, type 2 diabetes mellitus, familial hyperlipidemia OR: Odios ratio; Ps: psoriasis; PsA: psoriatic arthritis; PsARC: Psoriatic Arthritis
and cardiovascular disease. Individual genes associated Response Criteria; PASI: Psoriasis Area Severity Index; PSORS: psoriasis
susceptibility locus; RA: rheumatoid arthritis; RANKL: receptor activator of
with Ps, such as Cyclin-dependent kinase 5 regulatory nuclear factor-kappa ligand; SMMI: skeletal muscle mass index; TBF: total
subunit associated protein 1-like 1 (CDKAL1), are also body fat; TGFβ: transforming growth factor beta; Th: T-helper; TLM: total lean
associated with type 2 diabetes. Likewise, genes involved mass; TNF: tumor necrosis factor; UNIFESP: Federal University of São Paulo;
VAS: visual analogue scale; VEGF: vascular endothelial growth factor; VLDL:
with a higher risk of cardiovascular disease, such as the very low density lipoprotein; WHO: World Health Organization.
isoform ApoE4 of ApoE (Apolipoprotein E), are more
prevalent in Ps patients [40]. In the present study, type Acknowledgements
The authors would like to thank the staff at Sao Paulo Public Servants’
2 diabetes mellitus was more frequent in Ps patients. Hospital (especially Sonia Loducca, MD) and Dermatology Divison at
This is similar to the findings described by Sommer UNIFESP/EPM. This study was funded by a grant from Rheumatology
et al., who also found greater risk of hypertension and Division at UNIFESP/EPM.
dyslipidemia in these patients [41]. Furthermore, there Authors’ contributions
was a greater prevalence of hypertension in PsA and Ps PGG conducted data collection, interpretation and analysis of the data and
groups than HC; whereas, dyslipidemia has been more drafted the manuscript. MMP participated in study design, analyzed bone
scan DXA as well as spine X-ray for radiographic fractures, interpreted and
frequent in Ps patients. analyzed the data and helped to draft the manuscript. VLS participated in
Our data suggest that both PsA and Ps patients have a study design, interpretation and analysis of the data and helped to draft the
higher risk for developing metabolic syndrome and car- manuscript. All authors critically reviewed, contributed to and approved the
final manuscript.
diovascular disease. It is well established that Ps patients
have hyperuricemia, which could act as an aggravating Competing interests
factor for metabolic syndrome. Thus, we may suppose The authors declare that they have no competing interests.
greater prevalence of metabolic disease in PsA and Ps Received: 24 July 2010 Revised: 6 January 2011
patients than in RA or AS patients. Accepted: 7 February 2011 Published: 7 February 2011
Pedreira et al. Arthritis Research & Therapy 2011, 13:R16 Page 7 of 7
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