title: Management of osteoporosis in rheumatoid arthritis patients.
abstract: BACKGROUND
  In rheumatoid arthritis (RA) patients, the risk of both vertebral and non-vertebral fractures is roughly doubled, which is for an important part caused by inflammation-mediated amplification of bone loss and by immobilization. New treatments have become available in the last two decades to treat both RA and osteoporosis.
  
  
  METHODS
  Epidemiology and assessment of osteoporosis and fracture risk (including the influence of RA disease activity and bone-influencing medications such as glucocorticoids), the importance of vertebral fracture assessment in addition to bone density measurement in patients with RA, the use of disease-modifying antirheumatic drugs and their effects on generalized bone loss, and current and possible future anti-osteoporotic pharmacotherapeutic options are discussed with special focus on RA.
  
  
  CONCLUSIONS
  Assessment of osteoporosis in RA patients should include evaluation of the effects of disease activity and bone-influencing medications such as (the dose of) glucocorticoids, above standard risk factors for fractures or osteoporosis as defined by the FRAX instrument. Disease-modifying antirheumatic drugs are now well able to control disease activity using treat to target strategies. This lowering of disease activity by antirheumatic medications such as anti-TNF-α results in hampering of generalized bone loss; however, no fracture data are currently available. When treating osteoporosis in RA patients, additional focus should be on calcium supplementation, particularly in glucocorticoid users, and also on sufficient vitamin D use. Several anti-osteoporotic medications are now on the market; oral bisphosphonates are most commonly used, but in recent years, more agents have entered the market such as the parenteral antiresorptives denosumab (twice yearly) and zoledronic acid (once yearly), and the anabolic agent parathyroid hormone analogues. New agents, such as odanacatib and monoclonal antibodies against sclerostin, are now being tested and will most likely enlarge the possibilities of osteoporosis treatment in RA patients.
authors.affiliation: VU University Medical Center, Department of Rheumatology , De Boelelaan 1117, 1081 HV, Amsterdam , The Netherlands j.n.hoes@umcutrecht.nl.
authors.forename: Jos N
authors.initials: JN
authors.lastname: Hoes
authors.forename: Irene E M
authors.initials: IE
authors.lastname: Bultink
authors.forename: Willem F
authors.initials: WF
authors.lastname: Lems
mesh_terms: D045930:Anabolic Agents / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D015519:Bone Density / Q000187:drug effects; D050071:Bone Density Conservation Agents / Q000627:therapeutic use; D001842:Bone and Bones / Q000187:drug effects / Q000503:physiopathology; D019468:Disease Management; D050723:Fractures, Bone / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D008019:Life Style; D010024:Osteoporosis / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D012307:Risk Factors; D016103:Spinal Fractures / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control
chemical_list: D045930:Anabolic Agents; D018501:Antirheumatic Agents; D050071:Bone Density Conservation Agents; D005938:Glucocorticoids
keywords: fracture prevention; osteoporosis; rheumatoid arthritis