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58
Орипнальш дослiдження / Original Researches
БШЬ.
СуГЛОБИ. JOINTS. I ХРЕБЕТ SPINE I
УДК616.74-081-007.23-036.2-036.1 DOI: 10.22141/2224-1507.9.2.2019.172120
V.V. Povoroznyuk1, N.I. Dzerovych1, O.S. Ivanyk1, T.A. Karasevska2
'State Institution "D.F. Chebotarev Institute of Gerontology by the NAMS of Ukraine", Kyiv, Ukraine
2Bogomolets National Medical University, Kyiv, Ukraine
Sarcopenia and rheumatoid arthritis
For cite: Bol', sustavy, pozvonocnik. 2019;9(2):83-89. doi: 10.22141/2224-1507.9.2.2019.172120_
Abstract. Background. Nowadays in the field of syndromes and diseases associated with age, scientists focus especial attention on the problem of sarcopenia, which combines an increased risk of falls, deterioration of life quality, impaired functional activity, reduced life expectancy and increased mortality of patients. In 2016, sarcopenia has been included in the International Classification of Diseases. There are the primary and secondary forms of sarcopenia. This article presents the reference data and results of our own studies on sarcopenia in the rheumatoid arthritis patients. The aim of this study was to evaluate the bone mineral density, lean mass and frequency of pre-scarcopenia in patients with rheumatoid arthritis. Materials and methods. 461 women aged 40—87 years (age 57.17 ± 0.71 years) were examined, among them 71 patients with rheumatoid arthritis and 390 controls. We conducted the clinical and laboratory examination (erythrocyte sedimentation rate and C-reactive protein level in serum). Pain intensity was evaluated by the visual analogue scale, the quality of life — by the HAQ questionnaire. Lean mass, bone mineral density were measured by the X-ray absorptiometry (Prodigy, GEHC Lunar, Madison, WI, USA). Pre-sarcopenia (first stage of sarcopenia) was determined when an appendicular lean mass index was less than 5.72 kg/m2 (V.V. Povoroznyuk, N.I. Dzerovich, 2016). Statistical analysis was conducted using the "Statistica 6.0" software. Results. Patients with rheumatoid arthritis had a significantly lower femoral neck mineral density (p = 0.002), lean mass of the total body (p = 0.01) and appendicular lean mass (p < 0.01). The frequency of pre-sarcopenia in women with rheumatoid arthritis was 49 %, in the control group — 18 %. Conclusions. Patients with rheumatoid arthritis had not only bone tissue, but also skeletal muscle tissue disorders, resulting in a significant deterioration of functional capacity and quality of life. Given the significant medical and social significance of the problem, further studies into the mechanisms of pathogenesis, development of diagnostic methods, prevention and treatment of sarcopenia in patients with rheumatoid arthritis are required. Keywords: sarcopenia; rheumatoid arthritis; bone mineral density; lean mass
Introduction
The term 'sarcopenia' (from Greek «sarx» — flesh, body + «penia» — loss, reduction) was introduced in 1989 by I. Rozenberg to describe the age-associated skeletal muscle mass loss.
The role of skeletal muscles, their mass and strength in health maintenance and augmenting life expectancy has been underestimated; however, in the recent 30 years, the attitude on sarcopenia reversed. In 1998, Baumgartner R. described sarcopenia as a syndrome associated with an increased risk of falls and physical frailty [1]. According to the US Centers for Disease Control and Prevention (CDC), sarcopenia is recognized as one out of five key risk factors of morbidity and mortality of people over 65 [2, 3]. Sarco-penia is attended by the increased fall risk, depreciated life quality, deregulated mobility, decreased life expectancy and increased mortality [3-7].
In 2009, the European Union Geriatric Medicine Society (EUGMS) convened the European Working Group on Sarcopenia in Older People (EWGSOP) aimed at produc-
ing definitions and diagnostic criteria of sarcopenia in the clinical practice and holding clinical trials [3]. Members of other European societies, such as the European Society of Clinical Nutrition and Metabolism (ESPEN), the International Academy of Nutrition and Aging (IANA), the International Association of Gerontology, Geriatrics — European Region (IAGG-ER) were also invited to join the Working Group. As a result of 5 societies' (EWGSOP, EUGMS, ESPEN, IAGG-ER, IANA) collaboration, the first consensus on sarcopenia's diagnostics has been developed [3, 8]. According to it, sarcopenia is a condition characterized by a progressive generalized skeletal muscle mass and strength, associated with such complications, as deregulated mobility, depreciation of life quality, and potentially causing death.
