Low-dose prednisolone decelerates loss of hand bone density among patients with early rheumatoid arthritis (RA), according to new research in the June 13 issue of the Archives of Internal Medicine.1

In the double-blind study comparing oral prednisolone at 7.5 mg per day for 2 years with placebo in 95 early RA patients, those patients taking steroids showed less disease-related loss of hand bone density as assessed by digital x-ray radiogrammetry compared with patients taking placebo. All patients included in the study had disease duration of less than 2 years at baseline.

"This suggests that the negative effects of glucocorticoids on bone may at least partially be counteracted by decreasing disease activity in RA," conclude researchers led by Glenn Haugeberg, MD, rheumatologist at Diakonhjemmet Hospital in Oslo, Norway. "Our results fit into the current pathophysiological understanding of bone damage in RA that bone loss and joint destruction are related to the inflammatory disease process involving the osteoclast cell."

Some research shows that prednisolone has a deleterious effect on bone and is linked to generalized osteoporosis, the authors point out. Nonetheless, at 1 year, prednisolone-treated patients lost 2.8% less hand bone density than RA patients receiving placebo. At the 2-year follow-up, steroid-treated patients lost 3.5% less hand bone density than study participants randomized to placebo.

A subanalysis of the data showed that in the first year, inflammation (assessed by C-reactive protein [CRP]) correlated with hand bone loss, but only in placebo-treated patients. In the second year, a significant correlation between bone loss and CRP was observed in the prednisolone group but was no longer present in the placebo subjects, suggesting that prednisolone broke the link between bone loss and inflammation in the first year but not in the second.

Women experienced greater bone loss than men in the study. The authors attributed this trend to the added effects of postmenopausal osteoporosis, because no differences of disease activity measures were observed between gender groups.

CIAOMed editorial board member Nancy E. Lane, MD, professor of medicine and rheumatology at the University of California at Davis Medical Center in Sacramento, California, explains that "RA is an inflammatory disease, and the more inflammation there is, the more bone loss will occur." She adds that "prednisolone, a potent anti-inflammatory agent, inhibits inflammation and [thus] subsequent bone loss."

 

Steroids less costly than biologics

"It's cheaper to treat with low-dose prednisolone and agents to prevent bone loss than tumor necrosis factor-alpha blockers," Dr. Lane says, adding that she feels that TNF-α blockers are equivalent to "very expensive steroids."

"Bone density is maintained in RA patients, and x-rays [show that it] does not deteriorate quickly, so prednisolone is a potent anti-inflammatory agent," she adds. But Dr. Lane points out that corticosteroid use can and does have other long-term side effects. "There are nonskeletal consequences that need to be carefully monitored and evaluated, but in terms of efficacy, this works."

Reference:

Haugeberg G, Strand A, Kvien TK, Kirwan JR. Reduced loss of hand bone density with prednisolone in early rheumatoid arthritis: results form a randomized placebo-controlled trial. Arch Intern Med. 2005;165:1293-1297.