BONE MINERAL DENSITY IN PREMENOPAUSAL WOMEN WITH RHEUMATOID ARTHRITIS AND SYSTEMIC LUPUS ERYTHEMATOSUS

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1 Egypt Rheumatol Rehab Vol. 32. No. 2, March, 2005 BONE MINERAL DENSITY IN PREMENOPAUSAL WOMEN WITH RHEUMATOID ARTHRITIS AND SYSTEMIC LUPUS ERYTHEMATOSUS TAREK KOURAH, EIHAB ABDUL-AATTY, NEVINE MOHAMMAD BADRE*, AND AMAAL MUSTAFA AL-GANZOURY* Internal Medicine Department, Menoufiya University and Rheumatology & Rehabilitation Department, Ain Shams University* Faculties of Medicine KEY WORDS: BONE MINERAL DENSITY CORTICOSTEROIDS RHEUMATOID ARTHRITIS - SYSTEMIC LUPUS ERYTHEMATOSUS. ABSTRACT Background: Little is known about bone mineral density (BMD), as measured by dual energy x-ray absorptiometry (DEXA), in patients with rheumatoid arthritis (RA) versus matched systemic lupus erythematosus (SLE) and healthy controls at the same time. However, most of these data have been confined to Caucasian population with conflicting results. Also factors controlling bone homeostasis may be different between ethnic groups with lacking data in Orientals. Objectives: Is to study BMD in premenopausal women with RA and to compare the data of RA patients with matched SLE patients and healthy controls. Moreover, is to evaluate the possible relationship between BMD and disease variables. Methods: This study included 60 premenopausal women divided into three equal groups, 20 subjects each, RA patients group, SLE patients group, and healthy controls group. BMD at the lumbar spine (L1-L4) was measured by DEXA. Also, disease variables and biochemical parameters were assessed. Results: Patients with RA and SLE had significantly lower BMD values at lumbar spine compared to healthy controls (p=0.0001). Similar BMD values were detected in RA and SLE patients. Osteopenia was detected in 40% of RA and SLE patients groups, while osteoporosis (OP) was detected in 251

2 Bone Mineral Density in Pre-Menopausal RA & SLE Kourah et al. 40% and 30% of those patients, respectively. There was no correlation between BMD and age of patients, body mass index (BMI), disease activity, as well as disease duration. In contrast, there was an inverse correlation between BMD and dose as well as duration of corticosteroid (CS) therapy (p<0.05). Conclusion: A high incidence of low BMD at the lumbar spine was found in our premenopausal women with RA and SLE on chronic CS and calcium supplementation compared with healthy controls. In those patients, BMD was related to the dose and duration of CS therapy, but not with disease duration or disease activity. INTRODUCTION Rheumatoid arthritis (RA) is a disease that has been shown to affect bone metabolism. The role of corticosteroids (CS) in promoting bone loss in RA remains unclear (Sambrook et al, 1995). There have been controversies on whether all or only some patients with RA are affected by osteoporosis (OP), the dose of CS that causes or does not cause bone loss, and the clinical significance of this (Woolf., 1991 and Laan et al., 1992). In fact, some reports have suggested that steroids, by reducing the disease activity and improving mobility, can stop bone loss (Sambrook et al., 1989). Over recent decades, the life expectancy of patients with systemic lupus erythematosus (SLE) has improved dramatically. This raises concerns about CS-induced side effects including OP (Reveille et al., 1990 and Somachai et al., 2003). Although the effect of disease activity and CS therapy on bone mineral density (BMD) in patients with SLE has been assessed, most studies have been confined to the Caucasian population and the conclusions have been conflicting (Dhillon et al., 1990, Pons et al., 1995 and Houssiau et al., 1996). Moreover, the conclusions regarding the effects of CS dose and the duration of therapy on bone loss in SLE have been equally conflicting (Pons et al., 1995 and Houssiau et al., 1996). Many of the previous studies done on OP in RA and SLE patients have used older methods, making comparison with newer studies difficult. Nevertheless, the availability of dual energy x-ray absorptiometry (DEXA) constitutes a new significant advance in the non-invasive assessment of patients with metabolic bone disease. However, only few studies have considered the question, if patients with SLE have an increased incidence of osteopenia or OP, with conflicting results (Dhillon et al., 1990 and Kalla et al., 1993). Meanwhile, little is known about the changes in BMD, as assessed by DEXA, in RA and SLE patients versus healthy controls. 252