In October 2016, sarcopenia was included into the International Classification of Diseases (ICD) under the code M62.84 [9, 10].
Sarcopenia's prevalence is widely varied (5-70 %) in relation to age, gender and ethnic origin [3, 11] (Table 1). In the New Mexico Elder Health Survey, one of the earliest sarco-
© 2019. The Authors. This is an open access article under the terms of the Creative Commons Attribution 4.0 International License, CC BY, which allows others to freely distribute the published article, with the obligatory reference to the authors of original works and original publication in this journal.
Для кореспонденцй: Дзерович Наталiя 1вашвна, доктор медичних наук, головний науковий сшвробггник вщдту шшчноТ фвюлогй i патологи' опорно-рухового апарату, ДУ «1нсппут геронтологи iMeHi Д.Ф. Чебопарьова НАМН Украши», вул. Вишгородська, 67, м. Ки'в, 04114, Укра'на; e-mail: [email protected]
For correspondence: Nataliia Dzerovych, MD, PhD, Leading Research Fellow at the Department of clinical physiology and pathology of locomotor apparatus, State Institution "D.F. Chebotarev Institute of Gerontology of the NAMS of Ukraine', Vyshgorodska st., 67, Kyiv, 04114, Ukraine; e-mail: [email protected] Full list of author information is available at the end of the article.
penia studies, R. Baumgartner et al. developed the following gender-specific age-associated sarcopenia divergences: under 80 years of age sarcopenia is more characteristic of women, over 80 — of men (Table 1).
According to other studies held in the recent years, sarco-penia's prevalence along the EWGSOP criteria is presented in Table 2. According to V.V. Povoroznyuk, N.I. Dzerovych, sarcopenia's prevalence among the Ukrainian women significantly increases with age: 4.1 % in the age group of 5059 years, 3.7 % - 60-69 years, 70-79 years - 18.4 %, 80-89 years - 30.8 %.
Researchers differentiate between a primary and secondary form of sarcopenia [10]. Primary form develops with age unless there as other secondary factors affecting skeletal muscle tissue. Secondary form is a consequence of one or several factors/conditions influencing muscle tissue state (sarcopenia associated with a comorbidity, reduced physical activity, nutrition etc.).
Further on, we're going to discuss features of body composition and sarcopenia's prevalence in rheumatoid arthritis patients, according to the reference data and our own observations.
Meta-analysis published in 2018 revealed sarcopenia's prevalence among the rheumatoid arthritis patients varies from 15 to 32 % [19].
A. Tournadre et al. report sarcopenia's prevalence among the rheumatoid arthritis patients to be 28.6 %, which significantly differs from the similar rate of the controls — 4.8 % [20].
J. T. Giles et al. found that females with rheumatoid arthritis and normal body mass (body mass index (BMI) is
less than 25 kg/m2) lose the lean mass 3 times as quickly as the controls (odds ratio (OR) 3.41, CI: 1.51-7.69, p <0.05) [21].
According to S. C. Dogan et al., appendicular lean mass index of females with rheumatoid arthritis was significantly lower thanthat ofcontrols (5.83±0.81 versus7.30±1.64 kg/m2, p<0.05). No connection between sarcopenia and disease activity (DAS 28) was revealed in this study (p=0.53), and C-reactive protein level was significantly higher in sarcopenia patients (p=0.02) compared to the subjects without it [22].
In another study, lean mass loss in the group of females with rheumatoid arthritis (mean age - 47.7 years) was 43.3 and 10 % for veritably healthy subjects. It was also revealed that females with rheumatoid arthritis and reduced lean mass had almost twice as much C-reactive protein as the rheumatoid arthritis patients with normal lean mass index (61,5 versus 38.5 %). [23]. Among the anti-inflammatory cytokines playing an important part in sarcopenia pathogenesis when associated with rheumatoid arthritis, tumor necrosis factor alpha (TNFa) and interleukin-1 P are especially worthy of mentioning [20, 24, 25, 26]. It should be emphasized that with primary sarcopenia other anti-inflammatory cytokines gradually increase, namely interleukin-1 (IL-1) and inter-leukin-6 (IL-6) [11].
