Are changes in bone mineral density different between groups of early rheumatoid arthritis patients treated according to a tight control strategy with or without prednisone if osteoporosis prophylaxis is applied?

Abstract

SummaryAddition of 10 mg prednisone daily to a methotrexate-based tight control strategy does not lead to bone loss in early rheumatoid arthritis (RA) patients receiving preventive treatment for osteoporosis. A small increase in lumbar bone mineral density (BMD) during the first year of treatment was recorded, regardless of use of glucocorticoids.IntroductionThis study aims to describe effects on BMD of treatment according to EULAR guidelines with a methotrexate-based tight control strategy including 10 mg prednisone daily versus the same strategy without prednisone in early RA patients who received preventive therapy for osteoporosis.MethodsEarly RA patients were included in the CAMERA-II trial: a randomized, placebo-controlled, double-blind 2-year trial, in which effects of addition of 10 mg prednisone daily to a methotrexate-based tight control strategy were studied. All patients received calcium, vitamin D and bisphosphonates. Disease activity was assessed every 4 weeks. Radiographs of hands and feet and dual-energy X-ray absorptiometry of lumbar spine and left hip were performed at baseline and after 1 and 2 years of treatment.ResultsBMD increased significantly over time in both treatment groups at the lumbar spine with a mean of 2.6 % during the first year (p < 0.001), but not at the hip; at none of the time points did BMD differ significantly between the prednisone and placebo group. Higher age and lower weight at baseline and higher disease activity scores during the trial, but not glucocorticoid therapy, were associated with lower BMD at both the lumbar spine and the hip in mixed-model analyses.ConclusionAddition of 10 mg prednisone daily to a methotrexate-based tight control strategy does not lead to bone loss in early RA patients on bisphosphonates. A small increase in lumbar BMD during the first year of treatment was found, regardless of use of glucocorticoids.

Efficacy of conventional synthetic disease-modifying antirheumatic drugs, glucocorticoids and tofacitinib: a systematic literature review informing the 2013 update of the EULAR recommendations for management of rheumatoid arthritis

“…Moreover, accumulating evidence suggests that low-dose treatment is well tolerated and similarly effective, while reducing the risk of side effects associated with higher doses 13 42. However, bone loss should be prevented using appropriate strategies 43. Further research is needed, especially into chronotherapy44 and intra-articular GC therapy.…”

Glucocorticoids in Early Rheumatoid Arthritis: Are the Benefits of Joint-Sparing Effects Offset by the Adverse Effect of Osteoporosis? The Effects on Bone in the Utrecht Study and the CAMERA-II Study

“…Bone mineral density even increased significantly over time in both treatment groups in the lumbar spine with a mean of 2.8% (p < 0.001), but not in the hip. Higher age and lower weight at baseline, and higher disease activity scores during the trial, but not glucocorticoid therapy, were associated with a lower bone mineral density at both the lumbar spine and the hip in mixed model analyses [10]. …”

Balancing benefits and risks of glucocorticoids in rheumatic diseases and other inflammatory joint disorders: new insights from emerging data. An expert consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

“…Widely prescribed were the bisphosphonates [90,91], as well as calcium and vitamin D supplementation [92]. The combination of bisphosphonates with GC and a DMARD can protect against bone loss and may even increase BMD in the lumbar region [93]. The evidence of long-term safety of bisphosphonates in GC-users is sparse [94] and it may be that patients should be switched to a different bone-preserving agent after 2 years since their continued use may be associated with low bone turnover and atypical fractures [95].…”