3 Egypt Rheumatol Rehab Vol. 32. No. 2, March, 2005 Furthermore, evidence is now growing that calcium homeostasis and the effects of declining BMD varies among different ethnic groups (Hegsted., 1986, Sugimoto et al., 1992 and Luz & Nelson., 1996). Therefore, the aim of the present study is to assess BMD using DEXA, in pre-menopausal women with RA and matched SLE patients treated with CS and calcium supplementation, compared to healthy controls. Also, to assess the influence of CS and disease variables on BMD. PATIENTS AND METHODS A total of 60 premenopausal Saudi women were included in this study. Patients were recruited from the outpatient clinics of the internal medicine and rheumatology departments, in a big eastern district region hospital in the Kingdom of Saudi Arabia. They were divided into three equal groups, each constitutes 20 subjects, RA patients group, SLE patients group, and healthy controls group. The mean age was 36±6.7, 34.2±5.6, and 35.7±6.7 years, respectively. Patients with RA and SLE were matched for age and disease duration. Healthy controls were matched for age and geographical area. None of the healthy controls had rheumatic disease or used CS as a management for other diseases. Inclusion criteria included premenopausal Saudi female patients with an established diagnosis of RA or SLE. All patients fulfilling the criteria of the American College of Rheumatology for diagnosis of RA or SLE, respectively (Arnett et al., 1988 and Tan et al., 1982). All patients were non-smokers, ambulatory, functional class I (Steinbrocker et al., 1947). All patients had been on CS and calcium supplementation for at least 5 months at the time of BMD measurement. Exclusion criteria included all patients with renal impairment (serum creatinine of more than 2 mg%), severe hepatic disease, severe transient amenorrhea lasting more than two months, hyperthyroidism, use of any medication known to affect bone metabolism (except CS and calcium), women unable to walk without assistance and women with history of hysterectomy. Disease duration, mean daily and cumulative CS dose, duration of CS treatment and the use of immunosuppressive agents were recorded, by reviewing patients records. All (100%) RA patients were treated with prednisone and non-steroidal anti-inflammatory drugs (NSAIDs), 15 (75%) with methotrexate, 2 (10%) with injectable gold and 3 (15%) with penicillamine. In contrast, all (100%) patients with SLE were on prednisone as well as NSAIDs. 253

4 Bone Mineral Density in Pre-Menopausal RA & SLE Kourah et al. The disease activity score (DAS) composite index was used to assess disease activity and was calculated from 28 joints (Prevoo et al., 1995). This includes the number of swollen joints, number of tender joints and patients global assessment of disease activity, measured on a visual analogue scale ranging from mm and the erythrocyte sedimentation rate, creating a score ranging from Lupus disease activity and severity were also evaluated by the systemic lupus erythematosus Disease Activity Index (Bombardier et al., 1992) and simple severity of disease index for systemic lupus erythematosus (Katz et al., 1993), respectively. Blood samples were collected for measurement of serum hemoglobin (Hb), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serum calcium, serum phosphorus, and serum alkaline phosphatase. BMD was measured in all subjects at the lumbar spine (L1-L4) with antero-posterior view, by DEXA equipment (Lunar Expert, Madison, Wisconcin). BMD was expressed as the number of standard deviations (SD) from the mean of young healthy people, the T score and the number of SD from the mean of healthy age and sex matched people, the Z score. Based on the WHO criteria for OP (Kanis et al., 1994), patients were determined to be either normal (T score >-1), osteopenic (T score <-1), osteoporotic (T score <-2.5), or severely osteoporotic (T score <-2.5 with bone fracture). The BMD in RA patients was compared with the BMD of SLE patients and healthy controls. Statistical analysis: Data were collected and transferred into the computer. Results were expressed as mean ± SD. Statistical difference among groups was performed using unpaired Student s t-test and ANOVA test. Correlations between BMD and different variables of the patients were evaluated using Pearson correlation coefficient. The level of significance was set at P<0.05. RESULTS This study included 20 patients with RA, 20 patients with SLE, and 20 healthy controls. All patients and controls were premenopausal females. Characteristics of studied patients and controls were shown in table 1. There was no significant difference between RA and SLE patients versus controls with regard to age and serum alkaline phosphatase (p=0.223, and p=0.18, respectively). There was a significant difference among the groups as regards weight, hemoglobin level, ESR, CRP, serum calcium and serum phosphorus. The weight of the patients was significantly lower than controls (p=0.0001), but there was no significant difference between 254

