Meta‐Analysis of Tumor Necrosis Factor Inhibitors and Glucocorticoids on Bone Density in Rheumatoid Arthritis and Ankylosing Spondylitis Trials

Abstract

Objective. To examine the impact of antirheumatic drugs on bone mineral density (BMD) in rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), and psoriasis using a systematic review. Methods. Electronic databases were systematically searched for randomized controlled trials. Studies were grouped based on disease, treatment, and site of BMD measurement. Change in BMD (DBMD) from baseline to end of study was recorded. Standardized mean difference (SMD) of DBMD between treatment and controls was standardized for meta-analyses and 95% confidence intervals (95% CIs) were calculated. Results. Treatment effects on BMD were not the primary outcomes of the trials. Thirteen studies were eligible (11 RA, 2 AS, 0 PsA, and 0 psoriasis). For RA, significantly less hand bone loss was seen with tumor necrosis factor inhibitors (TNFi; SMD DBMD 0.33 [95% CI 0.13, 0.53], P 5 0.001, I 2 5 0%) and glucocorticoids (SMD DBMD 0.51 [95% CI 0.20, 0.81], P 5 0.001, I 2 5 0%). TNFi had no significant effect on lumbar spine and hip BMD. Glucocorticoids were associated with a negative effect on lumbar spine (SMD DBMD 20.30 [95% CI 20.55,20.04], P 5 0.02, I 2 5 52%), but not hip BMD. For AS, a significant increase in BMD was seen with TNFi at the lumbar spine (SMD DBMD 0.96 [95% CI 0.64, 1.27], P < 0.001, I 2 5 16%) and hip (SMD DBMD 0.38 [95% CI 0.13, 0.62], P 5 0.003, I 2 5 0%). Data were insufficient to perform meta-analyses in PsA and psoriasis or for other antirheumatic drugs. Conclusion. In RA, TNFi and glucocorticoids appeared to attenuate hand bone loss. TNFi did not impact lumbar spine and hip BMD and glucocorticoids had negative effects on lumbar spine and no effect on hip BMD. In AS, TNFi was associated with improved lumbar spine and hip BMD.

Evidence-based Recommendations for the Management of Comorbidities in Rheumatoid Arthritis, Psoriasis, and Psoriatic Arthritis: Expert Opinion of the Canadian Dermatology-Rheumatology Comorbidity Initiative

“…In RA, our metaanalysis of randomized controlled trials that studied the effects of CS on bone loss showed an association between oral CS use and lumbar spine bone loss (mean difference in DBMD -0.3, 95% CI -0.55 --0.04) 96 . Included studies used an average daily dose of prednisone or prednisolone ranging from 6 mg to 12 mg for a study period ranging from 20 weeks up to 2 years.…”

Limitations in the Full Reporting of Systematic Literature Review

“…The large amount of data and evidence. Some clinical questions and recommendations had enough data and evidence in the literature to warrant separate publication and discussion; these have been published in peer-reviewed journals and presented at international conferences 3,4,5,6,7 . Other questions, which lacked data or evidence in the literature, could not lead to separate publications; these limitations were mentioned in our discussion.…”

New Guidelines for the Management of Rheumatoid Arthritis (Eular, 2013): The Place of Glucocorticoids

“…По данным ме-таанализа S. Siu и соавт. [94] (5 РПКИ), при РА лечение ГК ассоциируется с уменьшением потери МПК в зоне луче-вой кости, не влияет на МПК бедра, но приводит к сниже-нию МПК поясничного отдела позвоночника (p=0,02 по сравнению с пациентами, не получавшими ГК). Однако при раннем РА ГК не оказывают негативного влияния на МПК бедра и позвоночника.…”