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Longitudinal study of hand bone densitometry in rheumatoid arthritis.

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ARTHRITIS & RHEUMATISM
Vol. 38, No. 9, September 1995, pp 1204-1210
0 1995, American College of Rheumatology
1204
LONGITUDINAL STUDY OF HAND BONE DENSITOMETRY IN
RHEUMATOID ARTHRITIS
ATUL A. DEODHAR, J. BRABYN, PETER W. JONES, MARTIN J. DAVIS, and ANTHONY D. WOOLF
Objective. To measure hand bone mineral content
(BMC) by dual x-ray absorptiometry and to seek clinical
correlates in patients with rheumatoid arthritis (RA), in
a prospective, longitudinal study.
Methods. Eighty-one patients with non-steroidtreated RA were assessed at baseline and at month 12,
for hand BMC and for disease activity and severity.
Hand BMC in patients was compared with that in a
control group of 95 normal volunteers, and rate of loss
was compared with that in 37 controls.
Results. At the initial assessment, male and female patients with RA had lower hand BMC than
controls, after correction for age, height, and weight
(mean reduction 7.5% in men [P= 0.0031 and 7.8% in
women [P = 0.011). After 1 year, there was a further
loss of hand BMC in patients (median loss 3.25% in men
[P = 0.0011 and 1.46% in women [P = 0.05]), but
normal controls did not have significant changes in their
hand BMC. In patients with disease duration of <2
years at study entry, the parameters of disease activity
improved over 1year, but they lost significant amounts
of hand BMC. Hand BMC loss correlated with baseline C-reactive protein levels. In those with RA of
>2 years duration at entry, the Health Assessment
Questionnaire scores and Larsen scores had worsened
after 1 year, but there was no significant loss of hand
BMC.
Conclusion. Patients with RA had low hand BMC
compared with normal controls, even within 2 years of
disease onset. The rate of loss was highest in patients
with early disease and correlated with measures of
Atul A. Deodhar, MD, MRCP, J. Brabyn, Martin J. Davis,
MRCP, Anthony D. Woolf, BSc, FRCP: Duke of Cornwall Rheumatology Unit, Royal Cornwall Hospital, Truro, UK (Dr. Deodhar
is currently at the Oregon Health Sciences University, Portland,
OR); Peter W. Jones, PhD: University of Keele, Keele, UK.
Address reprint requests to Anthony D. Woolf, BSc,
FRCP, Duke of Cornwall Rheumatology Unit, Royal Cornwall
Hospital (City) Truro, TRl 2HZ, UK.
Submitted for publication December 23, 1994; accepted in
revised form March 21, 1995.
initial disease activity. This loss continued despite clinical improvement.
Rheumatoid arthritis (RA) is a disease that
principally affects the synovium, but there are extraarticular manifestations involving the skeleton, first
described in 1865 (1). Periarticular osteoporosis is an
early feature of RA, and more recently, generalized
skeletal effects of the disease have been recognized
(24). Major etiologic factors leading to this bone loss
include the direct effect of inflammatory mediators,
decrease in physical activity, and corticosteroid treatment (3,5,6). Recent longitudinal studies have shown
significant generalized bone loss within the first few
years of disease in patients with RA, which correlated
with disease activity (7,8).
Most studies of skeletal changes in RA have
been limited by the techniques available and have
investigated total body calcium or bone mass at the
lumbar spine, femoral neck, or distal radius, with
varying results (2-8). However these may not be the
ideal sites to monitor RA. Longitudinal study of bone
mass at a peripheral site such as the hand, which is one
of the earliest sites to be directly affected by RA (9),
may be a better way to assess severity and may be
more sensitive in measuring the progression of RA.
We have previously shown that hand bone mineral
content (BMC) can be reproducibly measured by dual
x-ray absorptiometry (DXA) using a custom-built perspex-aluminum plate and a locally modified spine
analysis program (10). Earlier studies have demonstrated that the reproducibility of this method (coefficient of variation) is 2.3%. In a cross-sectional study,
we have also shown that hand BMC is reduced in
patients with established RA and that this correlates
with disease severity (10). In the present investigation,
we have evaluated the potential of this technique for
monitoring disease progression in a prospective study
conducted over a l-year period in patients with RA of
varying duration and severity.
1205
HAND BMC IN RA
Table 1. Demographic characteristics of the rheumatoid arthritis
(RA) patients
No.
Median age
Age range
No. premenopausal
No. taking DMARDS*
No. with past steroid use
Early RA group
(disease duration
<2 years)
(n = 42)
Late RA group
(disease duration
>2 years)
Male
Female
Male
Female
17
53
35-77
16
0
25
55
2%71
8
25
3
16
65.5
30-84
23
63
33-84
7
21
7
(n = 39)
-
15
4
* Disease-modifying antirheumatic drugs.