A. Ngeuleu et al. report sarcopenia's frequency in rheumatoid arthritis patients to be 39.8 %. Simple regression analysis shows that sarcopenia is related to BMI, disease activity (DAS 28 ESR), bone erosions, waist circumference and life quality. However, multiple regression analysis also revealed a positive correlation between sarcopenia
Table 1. Sarcopenia's prevalence, according to the New Mexico Elder Health Survey, 1998
Age group, years Males (n=205) Females (n=173)
< 70 13,5 23,1
70-74 19,8 33,3
75-80 26,7 35,9
> 80 52,6 43,2
Study Patients' age, years Females, n Sarcopenia's prevalence in females, n (%) Males, n Sarcopenia's prevalence in males, n (%)
V.V. Povoroznyuk, N.I. Dzerovych, 2016 [11] > 65 118 25 (21,3) H/B H/B
Doods R. M. et al., 2016 [12] > 85 437 90 (20,6) 282 59 (20,9)
J. C.Brown et al., 2016 [13] > 60 2500 756 (30,2) 1925 862 (44,8)
J. H. Kim et al., 2014 [14] > 65 272 24 (8,8) 284 25 (8,8)
H.P. Patel et al., 2014 [15] 68-76 H/B H/B 88 18 (20,4)
M. Yamada et al., 2013 [16] 65-89 1314 H/B (22,1) 568 H/B (21,8)
D. Legrand et al., 2013 [17] > 80 185 23 (12,4) 103 13 (12,6)
F. Landi et al., 2012 [18] > 70 91 19 (21,0) 31 21 (68,0)
Note: UNDEF - undefined.
Table 2. Sarcopenia's prevalence along the EWGSOP criteria, 2010
and increased cardiometabolic risk (p=0.025, OR 0.176, CI: 0.038-0.980), BMI within normal ranges (p=0.004, OR 12.3, CI: 2.27-67.6), increased BMI (p=0.004, OR 12.3, CI: 2.27-67.6) and presence of bone erosions (p=0.012, OR 0.057, CI: 0.006-0.532). There was no significant statistical difference found as to the disease duration or glucocorticoid use in rheumatoid arthritis patients if related to sarcopenia [27].
M. Torii et al. observe sarcopenia's prevalence in females with rheumatoid arthritis to be 37.1 % (sarcopenia — 22.4 %, advanced sarcopenia — 14.7 %), while pre-sarcopenia's frequency is 49.0 %. Frequency of falls, fractures and reduced bone mineral density (BMD) was higher in patients with sarcopenia than in subjects without it. Among the independent factors of sarcopenia's development in patients with rheumatoid arthritis there are age, duration of the disease, Steinbroker class, dietary habits and basic therapy medication [28].
Other researchers [29] consider basic disease-modifying and biological therapy in patients with rheumatoid arthritis to be reducing sarcopenia's risk. A. Tournadre et al., while treating rheumatoid arthritis for 1 year with To-cilizumab, observed a significant increase of appendicular lean mass index [20]. Efficacy of anabolic medications in combinations with a protein-rich diet is not yet confirmed. As of today, regular physical exercises, namely aerobic and loading exercises, are considered to be an ef-
fective prophylaxis method against muscle loss of rheumatoid arthritis patients [29].
This study is aimed at evaluating bone mineral density, lean mass and pre-sarcopenia frequency data of rheumatoid arthritis patients.
Materials and methods
461 women of 40-87 years, among them 71 rheumatoid arthritis patients and 390 controls. Their demographic and anthropometric parameters are presented in Table 3.
General clinical examination was performed. Acuity of pain syndrome was determined by means of a visual analogue scale (VAS), life quality — by means of the HAQ questionnaire. Rheumatoid arthritis' activity was determined based on the erythrocyte sedimentation rate (ESR), integral DAS-28 index, C-reactive protein (CRP) level in blood serum by immunoenzyme assay (test-sample collection by BioSystem S. A., Spain).