5 Egypt Rheumatol Rehab Vol. 32. No. 2, March, 2005 patients with RA and those with SLE (p=0.17). The height of the patients with RA was significantly lower than controls (p=0.003), but there was no significant difference between patients with SLE and controls (p=0.11). The body mass index (BMI) was significantly lower in patients with SLE than controls (p=0.0001), but there was no significant difference between patients with RA and controls (p=0.08). Hemoglobin level was significantly lower in patients than controls (p=0.0001), but there was no significant difference between patients with RA and those with SLE (p=0.42). The ESR of RA patients was significantly higher than SLE patients (p=0.001). CRP was significantly higher in patients than controls (p=0.0001), but there was no significant difference between patients with RA and those with SLE (p=0.29). Serum calcium was significantly lower in RA patients than SLE patients and controls (p=0.002), but there was no significant difference between patients with SLE and controls (p=0.21). Serum phosphorus was significantly lower in patients than controls (p=0.01), but there was no significant difference between patients with RA and those with SLE (p=0.07). There was no significant difference between patients with RA and SLE as regards the disease duration (p=0.476). Lumbar BMD for all studied subjects was shown in table 2. Both the T-score and BMD of all patients were significantly lower than controls (p=0.0001), but there was no significant difference between patients with RA and those with SLE (p=0.21, p=0.08, respectively). However, the Z- score of the patients was significantly higher than controls (p=0.0001), but there was no significant difference between patients with RA and those with SLE (p=0.22). The overall proportion of RA and SLE patients with reduced BMD (T-score <-1 SD) was higher than controls, but it did not reach statistical significance (p=0.11). The frequency of those with osteopenia (T-score <-1 SD) or OP (T-score <2.5 SD) in RA and SLE patients was significantly higher compared to healthy controls (p=0.03) (Table 3). There was no significant difference between patients with RA and those with SLE regarding CS therapy (daily dose, duration of therapy, and cumulative dose) and calcium supplementation (p>0.05) (Table 4). Also, there was no correlation between BMD and disease variables as regards patients age, BMI, hemoglobin level, ESR, CRP, and disease duration. However, there was an inverse correlation between the dose as well as the duration of CS therapy and BMD (p<0.05) (Table 5). 255

6 Bone Mineral Density in Pre-Menopausal RA & SLE Kourah et al. Table (1): Characteristics of patients with RA and SLE versus controls (Data expressed as mean ±SD). Range of Criteria RA group SLE group Control group p-value Age, years 36 ± 6.7(23-46) 34 ± 5.6 (28-46) 35 ± 6.7(26-45) Weight, Kg ± 12.8(44-88) 68 ± 8.9(55-86) 84 ±7(75±101) * Height, cm ± 6( ) 157± 7.5( ) 160 ± 8( ) 0.01* BMI, Kg / m² ± 6(20±41.4) ± 3.3(20-32) ± 3(29-39) 0.08* Dis. Duration 4.24 ± 2.68(2-11) 4.2 ± 1.1 (2.5-6) NA Hb, gm/dl 10.6 ± 0.9( ) ± 1( ) 13.1 ± 1(11-16) * ESR, mm 42.4 ± 12.1(25-61) 24.3 ± 8.83(13-43) 9.6 ± 2.48(6-14) 0.001* CRP, mg 17.6 ± 12.9(4-49) 15.5 ± 10.1(5-41) 2.3 ± 1.78(1-5) * S. Calcium, mg 8.97 ± 0.29( ) 9.3 ± 0.38(8.8-10) 9.22 ± 0.2(9-9.6) 0.002* S. Phos, mg 3.35 ± 0.38( ) 3.17 ± 0.32( ) 3.6 ± 0.6(2.9-4) 0.01* S.A. Phos. U/L 89.8 ± 27.4(53-141) 82.8 ±17.9(58-113) 89 ±17(69-117) 0.18 NA = Not applicable. A. Phos. = Alkaline phosphatase. S. = Serum. Hb = Hemoglobin. Dis. =Disease. *= Significant. Table (2): Lumbar bone mineral density for all studied subjects (Data expressed as mean ±SD). RA group SLE group Control group p-value T score ± ± ± * Z score ± ± ± * BMD (gm/cm²) ± ± ± * * = Significant Table (3): Overall frequency of osteopenia and osteoporosis in all studied subjects (According to WHO Criteria for osteoporosis). WHO Classification RA group SLE group Control group No. (%) No. (%) No. (%) Normal 4 (20) 6 (30) 18 (90) Osteopenia 8 (40) 8 (40) 2 (10) Osteoporosis 8 (40) 6 (30) 0 (0) Severe osteoporosis 0 (0) 0 (0) 0 (0) Total 20 (100) 20 (100) 20 (100) 256

