A new review has found disease-modifying anti-rheumatic drugs (DMARDs) to be effective in halting progressive bone loss in rheumatoid arthritis (RA) patients, and suggests that they should be used early in treatment. The review was conducted by the International Osteoporosis Foundation (IOF) Chronic Inflammation and Bone Structure (CIBS) Working Group.
DMARDs are known to be very effective in the inhibition of inflammation, but few studies have looked at their role in bone protection. To inspect this, the authors conducted an electronic and manual search of the Medline and Science Direct databases using a group of MESH terms, such as rheumatoid arthritis, osteoporosis, clinical trials, bone mineral density, bone markers, fractures, and a list of immunosuppressants and TNF-antagonists. Their search resulted in the retrieval of 28 studies.
They found that early and ‘aggressive’ treatment with biologic drugs rapidly lowered the level of inflammation and halted the progressive loss of bone. Studies showed that targeting specific cytokines with biologic DMARDs may protect the skeleton. However, the authors noted that outcomes in these studies were based mostly on changes in biological markers and not on BMD or localized osteoporosis. Additionally, most of these studies were performed with the anti-TNF drug infliximab.
In RA patients who were not responsive to treatment with TNF blockers, a protective effect on bone was observed, suggesting that anti-TNF therapy may restore coupling of the bone remodeling independent of its anti-inflammatory action. IL-6 blocking agents displayed greater results in improving localized bone loss than anti-TNF agents.
The full review is titled ‘Biologic therapies and bone loss in rheumatoid arthritis’, and despite the results indicating positive outcomes with biologics in bone protection, the authors cautioned that there is still ‘unmet needs for research into their actions on the risk of bone fractures in RA patients’.
“We recommend that all physicians treating RA remain vigilant of the high risk of bone loss and fractures in their patients,” said Patricia Clark, MD, co-author of the study and head of clinical epidemiology at Hospital Infantil de Mexico, Mexico City. “For many such high risk patients, it is important that osteoporosis treatment be considered to reduce fracture risk.”
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