title: Incident Vertebral Fractures and Risk Factors in the First Three Years Following Glucocorticoid Initiation Among Pediatric Patients With Rheumatic Disorders.
abstract: Vertebral fractures are an important yet underrecognized manifestation of osteoporosis in children with chronic, glucocorticoid-treated illnesses. Our goal was to determine the incidence and clinical predictors of vertebral fractures in the 3 years following glucocorticoid initiation among pediatric patients with rheumatic disorders. Incident vertebral fractures were evaluated according to the Genant semiquantitative method on lateral radiographs at baseline and then annually in the 3 years following glucocorticoid initiation. Extended Cox models were used to assess the association between vertebral fractures and clinical risk predictors. A total of 134 children with rheumatic disorders were enrolled in the study (mean ± standard deviation (SD) age 9.9 ± 4.4 years; 65% girls). The unadjusted vertebral fracture incidence rate was 4.4 per 100 person-years, with a 3-year incidence proportion of 12.4%. The highest annual incidence occurred in the first year (6.0%; 95% confidence interval (CI) 2.9% to 11.7%). Almost one-half of the patients with fractures were asymptomatic. Every 0.5 mg/kg increase in average daily glucocorticoid (prednisone equivalents) dose was associated with a twofold increased fracture risk (hazard ratio (HR) 2.0; 95% CI 1.1 to 3.5). Other predictors of increased vertebral fracture risk included: (1) increases in disease severity scores between baseline and 12 months; (2) increases in body mass index Z-scores in the first 6 months of each 12-month period preceding the annual fracture assessment; and (3) decreases in lumbar spine bone mineral density Z-scores in the first 6 months of glucocorticoid therapy. As such, we observed that a clinically significant number of children with rheumatic disorders developed incident vertebral fractures in the 3 years following glucocorticoid initiation. Almost one-half of the children were asymptomatic and thereby would have been undiagnosed in the absence of radiographic monitoring. In addition, discrete clinical predictors of incident vertebral fractures were evident early in the course of glucocorticoid therapy.
authors: Department of Pediatrics, McGill University, Montreal, QC, Canada.
authors: Claire M A
authors: CM
authors: LeBlanc
authors: School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
authors: Jinhui
authors: J
authors: Ma
authors: School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
authors: Monica
authors: M
authors: Taljaard
authors: Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
authors: Johannes
authors: J
authors: Roth
authors: Department of Pediatrics, McGill University, Montreal, QC, Canada.
authors: Rosie
authors: R
authors: Scuccimarri
authors: Department of Pediatrics, University of Calgary, Calgary, AB, Canada.
authors: Paivi
authors: P
authors: Miettunen
authors: Department of Pediatrics, Dalhousie University, Halifax, NS, Canada.
authors: Bianca
authors: B
authors: Lang
authors: Department of Pediatrics, Dalhousie University, Halifax, NS, Canada.
authors: Adam M
authors: AM
authors: Huber
authors: Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
authors: Kristin
authors: K
authors: Houghton
authors: Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada.
authors: Jacob L
authors: JL
authors: Jaremko
authors: Department of Pediatrics, University of Calgary, Calgary, AB, Canada.
authors: Josephine
authors: J
authors: Ho
authors: Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada.
authors: Nazih
authors: N
authors: Shenouda
authors: Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada.
authors: Mary Ann
authors: MA
authors: Matzinger
authors: Department of Radiology, University of British Columbia, Vancouver, BC, Canada.
authors: Brian
authors: B
authors: Lentle
authors: Department of Pediatrics, University of Western Ontario, London, ON, Canada.
authors: Robert
authors: R
authors: Stein
authors: Department of Pediatrics, McGill University, Montreal, QC, Canada.
authors: Anne Marie
authors: AM
authors: Sbrocchi
authors: Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada.
authors: Kiem
authors: K
authors: Oen
authors: Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada.
authors: Celia
authors: C
authors: Rodd
authors: Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
authors: Roman
authors: R
authors: Jurencak
authors: Department of Pediatrics, Dalhousie University, Halifax, NS, Canada.
authors: Elizabeth A
authors: EA
authors: Cummings
authors: Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
authors: Robert
authors: R
authors: Couch
authors: Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
authors: David A
authors: DA
authors: Cabral
authors: Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
authors: Stephanie
authors: S
authors: Atkinson
authors: Department of Pediatrics, Université de Montréal, Montréal, QC, Canada.
authors: Nathalie
authors: N
authors: Alos
authors: Department of Pediatrics, McGill University, Montreal, QC, Canada.
authors: Frank
authors: F
authors: Rauch
authors: Department of Radiology and Diagnostic Imaging, and Department of Medicine, University of Alberta, Edmonton, AB, Canada.
authors: Kerry
authors: K
authors: Siminoski
authors: Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
authors: Leanne M
authors: LM
authors: Ward
mesh_terms: D000293:Adolescent; D001171:Arthritis, Juvenile / Q000150:complications / Q000188:drug therapy; D015519:Bone Density; D002648:Child; D015331:Cohort Studies; D003882:Dermatomyositis / Q000150:complications / Q000188:drug therapy; D005260:Female; D005938:Glucocorticoids / Q000009:adverse effects* / Q000627:therapeutic use*; D006801:Humans; D015994:Incidence; D008180:Lupus Erythematosus, Systemic / Q000150:complications / Q000188:drug therapy; D008297:Male; D010024:Osteoporosis / Q000188:drug therapy; D016016:Proportional Hazards Models; D012216:Rheumatic Diseases / Q000150:complications / Q000188:drug therapy*; D012307:Risk Factors; D012594:Scleroderma, Localized / Q000150:complications / Q000188:drug therapy; D012595:Scleroderma, Systemic / Q000150:complications / Q000188:drug therapy; D016103:Spinal Fractures / Q000139:chemically induced* / Q000175:diagnosis / Q000453:epidemiology; D056647:Systemic Vasculitis / Q000150:complications / Q000188:drug therapy
chemical_list: D005938:Glucocorticoids
keywords: ADOLESCENTS; BONE DENSITY; CHILDREN; GLUCOCORTICOIDS; RHEUMATIC DISORDERS; VERTEBRAL FRACTURES