Hoes Jos N, Bultink Irene E M, Lems Willem F
VU University Medical Center, Department of Rheumatology , De Boelelaan 1117, 1081 HV, Amsterdam , The Netherlands
Expert Opin Pharmacother. 2015 Mar;16(4):559-71. doi: 10.1517/14656566.2015.997709. Epub 2015 Jan 27.
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.
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.
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.
类风湿关节炎（RA）患者发生椎体骨折和非椎体骨折的风险大约会增加一倍，这在很大程度上是由炎症介导的骨质流失加剧以及活动受限所致。在过去二十年中，出现了新的治疗方法来治疗RA和骨质疏松症。
骨质疏松症的流行病学及骨折风险评估（包括RA疾病活动度的影响以及糖皮质激素等影响骨骼的药物）、除骨密度测量外椎体骨折评估在RA患者中的重要性、改善病情抗风湿药的使用及其对全身性骨质流失的影响，以及当前和未来可能的抗骨质疏松药物治疗选择，并特别关注RA。
对RA患者骨质疏松症的评估应包括评估疾病活动度以及糖皮质激素等影响骨骼的药物（如剂量）的作用，这些因素超出了FRAX工具所定义的骨折或骨质疏松症的标准风险因素。改善病情抗风湿药现在能够很好地通过达标治疗策略控制疾病活动度。抗风湿药物（如抗TNF-α）降低疾病活动度会阻碍全身性骨质流失；然而，目前尚无骨折数据。在治疗RA患者的骨质疏松症时，应额外关注补钙，尤其是糖皮质激素使用者，同时也要确保充足使用维生素D。目前市场上有几种抗骨质疏松药物；口服双膦酸盐是最常用的，但近年来，更多药物进入市场，如肠外抗吸收药物地诺单抗（每年两次）和唑来膦酸（每年一次），以及促合成药物甲状旁腺激素类似物。新型药物，如odanacatib和抗硬化蛋白单克隆抗体，目前正在进行测试，很可能会扩大RA患者骨质疏松症的治疗选择。