Lean mass index, BMD were measured by means of X-ray absorptiometry (Prodigy, GEHC Lunar, Madison, WI, USA). To evaluate the lean mass, appendicular lean mass index (ALMI) was used, with a formula: ALMI = lean mass od upper and lower limbs (kg) / height (m2). Pre-sarcopenia (I stage of sarcopenia, i.e. reduced lean mass) was diagnosed when ALMI was less than 5.72 kg/m2 [1]. Statistical analysis was made with «Statistica 6.0» software. Distribution in each sample was determined according to the Kolmogorov—
Parameters Females with rheumatoid arthritis (n = 71) Female controls (n = 390) P
Age, years 55,4 ± 1,2 57,5 ± 0,8 IS
Height, cm 161,7 ± 0,8 162,0 ± 0,3 IS
Weight, kg 62,8 ± 1,2 63,9 ± 0,5 IS
Body mass index, kg/m2 24,0 ± 0,4 24,4 ± 0,2 IS
Note. IS - insignificant differences (р>0.05).
Fig. 1. Causes of secondary sarcopenia Table 3. Demographic and anthropometric parameters of the examined subjects
Table 4. Bone mineral density, fat and lean mass in females with rheumatoid arthritis and controls
Index Females with rheumatoid arthritis Female controls P
BMD of lumber spine, g/cm2 0,99 ± 0,02 1,02 ± 0,01 0,3
BMD of femoral neck, g/cm2 0,78 ± 0,02 0,84 ± 0,01 0,002
Lean mass of total body, kg 37,57 ± 0,47 38,86 ± 0,19 0,01
Appendicular lean mass, kg 15,07 ± 0,27 16,47 ± 0,10 < 0,01
Appendicular lean mass index, kg/m2 5,76 ± 0,09 6,27 ± 0,03 < 0,01
Note. BMD - bone mineral density.
□ RA ■ Controls
Fig. 2. Lean mass of women with rheumatoid arthritis and control subjects. Note. A - appendicular lean mass, B - lean mass of total body, C - appendicular lean mass index; RA - women with rheumatoid arthritis.
Table 5. Correlation among activity parameters, duration of the disease, life quality and lean mass indices in patients with
rheumatoid arthritis
Показник Знежирена маса BepxHix кшфвок Знежирена маса нижшх кшщвок Апендикулярна знежирена маса ALMI
Тривалють захворювання r = 0,51 r = 0,50 r = 0,52 r = 0,48
p = 0,1 p = 0,1 p = 0,1 p = 0,1
С-реактивний бшок r = 0,18 r = -0,15 r = -0,76 r = -0,10
p = 0,6 p = 0,7 p = 0,8 p = 0,8
Швидкють осщання еритроци™ r = 0,034 r = -0,084 r = -0,060 r = -0,11
p = 0,9 p = 0,8 p = 0,9 p = 0,7
Кшькють набряклих cymo6iB r = 0,70 r = 0,50 r = 0,56 r = 0,44
p = 0,02 p = 0,1 p = 0,08 p = 0,2
Кшькють чутливих cymo6iB r = 0,15 r = 0,11 r = 0,12 r = -0,06
p = 0,7 p = 0,7 p = 0,7 p = 0,9
ВАШ r = -0,26 r = -0,12 r = -0,16 r = -0,24
p = 0,4 p = 0,7 p = 0,6 p = 0,5
DAS-28 r = 0,15 r = 0,11 r = 0,13 r = -0,10
p = 0,7 p = 0,7 p = 0,7 p = 0,8
Якють життя (за шкалою HAQ) r = 0,09 r = 0,10 r = 0,10 r = 0,08
p = 0,8 p = 0,8 p = 0,8 p = 0,8
Note. ESR - erythrocyte sedimentation rate,VAS - visual analogue scale.
Smirnov test. Differences between the two groups were determined according to the Student's criterion (t). Correlation analysis was also performed. Results are presented in the following manner: M±SD. Critical level of significance was assigned at p<0.05 to prove the hypotheses were correct.
Results
Women with rheumatoid arthritis had a significantly lower index of BMD at femoral neck (p=0.002) compared with the controls, while the BMD of lumbar spine did not differ significantly (p=0.3; Table 4). Lean mass of total body, ap-pendicular lean mass, ALMI were significantly lower compared to the controls (Table 4, Fig. 2).
Pre-sarcopenia frequency in women with rheumatoid arthritis amounted to 49 %, while in the controls - 18 %.
While performing the correlation analysis, we didn't find any significant connection among the activity parameters (C-reactive protein, ESR, pain VAS, DAS-28), duration of the disease, life quality and lean mass indices in patients with rheumatoid arthritis (Table 5). However, a significant correlation was found between the number of swollen joints and lean mass of upper limbs (r=0,67; p=0,02).