PATIENTS AND METHODS
Control population. As controls, 95 healthy volunteers (46 men [ages 24-81, median 331 and 49 women [ages
20-83, median 41,31 were premenopausal and 18 postmenopausal]) were recruited from among the hospital staff, staff
members’ spouses, and volunteer workers in the hospital.
Women who might be pregnant were excluded. None of the
controls had a history of arthritis or any other illness likely to
affect hand bone mass, and none had ever used corticosteroids.
Patient population. Eighty-one patients with RA according to the criteria of the American College of Rheumatology (formerly, the American Rheumatism Association)
(11) were selected consecutively from the outpatients and
inpatients of the Duke of Cornwall Rheurnatology Unit,
Truro. Because we wished to examine the effects of disease
duration, we also specifically recruited consecutive new
patients with symptoms of <2 years duration who met the
diagnostic criteria for RA (1 1). The total group had a median
disease duration of 18 months (interquartile range [IQR] 97
months, range 2-480 months) and consisted of 33 men (ages
30-84 years, median 60) and 48 women (ages 29-84 years,
median 61.5; 15 premenopausal and 33 postmenopausal).
Patients with any other disease that could affect bone
metabolism and female patients who might be pregnant
during the study period were excluded from the study. To
investigate the effect of disease duration on loss of hand
BMC, patients were divided into 2 groups: early RA and late
RA (Table 1). Early RA and late RA were arbitrarily defined
as RA with a duration of <2 years and RA with a duration of
>2 years, respectively.
The early RA group (median disease duration 9
months, IQR 10 months, range 2-22 months) consisted of 42
patients: 17 men (ages 35-77 years, median 53) and 25
women (ages 29-71 years, median 55; 8 premenopausal)
(Table 1). None of these patients was taking any diseasemodifying antirheumatic drug (DMARD) at the time of
enrollment in the study, but during the study period, all
except 1 started treatment with DMARDs (sulfasalazine in
20, penicillamine in 8, hydroxychloroquine in 5, intramuscular sodium aurothiomalate in 3, pyritinol in 3, methotrexate
in 1, and sodium aurothiomalate injection and sulfasalazine
together in 1).
The late RA group (median disease duration 108
months, IQR 132 months, range 36-480 months) consisted of
39 patients: 16 men (ages 30-84 years, median 65.5) and 23
women (ages 33-84 years, median 63; 7 premenopausal)
(Table 1). All except 3 patients in this group were receiving
DMARDs during the study period (penicillamine in 13,
sulfasalazine in 9, intramuscular sodium aurothiomalate in 4,
methotrexate in 4, azathioprine in 4, hydroxychloroquine in
1, and sodium aurothiomalate injection and sulfasalazine
together in 1). During the study period none of the patients in
either group received oral corticosteroids, though 11 patients
in the late RA group and 3 in the early RA group had taken
oral steroids for other reasons in the past.
Assessment methods. Controls. Variables recorded in
the healthy volunteers were age, weight, and height. Hand
bone density measurement was performed by DXA (Hologic
QDR lOOO), using the custom-built perspex-aluminum plate
and modified spine analysis protocol described elsewhere
(10). Thirty-seven of the controls (9 men, 14 premenopausal
women, and 14 postmenopausal women) agreed to undergo
rescanning and had a repeat measurement of hand BMC
performed after 1 4 years, to establish the annual rate of
change in hand BMC.
Patients. All patients were assessed at baseline and
at month 12. Informed written consent was obtained at the
baseline visit. At each visit a physical examination was
performed. Clinical activity was determined by early morning stiffness, Ritchie articular index (12), and swollen joint
count. The general functional status was estimated by
Health Assessment Questionnaire (HAQ) score (13). Hand
function was assessed by grip strength (only at the final visit
in the late RA group). Radiologic severity was assessed on
hand radiographs evaluated by 1 observer and graded using
the Larsen score (14). C-reactive protein (CRP) and plasma
viscosity were measured at each visit. BMC of the dominant
hand was measured at each visit by DXA (Hologic QDR
lOOO), using the custom-built perspex-aluminum plate and
locally modified spine analysis program (10) (Figure 1).
Statistical analysis. The Number Cruncher Statistical
System (NCSS) program was used for statistical analysis.
Hand BMC of controls and patients was compared by
Mann-Whitney U test. Baseline results in patients were
compared with results at month 12 by the Wilcoxon matched
pairs test. In both groups of patients, the differences in hand
BMC (initial - final) were correlated with the baseline
parameters of disease activity by Spearman’s correlation
coefficient. Comparisons were made between the 3 groupscontrols, patients with early RA, and patients with late
RA-by carrying out an analysis of covariance (ANCOVA),
with age, weight, and height as covariates. Only those
covariates which indicated a significant association with
BMC were included in the final analysis.
