title: Low bone density in systemic sclerosis. A systematic review.
abstract: OBJECTIVE
  The effect of systemic sclerosis (SSc) on bone density is not well understood. Through systematic review of the literature, the objectives of this study were to synthesize data about the prevalence of low bone mineral density (BMD), risk factors for low BMD, and occurrence of fracture and fracture-related mortality in SSc.
  
  
  METHODS
  A search was conducted of MEDLINE (1948-2012), Evidence Based Medicine Reviews (1991-2012), EMBASE (1980-2012), and CINAHL (1981-2012). Abstracts were screened to identify studies that evaluated low BMD in patients with SSc. Two investigators independently used a standardized form to abstract prevalence of osteopenia and osteoporosis (OP); risk factors for low BMD, BMD measurements, frequency of fracture, and fracture-related mortality.
  
  
  RESULTS
  Screening of 1032 citations identified 19 articles. Fifteen studies compared patients with SSc to controls. Most patients were white, female (prevalence 74%-100%), and postmenopausal (prevalence 45.9%-100%). The prevalence of low BMD and OP was 27%-53.3% and 3%-51.1%, respectively. Ten studies reported a lower BMD in patients with SSc compared to matched controls, whereas 2 studies reported no difference. Candidate risk factors for low BMD in SSc include family history of OP, age, menopause, diffuse subtype, presence of internal organ involvement, low vitamin D levels, and calcinosis. However, the studies supporting these factors were conflicting. Fracture rate ranged between 0% and 38%. No study reported OP-related fracture mortality.
  
  
  CONCLUSIONS
  The data suggest that patients with SSc are at risk of low BMD and fracture, especially when other risk factors for OP are present. The interaction of SSc manifestations, traditional OP risk factors, and clinically relevant outcomes is complex and warrants further research.
authors.affiliation: From the Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital; Osteoporosis Program, Toronto General Hospital; Division of Rheumatology, Department of Medicine, Toronto Western Hospital; and Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Omair
authors.forename: Christian
authors.initials: C
authors.lastname: Pagnoux
authors.forename: Heather
authors.initials: H
authors.lastname: McDonald-Blumer
authors.forename: Sindhu R
authors.initials: SR
authors.lastname: Johnson
mesh_terms: D015519:Bone Density / Q000502:physiology*; D001851:Bone Diseases, Metabolic / Q000150:complications* / Q000503:physiopathology; D006801:Humans; D010024:Osteoporosis / Q000150:complications* / Q000503:physiopathology; D058866:Osteoporotic Fractures / Q000209:etiology* / Q000503:physiopathology; D012307:Risk Factors; D012595:Scleroderma, Systemic / Q000150:complications* / Q000503:physiopathology
keywords: BONE DENSITY; FRACTURE REVIEW; OSTEOPENIA; OSTEOPOROSIS; SCLERODERMA; SYSTEMIC SCLEROSIS