7 Egypt Rheumatol Rehab Vol. 32. No. 2, March, 2005 Table (4): Comparison between patients with RA and SLE on Corticosteroid (Prednisone) therapy and calcium supplementation (Data expressed as mean ±SD). CS. Therapy Calcium Supplement Daily dose, mg Duration of therapy, year Cumulative dose, gm Daily dose, mg Duration of therapy, year RA group SLE group p- value 8.75±2.07 (5-10) 10.25±3.53(5-15) ±2.68 (2-11) 3.45±1.06(2-6) ±18.6(10-66) 33±13.17(15-60) ±217( ) 780±228( ) ±1.2( ) 2.4±1.5(1-6) Table (5): Correlation between lumbar Bone mineral density, disease variables and corticosteroid (Prednisone) therapy in all patients. Disease variables RA group SLE group R r Age (years) BMI (kg/m²) Hemoglobin (gm/dl) ESR CRP Disease duration (years) Corticosteroid therapy Daily dose, mg Duration of therapy, year Cumulative dose, gm DISCUSSION There are limited data comparing the changes of BMD in premenopausal women having RA, with age and disease duration matched SLE patients as well as healthy controls. Most of these data are confined to Caucasians with conflicting results. Therefore, the present study aimed at studying BMD in RA patients and comparing it with matched SLE patients and healthy controls. Our study has shown that BMD, as assessed by DEXA of the lumbar region, is significantly lower in premenopausal women with RA and SLE, taking chronic prednisone therapy, compared with healthy controls from the 257

8 Bone Mineral Density in Pre-Menopausal RA & SLE Kourah et al. same geographical area. Also, there was no significant difference in the frequencies of osteopenia or OP between RA and SLE patients, at the lumbar spine. The similar BMD values, in RA and SLE patients, are interesting in view of the clearly documented impact of RA on BMD (Hall et al., 1993 and Deodhar et al., 1996). In agreement with our results, a recent study from the same geographical area, conducted by Noorwali (2004), measured BMD using DEXA in 30 Saudi premenopausal women with RA, in addition to 10 healthy controls, and found a significant decrease in BMD in those patients compared with controls. Also, compatible to our results, he found no correlation between BMD and age, body weight, as well as disease duration. Moreover, in agreement with the majority of studies done on Caucasians (Formiga et al., 1995 and Pons et al., 1995), our study has demonstrated that BMD is significantly lower in SLE patients on chronic corticosteroids (CS). Furthermore, comparable to most studies, we did not find any relationship between BMD and duration of SLE. In our study, the prevalence of osteopenia and OP in SLE was 40 % and 30 %, respectively. This frequency of osteopenia is compatible with those reported in Caucasians (25%) (Kalla et al., 1993), in Chinese population (32%) (Li et al., 1998), and Thailandian population (32.5%) (Somachi et al., 2003). In contrast, the frequency of OP was higher than the results previously reported in Caucasians (12-18 %) (Formiga et al., 1995 and Pons et al., 1995). In the study done by Formiga et al, all SLE patients were on CS therapy (n=74) and had lower BMD at the lumbar spine compared to healthy controls. In that study, BMD did not correlate with either cumulative or current prednisone dose. Moreover, a much lower prevalence of OP has been described in Chinese and Thailandian SLE female patients treated with CS, 6% and 1.4%, respectively (Li et al., 1998 and Somachi et al., 2003). In the study done by Li-et al, a much lower frequency than that reported in Caucasians was observed in steroid-treated patients. There was no difference in prednisone treatment with respect to mean daily dose and duration of treatment. Many factors can contribute to the different BMD values. First, there were several studies showing that calcium homeostasis was different in certain ethnic groups such as Thailandian population, compared to other groups (Hegsted DM, 1986, Sugimoto et al., 1992 and Komidar et al., 1996). Therefore, it is possible that interethnic difference in calcium homeostasis through effects on BMD, may in part explain the lower rate of OP in Thailandian as well as in Chinese SLE patients on CS, compared to those reported in Caucasians and to our Saudi patients. Second, a genetic 258

