Meta-analysis of tumor necrosis factor inhibitors and glucocorticoids on bone density in rheumatoid arthritis and ankylosing spondylitis trials.

ObjectiveTo 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. MethodsElectronic databases were systematically searched for randomized controlled trials. Studies were grouped based on disease, treatment, and site of BMD measurement. Change in BMD (BMD) from baseline to end of study was recorded. Standardized mean difference (SMD) of BMD between treatment and controls was standardized for meta-analyses and 95% confidence intervals (95% CIs) were calculated. ResultsTreatment 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 BMD 0.33 [95% CI 0.13, 0.53], P=0.001, I-2=0%) and glucocorticoids (SMD BMD 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 BMD -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 BMD 0.96 [95% CI 0.64, 1.27], P<0.001, I-2=16%) and hip (SMD BMD 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. ConclusionIn 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.