Discussion
We've established significantly lower parameters of lean mass in patients with rheumatoid arthritis compared to the controls. Similar results were obtained in the other recent studies [23, 29]. Pre-sarcopenia's frequency in the Ukrainian women with rheumatoid arthritisis veritably higher, amounting to 49 %, than that of controls - 18 %. On comparing these results with reference data, it's worthy of mentioning that pre-sarcopenia's frequency is similar to M. To-rii et al.'s findings (49 %) and higher than those presented by A. Tournadre et al. (28.6 %) [28].
Our study had the following limitation: we didn't evaluate strength and function of skeletal muscles in women with rheumatoid arthritisis, which is why we could establish frequency only for pre-sarcopenia, and not for sarcopenia's II or III stage.
Correlation analysis did not provide any data on connection among disease activity, its duration, life quality and lean mass for women with rheumatoid arthritisis, which might be supposedly attributed to a comparatively 'small' sample.
Conclusions
It should thus be emphasized that rheumatoid arthritisis is associated not only with bone tissue, but also with skeletal tissue, disorders, resulting in a significant depreciation of functional capacities and life quality.
Taking into account the vital medicosocial importance of the issue, further studies are required into the mechanisms of development, methods of sarcopenia's prevention and treatment among the rheumatoid arthritisis patients.
Conflicts of interests. Authors declare the absence of any conflicts of interests that might be construed to influence the results or interpretation of their manuscript.
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Received 11.05.2019 Revised 28.05.2019 Accepted 1.07.2019
Information about authors
Vladyslav Povoroznyuk, MD, PhD, Professor, Head of the Department of clinical physiology and pathology of locomotor apparatus, State Institution "D.F. Chebotarev Institute of Gerontology of the NAMS of Ukraine', Kyiv, Ukraine, e-mail: [email protected], ORCID iD: http://orcid.org/0000-0002-9770-4113
Nataliia Dzerovych, MD, PhD, Leading Research Fellow at the Department of clinical physiology and pathology of locomotor apparatus, State Institution "D.F. Chebotarev Institute of Gerontology of the NAMS of Ukraine', Kyiv, Ukraine; e-mail: [email protected]
Oksana Ivanyk, doctor-rheumatologist, Lviv regional hospital, Lviv, Ukraine; e-mail: [email protected]
Tetiana Karasevska, PhD, Associate Professor at the Department of internal medicine 2, Bogomolets National Medical University, Kyiv, Ukraine; e-mail: [email protected]
Поворознюк В.В.Дзерович Н.1.', 1ваник О.С.1, Карасевська Т.А.2
1ДУ «1нститут геронтологи 'тен'1 Д.Ф. Чеботарьова НАМН Украни», м. Кив, Украша
2Нац'юнальниймедичнийун'верситет теш О.О. Богомольця,м. Кив, Украша
Саркопешя i ревматоТдний артрит
Резюме. Актуальтсть. На сьогодт серед синIдромiв i захво-рювань, асоцшованих iз вшом, науковщ придшяють велику увагу вивченню саркопени, за наявносп яко! спостериаеть-ся збшьшення ризику падгнь, попршення якосп життя, пору-шення рухово! активносй, зниження тривалосп життя та зро-стання летальносп пащентгв. У 2016 рощ саркопешя внесена до Мгжнародно! класифгкаци хвороб. Видаляють первинну та вторинну форми саркопени. У статй наведет дат литера-тури та результати власних досладжень щодо саркопени у па-щенпв iз ревмато!дним артритом. Метою даного досладжен-ня було оцшити показники мшерально! щiльностi юстково! тканини, знежирено! маси та частоту пресаркопенй у пащен-
TiB i3 ревматощним артритом. MamepiaAU та методи. Обсте-жено 461 ж1нку вгком 40—87 роив (середнш BiK — 57,17 ± 0,71 року), серед яких 71 пацieнтка з ревмато1дним артритом i 390 жгнок контрольно! групи. Проводили клiнiчне й лаборатор-не обстеження (визначення швидкостi ос!дання еритроцитш та С-реактивного бiлка у сироватщ кровi). Вираженiсть боль-ового синдрому визначали за допомогою вiзуально-аналого-во! шкали болю, якiсть життя — за допомогою анкети HAQ. Показники знежирено! маси, мшерально! щiльностi юстково! тканини визначали за допомогою рентгешвсько! абсорбцiо-метрГ! (Prodigy, GEHC Lunar, Madison, WI, USA). Пресарко-пенш (I стадгю саркопенГ!) визначали при шдека апендику-
