First Do No Harm - A Bone of Contention in Rheumatoid Arthritis

[Guest guest]

" First Do No Harm - A Bone of Contention in Rheumatoid Arthritis

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JANE ZOCHLING, MBBS, FRACP,

Research Fellow in Rheumatology,

Institute of Bone and Joint Research,

Department of Rheumatology;

LYN MARCH, MBBS, MSc, PhD, FRACP, FAFPHM,

Associate Professor of Medicine,

Senior Staff Specialist in Rheumatology and Clinical Epidemiology,

Institute of Bone and Joint Research,

Royal North Shore Hospital,

Pacific Highway,

St. Leonards, NSW, Australia 2065.

Address reprint requests to Dr. March.

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Jolles and Bogoch, in this issue of The Journal, discuss current

consensus recommendations for treatment of rheumatoid arthritis (RA) and

conclude that there are blind spots related to the prevention and

treatment of osteoporosis in RA1. They present what would appear to be

an open and shut case: a description of increased fracture risk in RA

with and without steroids, a consensus statement suggesting that

corticosteroids should be avoided due to unacceptable side effects, a

statement that treatments are available that can prevent the

osteoporosis and reduce the fracture risk, and a condemnation of

guideline producers for their failure to address the issue. However,

there are other, recently published consensus guidelines that do

recommend treatment with corticosteroids in RA and that also recommend

osteoporosis prevention2. Perhaps the blind spot is in the fact that

clinicians are not aware of or do not respond to the published

guidelines?

There remain many unanswered questions. What is the incidence of

fracture in early RA? Does the fracture risk vary over time? Will we

even be able to answer these questions now given that the pyramid has

been inverted and international consensus recommends that RA be treated

earlier and more aggressively to attain a state of low disease activity?

What influence does RA therapy have on fracture risk? What role should

corticosteroids play in the treatment of RA? Are they friend or foe when

it comes to bone density and fracture risk? Could their earlier use gain

initial control of disease activity and actually prevent bone loss? What

role does early periarticular osteopenia play in the subsequent

development of joint damage? Do guidelines address the issue

sufficiently? Both the American and British rheumatology societies have

published guidelines for the prevention of corticosteroid induced

osteoporosis. But do clinicians actually follow the guidelines? Are our

eyes wide shut? ... "

See the full editorial in the current issue of the Journal of

Rheumatology:

http://www.jrheum.com/subscribers/02/09/1818.html