Non-corticosteroid-related risk factors for osteonecrosis in patients with systemic lupus erythematosus: a meta-analysis

Background: Systemic lupus erythematosus (SLE) is a heterogeneous disease, and differences in the clinical features may be risk factors for osteonecrosis (ON) in addition to treatment with glucocorticoids. Objective: To assess the major risk factors for ON in SLE, and provide evidence for decision-making on prevention. Methods: The Cochrane library, PubMed, Ovid, and Science Direct were searched for published case-control studies on the risk factors of ON in SLE. A meta-analysis of 23 case-control studies (1,071 cases and 23,065 controls) that met the inclusion criteria was conducted using Revman 5.3 software. After analysis of homogeneity, the pooled odds ratios (OR) and 95% confidence intervals (CI) of each risk factor were calculated. Results: The pooled OR and 95% CI of each risk factor of ON in the patients with SLE were as follows: arthritis 1.69 [1.32, 2.17], central nervous system (CNS) involvement 1.34 [1.06, 1.71], diabetes mellitus 1.59 [1.03, 2.46], hypertension 1.69 [1.42, 2.02], oral ulcer 1.48 [1.06, 2.08], renal involvement 1.53 [1.27, 1.83], vasculitis 2.45 [1.54, 3.89], smoking history 1.64 [1.01, 2.65], leucopenia 1.54 [1.11, 2.13], thrombocytopenia 1.63 [1.14, 2.32], cytotoxic drugs 1.79 [1.25, 2.57], cyclophosphamide 3.13 [1.58, 6.21] and anti-Sm antibodies 0.48 [0.27, 0.85]. Conclusion: In addition to gluco-corticosteroids, other factors, including arthritis, CNS involvement, diabetes mellitus, hypertension, oral ulcer, renal involvement, vasculitis, smoking history, leucopenia, thrombocytopenia, cytotoxic drugs and cyclophosphamide are major risk factors of ON in patients with SLE. Anti-Sm antibodies represent a protective factor against ON in patients with SLE, while antimalarial drugs are not.