Early Biologic Treatment Critical for Bone Protection in Rheumatoid Arthritis

Treatment with biologic drugs may protect against bone loss in patients with rheumatoid arthritis, a recent study suggests.

The study found that early and aggressive treatment of rheumatoid arthritis with biologics is the most effective therapy for inhibiting bone loss in these patients, according to a press release from the Osteoporosis Foundation, whose Chronic Inflammation and Bone Structure Working Group conducted the review.

“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,” said co-author Cristiano Zerbini MD. “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.”

Rheumatoid arthritis is characterized by chronic inflammation, which can affect the immune system, and leads to symptoms that can increase bone loss. A lack of physical exercise and limited mobility associated with joint pain can also contribute to bone loss.

The use of corticosteroids for treatment is linked to swift rapid bone loss, according to the study. Even a small dose of prednisone for more than 3 months can be linked to these effects, and another study has shown that prednisone 10 mg per day over 90-days can increase the risk of vertebral fractures 17-fold.

The new review outlines the best treatment options to prevent bone loss in these patients, and also looks at the mechanisms behind bone loss, including serum markers, anti-citrullinated protein antibodies, the effects of TNF-inhibitors on bone mineral density, and more.

The investigators said that early treatment was the most effective in preventing inflammation, and resulting bone loss. They also found that introducing biologic disease-modifying anti-rheumatic drugs that target specific cytokines should be taken quickly as well, according to the study.

TNF inhibitors were shown to protect against bone loss, even in patients with rheumatoid arthritis who did not respond to treatment. These results suggest that this treatment may prevent bone loss independently of anti-inflammatory properties.

However, TNF inhibitors were not found to prevent bone loss in the hand, even though it improved bone mineral density in the spine and hip. Beneficial prevention of bone loss in localized areas were seen in anti-IL6 treatments, according to the study.

The investigators reported that there were relatively few studies showing rituximab and abatacept prevented bone loss. In these patients, anti-RANKL treatments were beneficial in stopping bone loss even though this treatment cannot stop inflammation.

The review also suggested non-biologic therapies that inhibit the cytokine network could protect against bone loss.

“Although several studies reported favorable 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,” said co-author Professor Patricia Clark, MD. “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.”