Osteoporosis (OP) is a chronic and debilitating condition causing bone fragility; its burden is projected to increase due to the aging population. The genesis of OP in patients with iRMD is based on a complex interplay between detrimental and protective factors. These factors are in part related to the disease, in part to treatment or are independent from both.
Wiebe et al. (2022) showed, for example, that high-dose GCs increase the risk for fractures, however, at lower doses, the protective effects of GCs by reducing inflammation might outweigh the direct negative effects of GCs on bone metabolism. The same has been shown in other iRMD such as polymyalgia rheumatica (Palmowski et al., 2022), psoriatic arthritis (Ogdie et al., 2017) and systemic lupus erythematosus (Tedeschi et al., 2019). The GLORIA randomized controlled trial indicated that low-dose mid-term GCs might not be as harmful for bone health as previously thought (Boers et al., 2022).
There are no national or international recommendations focusing on OP in iRMD. EULAR recommendations on the management of GCs in rheumatic disease have only mentioned OP as a potential complication if this treatment but did not consider the complex interplay between detrimental disease related factors and the possible protective effects of anti-inflammatory treatment as mentioned above. Similarly, the 2022 ACR guidelines focused on the potential negative effects of GCs on bone metabolism ignoring its benefits in terms of reducing active inflammation which in turn could reduce the fracture risk. The EULAR recommendations for managing fragility fractures focused on the secondary prevention of fractures in patients with post-menopausal OP (but not specifically patients with iRMD). Moreover, commonly utilized assessment tools for the determination of fracture risk (e.g., FRAX), despite including some iRMDs such as RA and SLE, largely neglect disease specific aspects (such as disease activity, disease duration, damage etc). We plan to specifically focus on management of OP in patients with iRMD, with or without GC treatment.
Numerous drugs are available to treat OP, including the recently approved monoclonal antibody romosozumab (a sclerostin inhibitor). Newer observational and interventional studies have provided evidence that such treatments are efficacious and safe for individuals with iRMDs. Indeed, the choice of the anti-osteoporotic drug might require some fine-tuning in patients with iRMD, e.g. when patients are using drugs that potentially increase the risk for cardiovascular events or when patients have rapidly progressive erosive disease, given that the RANKL antagonist denosumab has been demonstrated to prevent progression of erosions. Similarly, disease modifying anti-rheumatic drugs (DMARDs) might also significantly affect the fracture risk in patients with iRMDs, either in a positive or negative. All these factors may need to be taken in to account when treatment for OP is chosen in patients with iRMD.
The envisioned recommendations will provide guidance on these aspects. We aim to develop recommendations for management of OP in patients with iRMDs to be used in clinical practice to avoid both undertreatment and overtreatment.
As pessoas com doenças reumáticas inflamatórias do aparelho músculo-esquelético (DRIs) apresentam um risco acrescido de osteoporose (OP). O tratamento com doses elevadas de glucocorticoides (GC) está associado a uma taxa mais elevada de fraturas. No entanto, quando utilizados para reduzir a inflamação, doses mais baixas de GC podem até ser benéficas no que diz respeito à perda óssea.
Foram publicadas recomendações sobre a gestão da OP induzida por GC (GIOP). O ACR divulgou diretrizes para a gestão da GIOP; no entanto, estas são incompletas, uma vez que não têm em conta a interação entre a perda óssea relacionada com a inflamação e os efeitos dos GC no tratamento da inflamação. Contudo, não existem recomendações específicas da EULAR sobre o rastreio e a gestão da OP relacionada com as DRIs.
Esta proposta visa desenvolver recomendações aprovadas pela EULAR para o tratamento (ou seja, prevenção, rastreio e tratamento) da OP em pessoas com DRIs, tendo em conta os fatores de risco e de proteção relacionados com a doença e com o tratamento. O grupo de trabalho utilizará os procedimentos operacionais padronizados da EULAR. O nível de evidência será avaliado de acordo com a classificação de Oxford. O desenvolvimento destas recomendações irá colmatar uma lacuna importante nas orientações da prática atual e apoiará os clínicos com recomendações baseadas em evidências para a gestão da OP em pessoas com DRIs.
1) In patients with inflammatory rheumatic diseases, what is the comparative effectiveness of different screening strategies (e.g. tools, frequency, timing) for low bone mass, osteoporosis and/or fractures to reduce morbidity and mortality associated with low bone mass, osteoporosis and/or fractures?
2) In patients with inflammatory rheumatic diseases and low bone mass or osteoporosis (with or without fractures), what is the comparative effectiveness of different monitoring strategies (e.g. tools, frequency, timing) for low bone mass, osteoporosis and/or fractures to reduce morbidity and mortality associated with low bone mass, osteoporosis and/or fractures?
3) In patients with inflammatory rheumatic diseases, what is the performance of fracture risk assessment tools or individual tools to predict observed incident fractures?
4) In patients with inflammatory rheumatic diseases, what are the prognostic factors for the development (or worsening) of low bone mass, osteoporosis or fractures?
5) In patients with inflammatory rheumatic diseases, what is the efficacy and safety of anti-osteoporotic pharmacologic treatments to prevent fractures?
6) In patients with inflammatory rheumatic diseases, what is the efficacy and safety of glucocorticoids, biologic, targeted synthetic and conventional synthetic disease-modifying anti-rheumatic drugs (b/ts/cs-DMARDs) to prevent bone loss or fractures?
Steering Group – Frank Buttgereit (Convenor); Giovanni Adami (Co-Convenor); Myriam Reisch (Fellow # 1); Zhivana Boyadzhieva (Fellow # 2); Pedro Machado (Methodologist); Christian Dejaco; Piero Ruscitti; Eduardo Santos (Librarian).
Other members of the task force.
The Task Force comprises two patient research partners (citizens). European guidelines will be produced, informed by two or three systematic reviews of the literature. These guidelines will have a significant impact both scientifically and on society. A lay summary of the guidelines will be produced for lay citizens.
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Palmowski A, Wiebe E, Muche B, et al. Glucocorticoids Are Not Associated with Bone Mineral Density in Patients with Polymyalgia Rheumatica, Giant Cell Arteritis and Other Vasculitides-Cross-Sectional Baseline Analysis of the Prospective Rh-GIOP Cohort. Cells 2022;11:536. https://doi.org/10.3390/cells11030536
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31/07/2027
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Self-care and health-disease