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Risk factors associated with prevalent vertebral fractures in Duchenne muscular dystrophy

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Abstract

Summary

Patients with Duchenne muscular dystrophy (DMD) have a high fracture burden due to progressive myopathy and steroid-induced osteoporosis. This study in males with DMD showed that markers of systemic glucocorticoid exposure including shorter stature, greater bone age delay, and lower lumbar spine bone mineral density were associated with spine fragility.

Introduction

Fragility  fractures are frequent in DMD. The purpose of this study was to identify clinical factors associated with prevalent vertebral fractures (VF) in boys, teens/young adults with Duchenne muscular dystrophy (DMD).

Methods

This was a cross-sectional study of males aged 4–25 years with DMD. VF were evaluated using the modified Genant semi-quantitative method on T4-L4 lateral spine radiographs. Areal bone mineral density (aBMD) was measured at the lumbar spine (LS) and used to estimate volumetric BMD (vBMD). Clinical factors were analyzed for their association with the Spinal Deformity Index (SDI, the sum of the Genant grades).

Results

Sixty participants were enrolled (mean age 11.5 years, range 5.4–19.5). Nineteen participants (32%) had a total of 67 VF; 23/67 VF (34%) were moderate or severe. Participants with VF were shorter (mean height Z-score ± standard deviation: − 3.1 ± 1.4 vs. − 1.8 ± 1.4, p = 0.001), had longer glucocorticoid exposure (mean duration 6.0 ± 3.3 vs. 3.9 ± 3.3 years, p = 0.027), greater bone age (BA) delay (mean BA to chronological age difference − 3.2 ± 3.4 vs. − 1.3 ± 1.2 years, p = 0.035), and lower LSaBMD Z-scores (mean − 3.0 ± 1.0 vs. − 2.2 ± 1.2, p = 0.023). There was no difference in LSvBMD Z-scores.

Multivariable Poisson regression showed that every 0.1 mg/kg/day increment in average glucocorticoid daily dose was associated with a 1.4-fold SDI increase (95% confidence interval: 1.1–1.7, p = 0.013). Greater BA delay (p < 0.001), higher weight Z-score (p = 0.004), decreased height Z-score (p = 0.025), and lower LSvBMD Z-score (p = 0.025) were also associated with SDI increase.

Conclusion

Readily measurable clinical variables were associated with prevalent VF in males with glucocorticoid-treated DMD. These variables may be useful to identify candidates for primary osteoporosis prevention after glucocorticoid initiation.

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Funding

The Bone Fragility in Boys with DMD study was funded by the Physicians’ Services Inc. (Grant No. 14–03, awarded to LMW, Study Principal Investigator). The Steroid-associated Osteoporosis in the Pediatric Population (STOPP) study was funded by the Canadian Institutes for Health Research (Grant No. CIHR FRN 64285, awarded to LMW, Study Principal Investigator). KP was supported by a Clinical Research Fellowship funded by the Parent Project Muscular Dystrophy and Defeat Duchenne Canada (formerly Jesse’s Journey). LMW was supported by a Tier 1 Clinical Research Chair Award from the University of Ottawa and by the Children’s Hospital of Eastern Ontario Research Institute. MER was supported by a Junior Clinical Research Chair Award from the University of Ottawa and by the Children’s Hospital of Eastern Ontario Research Institute.

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Authors and Affiliations

  1. Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada

    Kim Phung, Kevin Smit, Scott Walker, Colleen Hartigan, Marika Page, Marie-Eve Robinson & Leanne M. Ward

  2. The Ottawa Pediatric Bone Health Research Group, Children’s Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada

    Kim Phung, Stefan Jackowski, Maya Scharke, Scott Walker, Colleen Hartigan, Nasrin Khan, Victor N. Konji, Lynn MacLeay, Marika Page, Elizabeth Sykes & Leanne M. Ward

  3. Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada

    Laura McAdam

  4. Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada

    Jinhui Ma

  5. Montreal Children’s Hospital, McGill University, Montreal, QC, Canada

    Hugh J. McMillan & Anne Marie Sbrocchi

  6. Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada

    Mary-Ann Matzinger, Nazih Shenouda & Khaldoun Koujok

  7. Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada

    Jacob L. Jaremko & Kerry Siminoski

  8. CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada

    Nathalie Alos

  9. IWK Health Centre, Dalhousie University, Halifax, NS, Canada

    Elizabeth A. Cummings

  10. Alberta Children’s Hospital, University of Calgary, Calgary, AB, Canada

    Josephine Ho

  11. London Health Sciences Centre, Western University, London, ON, Canada

    Robert Stein

  12. Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada

    David Saleh

  13. Department of Medicine, Temerty Faculty of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada

    B. Catharine Craven

  14. Department of Health Sciences, Carleton University, Ottawa, ON, Canada

    Utkarsh J. Dang

  15. Shriners Hospital for Children, McGill University, Montreal, QC, Canada

    Frank Rauch

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  1. Kim Phung
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Correspondence to Leanne M. Ward.

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Conflict of interest

None of the authors have conflicts of interest related to this observational study. Unrelated to the study, some of the authors report the following potential conflicts of interest: NA has participated in clinical trials with Amgen and Novartis. MER has received a study grant from Ascendis Biopharma, and consultancy fees from Ipsen Biopharmaceuticals and Ultragenyx, with funds to her institution. HJM has participated in clinical trials with Roche, PTC Therapeutics, ReveraGen, Catabasis, Novartis and Sarepta, been a consultant for Novartis Gene Therapies and received research support from Roche. UJD has been a consultant to, and participated in clinical trials with, ReveraGen Biopharma. LMW has been a consultant to, and participated in clinical trials with, Amgen, Novartis, PTC, ReveraGen, Catabasis, Ipsen, and Ultragenyx, with funds to her institution.

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Phung, K., McAdam, L., Ma, J. et al. Risk factors associated with prevalent vertebral fractures in Duchenne muscular dystrophy. Osteoporos Int 34, 147–160 (2023). https://doi.org/10.1007/s00198-022-06578-6

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