лярно! знежирено! маси менше 5,72 кг/м2 (Поворознюк В.В., Дзерович Н.1., 2016). Статистичний анатз проводили з вико-ристанням програми Statistica 6.0. Результаты. У пащенток i3 ревмато!дним артритом виявлеш вiрогiIдно нижчi показники мшерально! щiльностi юстково! тканини на рiвнi шийки стег-ново! кiстки (р = 0,002), знежирено! маси всього тша (р = 0,01) та апендикулярно! знежирено! маси (р < 0,01). Частота пре-саркопени у жшок iз ревмато!дним артритом становила 49 %, в осiб контрольно! групи — 18 %. Висновки. При ревмато!дно-
му артритi у пащентш виявлено ураження не тшьки к1стково! тканини, але й скелетно! м'язово! тканини, що призводить до значного попршення функцiональних можливостей та якосп життя пацiентiв. Враховуючи вагоме медико-сощальне зна-чення проблеми, необхщш подальшi дослвдження щодо вив-чення механiзмiв розвитку, розробка метод1в профшактики та лгкування саркопени у пащенйв iз ревмато!дним артритом. Ключовi слова: саркопенш; ревмато!дний артрит; мше-ральна щiльнiсть к1стково! тканини; знежирена маса тша
Поворознюк В.В.1, Дзерович Н.И.1, Иваник А.С.1, Карасевская Т.А.2 1ГУ «Институт геронтологии имени Д.Ф. Чеботарева НАМН Украины», г. Киев, Украина 2Национальний медицинский университет имени А.А. Богомольца, г. Киев, Украина
Саркопения и ревматоидный артрит
Резюме. Актуальность. На сегодняшний день среди синдромов и заболеваний, ассоциированных с возрастом, ученые уделяют большое внимание изучению саркопении, при наличии которой наблюдается увеличение риска падений, ухудшение качества жизни, нарушение двигательной активности, снижение продолжительности жизни и рост летальности пациентов. В 2016 году саркопения внесена в Международную классификацию болезней. Выделяют первичную и вторичную формы саркопении. В статье представлены данные литературы и результаты собственных исследований по саркопе-нии у пациентов с ревматоидным артритом. Целью данного исследования было оценить показатели минеральной плотности костной ткани, обезжиренной массы и частоту пресар-копении у пациентов с ревматоидным артритом. Материалы и методы. Обследована 461 женщина в возрасте 40—87 лет (средний возраст — 57,17 ± 0,71 года), среди которых 71 пациентка с ревматоидным артритом и 390 женщин контрольной группы. Проводили клиническое и лабораторное обследование (определение скорости оседания эритроцитов и С-реактивного белка в сыворотке крови). Выраженность болевого синдрома определяли с помощью визуально-аналоговой шкалы боли, качество жизни — с помощью анкеты HAQ. Показатели обезжиренной массы, минеральной плот-
ности костной ткани определяли с помощью рентгеновской абсорбциометрии (Prodigy, GEHC Lunar, Madison, WI, USA). Пресаркопению (I стадию саркопении) определяли при значении индекса аппендикулярной обезжиренной массы меньше 5,72 кг/м2 (Поворознюк В.В., Дзерович Н.И., 2016). Статистический анализ проводили с использованием программы Statistica 6.0. Результаты. У пациенток с ревматоидным артритом выявлены достоверно более низкие показатели минеральной плотности костной ткани на уровне шейки бедренной кости (р = 0,002), обезжиренной массы всего тела (р = 0,01) и аппендикулярной обезжиренной массы (р < 0,01). Частота пресаркопении у женщин с ревматоидным артритом составила 49 %, у лиц контрольной группы — 18 %. Выводы. При ревматоидном артрите у пациентов выявлено поражение не только костной ткани, но и скелетной мышечной ткани, что приводит к значительному ухудшению функциональных возможностей и качества жизни пациентов. Учитывая важное медико-социальное значение проблемы, необходимы дальнейшие исследования по изучению механизмов развития, разработка методов профилактики и лечения саркопе-нии у пациентов с ревматоидным артритом. Ключевые слова: саркопения; ревматоидный артрит; минеральная плотность костной ткани; обезжиренная масса тела
