title: 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 (ΔBMD) from baseline to end of study was recorded. Standardized mean difference (SMD) of ΔBMD 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 ΔBMD 0.33 [95% CI 0.13, 0.53], P = 0.001, I(2)  = 0%) and glucocorticoids (SMD ΔBMD 0.51 [95% CI 0.20, 0.81], P = 0.001, I(2)  = 0%). TNFi had no significant effect on lumbar spine and hip BMD. Glucocorticoids were associated with a negative effect on lumbar spine (SMD ΔBMD -0.30 [95% CI -0.55, -0.04], P = 0.02, I(2)  = 52%), but not hip BMD. For AS, a significant increase in BMD was seen with TNFi at the lumbar spine (SMD ΔBMD 0.96 [95% CI 0.64, 1.27], P < 0.001, I(2)  = 16%) and hip (SMD ΔBMD 0.38 [95% CI 0.13, 0.62], P = 0.003, I(2)  = 0%). Data were insufficient to perform meta-analyses in PsA and psoriasis or for other antirheumatic drugs.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Western University, London, Ontario, Canada.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Siu
authors.affiliation: Centre Hospitalier de l'Universite de Montreal and Institut de Rhumatologie de Montreal, Montreal, Quebec, Canada.
authors.forename: Boulos
authors.initials: B
authors.lastname: Haraoui
authors.affiliation: Inovaderm Research, Montreal, Quebec, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Bissonnette
authors.affiliation: Centre Hospitalier Universitaire de Quebec, Quebec City, Quebec, Canada.
authors.forename: Louis
authors.initials: L
authors.lastname: Bessette
authors.affiliation: University of Montreal Hospital Research Center and Notre-Dame Hospital, Montreal, Quebec, Canada.
authors.forename: Camille
authors.initials: C
authors.lastname: Roubille
authors.affiliation: Saint Luc Hospital, Montreal, Quebec, Canada.
authors.forename: Vincent
authors.initials: V
authors.lastname: Richer
authors.affiliation: Sacre-Coeur Hospital of Montreal and The University of Montreal, Montreal, Quebec, Canada.
authors.forename: Tara
authors.initials: T
authors.lastname: Starnino
authors.affiliation: University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Collette
authors.initials: C
authors.lastname: McCourt
authors.affiliation: University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Alexandra
authors.initials: A
authors.lastname: McFarlane
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.
authors.forename: Patrick
authors.initials: P
authors.lastname: Fleming
authors.affiliation: Lynde Dermatology, Markham, Ontario, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Kraft
authors.affiliation: Lynde Dermatology, Markham, Ontario, Canada.
authors.forename: Charles
authors.initials: C
authors.lastname: Lynde
authors.affiliation: Memorial University, St. John's, Newfoundland, Canada.
authors.forename: Wayne
authors.initials: W
authors.lastname: Gulliver
authors.affiliation: University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Keeling
authors.affiliation: University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jan
authors.initials: J
authors.lastname: Dutz
authors.affiliation: Western University, London, Ontario, Canada.
authors.forename: Janet E
authors.initials: JE
authors.lastname: Pope
mesh_terms: D018501:Antirheumatic Agents / Q000009:adverse effects*; D001172:Arthritis, Rheumatoid / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D001688:Biological Products / Q000009:adverse effects*; D015519:Bone Density / Q000187:drug effects*; D016009:Chi-Square Distribution; D002986:Clinical Trials as Topic; D005938:Glucocorticoids / Q000009:adverse effects*; D006801:Humans; D010024:Osteoporosis / Q000139:chemically induced* / Q000175:diagnosis / Q000503:physiopathology; D012307:Risk Factors; D013167:Spondylitis, Ankylosing / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products; D005938:Glucocorticoids; D014409:Tumor Necrosis Factor-alpha