Early treatment of rheumatoid arthritis (RA) with biologic drugs may protect against rapid bone loss, according to a review published in the journal Osteoporosis International.
The International Osteoporosis Foundation (IOF) Chronic Inflammation and Bone Structure (CIBS) Working Group found that treatment with biological disease-modifying anti-rheumatic drugs (DMARDs) may be the most effective way to halt progressive bone loss in patients with RA.
Co-Author Dr Cristiano Zerbini, director of the Centro Paulista de Investigação Clinica (CEPIC) in Sao Paolo, Brazil, said: “Bone loss is one of the most harmful effects induced by chronic inflammation as well as by medications taken to treat rheumatoid arthritis, such as glucocorticoids. It is therefore important that we gain a better understanding of which medications used to treat patients with chronic inflammation are less likely to impact negatively on bone health.”
The researchers found that early and “aggressive” treatment with biologic DMARDs was more effective in rapidly achieving a low level of inflammation and halting the progressive loss of bone.
The review also showed that:
• Therapies targeting specific cytokines and their signalling pathways with biologic DMARDs may protect the skeleton and should be introduced as soon as possible. However, outcomes in these clinical studies were based mostly on changes in biological markers and only a few reported modifications on bone mineral density (BMD) or localised osteoporosis. Only three retrospective studies reported reduction in fracture risk after anti-TNF therapy.
• The TNF blockade studies showed that, even in RA patients not responsive to treatment, a protective effect on bone was observed suggesting the possibility that anti-TNF therapy may restore coupling of the bone remodelling independently of its anti-inflammatory action.
• Lack of efficacy of TNF blockade on hand bone loss was found, despite its preservation of BMD in lumbar spine and hip. Better results regarding localised bone loss were observed with anti-IL6 treatment.
• Very few studies reported inhibition of bone loss after rituximab and abatacept treatment.
• Anti-RANKL therapy showed beneficial effects in the preservation of bone mass in RA, especially in juxta-articular osteoporosis, although this treatment cannot alter the inflammatory process.
• New therapies that are non-biologic but potent inhibitors of the cytokine network may offer future options for skeleton preservation in RA.
Co-author Professor Patricia Clark, head of Clinical Epidemiology at Hospital Infantil de Mexico, Mexico City, commented: “Although several studies reported favourable actions of biologic therapies on bone protection, it is clear that there are still unmet needs for research into their actions on the risk of bone fractures in RA patients. In the meantime, we recommend that all physicians treating RA remain vigilant of the high risk of bone loss and fractures in their patients. For many such high risk patients, it is important that osteoporosis treatment be considered to reduce fracture risk.”