9 Egypt Rheumatol Rehab Vol. 32. No. 2, March, 2005 polymorphism of the vitamin D receptor gene has been identified (Morrison et al., 1994). A particular variant has been found to be associated with higher dietary calcium absorption (Dawson et al., 1995) and a greater responsiveness of BMD to calcium and vitamin D supplementation (Matsuyama et al., 1995). Third, the higher frequency of OP in our SLE patients compared to these reports can be attributed to the higher cumulative prednisone doses in our study (33 gm versus 7.9 and 5.2 gm, respectively) (Li et al., 1998 and Somachai et al., 2003). In contrast to our study, Dhillon et al. (1990) did not find a significant reduction in BMD in their SLE patients compared to controls. In that study, no significant difference was observed in the lumbar spine BMD between controls (n=10) and SLE patients, either receiving (n=10) or not receiving (n=10) CS therapy. Although numbers are small, there was a trend towards lower BMD in SLE patients. However, in accordance to our data, the study of Kalla et al. (1993), showed that in SLE patients (n=46), 50 % of those on CS, had significantly lower BMD at lumbar spine. Although on comparing SLE patients receiving and those not receiving CS there was no difference in BMD, but groups were not matched for the duration of the disease. Our data showed a lack of correlation between BMD in SLE patients, and disease duration as well as disease activity. This agrees with most of the previous studies (Dhillon et al., 1990, Formiga et al., 1995 and Pons et al., 1995). However, in our study, we found an inverse correlation between the lumbar BMD in SLE patients and CS treatment (mean daily dose, cumulative dose, or treatment duration). This is in agreement with Houssiau et al. (1996), but not with Formiga et al. (1995) and Li et al. (1998). Most studies showed that the lumbar spine is more affected by CS than various hip subregions (Kalla et al., 1993 and Horslev et al., 1995). This may be due to the more pronounced inhibitory effect of CS on bone metabolism at this site (Sambrook et al., 1990 and Petri M., 1996), or may possibly be secondary to the effects of pro-inflammatory cytokines involved in the pathogenesis of SLE itself (Linker et al., 1991). Data from the three previous studies have compared bone mass in RA and SLE and showed conflicting results, however, none of them used DEXA for measurement (Dykman et al., 1985, Kalla et al., 1989 and Kalla et al., 1994). In line with our study, Dykman et al. (1985), found no difference in the proportion of CS-induced osteopenia in RA and SLE patients, where as Kalla et al. (1989) and (1994), observed significantly reduced bone mass in RA patients, only on performing radiometry in 259

10 Bone Mineral Density in Pre-Menopausal RA & SLE Kourah et al. premenopausal RA and SLE patients, as well as in healthy controls. Kalla et al. (1989) also observed endosteal resorption in RA, in contrast with the more severe periosteal resorption by metacarpal measures in SLE, suggesting differences in the mechanism of OP in the two diseases. In patients with RA and SLE, the factors provoking reduced BMD may, be different. In RA, the important factors implicated in the pathogenesis of bone loss are circulating cytokines (such as tumor necrosis factor and inteleukin-1) produced by the inflammatory process, reduced mobility due to functional impairment, and use of CS in the dose of 5mg or more (Deodhar et al., 1996). In contrast, SLE patients are more extensively exposed to CS i.e. receiving peak steroid doses rather than fixed doses, compared with RA. In SLE, factors other than CS may also be important such as avoidance of sun exposure, renal dysfunction, anticoagulant treatment (Segal et al., 1996). Nevertheless, in our study, no patient had renal dysfunction, or used an anticoagulant treatment. In conclusion, the present study showed that our premenopausal women with RA as well as SLE patients had significantly reduced BMD at the lumbar spine, as assessed by DEXA, compared to healthy controls. Moreover, there was no correlation between BMD in our patients and age of the patients, body mass index (BMI), disease duration or disease activity. In contrast, BMD correlated with the dose, and duration of CS therapy. Our results implicate several clinical consequences. First, low BMD in premenopausal women with RA and SLE justifies regular DEXA screening of those patients. Second, measures aimed at prophylaxis and treatment of reduced BMD should be included in the medical management of patients with RA and SLE, especially those on CS therapy. Further studies are needed to examine the possibility that calcium supplementation may be more effective mean of reducing CS-related bone loss in certain ethnic groups, but not in others. REFERENCES Arnett FC, Edworthy SM, Block DA et al. (1998): The American Rheumatism Association 1987 revised criteria for classification of rheumatoid arthritis. Arthritis Rheum 31: Bombadier C, Gladman DD, Urowitz MB, Caron D, Chang CH (1992): Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in Systemic Lupus Erythematosus. Arthritis Rheum 35: Dawson HB, Harris SS, Finneran S (1995): Calcium absorption on high and low calcium intakes in relation to vitamin D receptor genotype. J Clin Endocrinol Metab 80:

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14 Bone Mineral Density in Pre-Menopausal RA & SLE Kourah et al. آثافة العظام في السيدات قبل انقطاع الطمث المصابين بمرض المفصلي و الذي بة الحمراء طارق قورة إيهاب عبدالعاطي نيفين بدر* أمال الرثيان الجنزوري * قسم الباطنة العامة جامعة المنوفية وقسم الروماتيزم والتا هيل جامعة عين شمس* ملخص البحث: توجد معلومات قليلة ع ن قي اس آثاف ة العظ ام بواس طة جه از قي اس آثاف ة العظ ام ف ي م رض الرثي ان المف صلي والذي بي ة الحم راء مقارن ة بالا ش خاص الا ص حاء آ ذلك تختل ف العوامل المتحكمة في آثافة العظام بين الا جناس المختلفة. اله دف: م ن ه ذا البح ث ه و دراس ة آثاف ة العظ ام ف ي مرض ي الرثي ان المف صلي الذي ب ة الحم راء مقارن ه بالا ش خاص الا ص حاء وآ ذلك دراس ة احتم ال وج ود علاق ة ب ين آثاف ة العظ ام ومتغيرات هذين المرضين. الطريقة: وقد شمل البحث 60 مريضة في سن م ا قب ل انقط اع الطم ث مق سمة إل ى ث لاث مجموع ات تح وي آ ل منه ا عل ى 20 مري ضة: مجموع ة مرض ى الرثي ان المف صلي مجموع ة مرضى الذي بة الحمراء مجموعة الا شخاص الا صحاء للمقارنة. هذا وقد تم قي اس آثاف ة العظ ام ف ي الفقرات القطنية وآذلك متغيرات المرض في المجموعات الثلاث. النت اي ج: أظه رت أن آثاف ة العظ ام آان ت قليل ة ف ي مجم وعتي المرض ى وزادت دلال ة إحصاي ية بالمقارنة بمجموعة الا شخاص الا صحاء ولكن آثافة العظام آانت مت ساوية ف ي مجم وعتي المرضى. وقد أتضح أيضا أنه لا توجد علاقة بين آثافة العظام وبين هو لاء المرضى ومعام ل آتل ة الجسم وآذلك نشاط ومدة المرض ولكن بالمقابل اتضح وجود علاقة عكسية ذات دلال ة إ حاي ي ة ب ين آثافة العظام وجرعة وآذلك مدة استخدام العقاقير الاستيرودية. الخلاصة: أنه قد اتضح وجود نسبة عالية من نق ص آثاف ة العظ ام المقاص ة بجه از قي اس آثاف ة العظ ام ب الفقرات القطني ة ف ي ال سيدات قب ل س ن انقط اع الطم ث والم صابين بم رض الرثي ان المف صلي أو الذي ب ة الحم راء والمع الجين بالعق اقير الاس تيرودية والكال سيوم مقارن ة بالا ش خاص الا صحاء. آذلك تبين أن نقص آثافة العظام آان مرتبطا بجرعة ومدة العلاج بالعق اقير الاس تيرودية ولكنه آان غير مرتبطا بمدة أو نشاط المرض في هو لاء المرضى. 264