RESULTS
The disease characteristics of the early RA
group and the late RA group, respectively, at the start
1206
DEODHAR ET AL
Hon 82 .Now.1992 10 :22
A11029202
Name :
Comment :
I.D.:
s.s.n:
ZIPCode :
Scan Code:
BirthDate:
Physician:
LONGITUDINAL STUDY
258635
Sex:
H
- Ethnic:
U
Height: 167.50 cn
JB Weight: 65.00 ky
Aye:
35
DR DEODHfiR
TOTAL BHD CU FOR Ll - L 4
C.F.
1.887
Region
Area
(cmz)
_______ ________
1.1
107.14
1.047
1.8Z
1.000
BHC
BHD
(grams) (yms/cnZ)
_ _ _ _ _ _ _ _ __--_--48.03
8.448
A
.02.Nou.1992 14:31 [I35 x 1981
Holoyic QDR 1008 (S/N 242)
Hanrlc: U4 47
All019385
Mon 01.Nou.1993 10:54
Name :
Comment: LONGITUDINAL WITH PLflfE
I .D.:
258635
Sex:
M
- _
Ethnic :
U
s.s.##:
Z IPCode :
Height: 167.58 c m
Scan Code: AD Weight: 65.08 ky
BirthDate:
Aye:
36
Physician :
DR DEODHAR
TOTAL BHD CV FOR Ll - L4
C.F.
1.007
Region
Area
(cm2)
1.843
1.02
1.0BB
BMC
BMD
(grams) (gms/cm21
------_ --__--__
________ _____-__
L1 103.56
43.42
0.419
Holosic QDR 1008 (S/N 241)
Figure 1. Measurement of hand bone mineral content (BMC) at study entry (A) and at 12
months (B) in a patient with early rheumatoid arthritis. Note the loss of 4.6 gm (9.6%) in hand
BMC over the 1-year period. BMD = bone mineral density.
and at the end of the study, are shown in Tables 2
and 3.
Study entry. At the initial assessment, male and
female RA patients had significantly reduced hand
BMC compared with controls, after correction for age,
height, and weight. The corrected mean BMC in the
dominant hand in male subjects was 46.49 gm (95%
confidence interval [95% CI] 44.76, 47.92) in controls
and 42.70 gm (95% CI 41, 44.4) in RA patients (mean
reduction 7.5%; P = 0.003); in female subjects it was
1207
HAND BMC IN RA
Table 2. Disease characteristics of the early rheumatoid arthritis
group (n = 42) at study entry and at 1 year
Table 4. Percent change in dominant hand bone mineral content
over 1 year*
Group (n)
Median (interquartile range)
Median (IQR)
Pt
0.9 (1.73)
-0.9 (1.92)
0.2
0.08
-5.26 (11.49)
-2.14 (10.1)
0.007
0.03
-2.24 (4.33)
0.11 (11.56)
0.1
0.2
~~
Characteristic*
Entry
1 year
Pt
stiffness, minutes
RAI
No. of swollen joints
HAQ score
Grip strength, mm Hg
CRP, mg/dl
Plasma viscosity, units
Larsen score
Hand BMC, gm
52.5 (30)
14.5 (16)
6.5 (8)
1.3 (1.5)
27.3 (15)
19 (62)
1.84 (0.22)
4 (5)
34 (15)
17.5 (55)
11 (13.5)
3 (5)
I(1.6)
46 (34.4)
8 (27)
1.73 (0.16)
8.5 (12)
32 (14)
0.04
0.04
0.001
AM
0.1
0.001
0.01
<0.0001
0.008
0.0003
* RAI = Ritchie Articular Index (ref. 12); HAQ = Health Assessment Questionnaire (ref. 13); CRP = C-reactive protein; BMC =
bone mineral content. Larsen score (ref. 14) was derived from
radiographs of both hands.
t By Wilcoxon matched pairs test.
30.82 gm (95% CI 29.63, 32.01) in controls and 28.41
gm (95% CI 27.18, 29.64) in patients (mean reduction
7.8%; P = 0.01). Hand BMC values in controls were
again compared with those in patients after the patient
population was divided according to disease duration
and the female subjects were divided into pre- and
postmenopausal groups. Male and postmenopausal
female patients with early RA had significantly lower
hand BMC than controls (P < 0.002 and P = 0.04,
respectively) after correction for the covariates age
and weight in male subjects. Male and postmenopausal
female patients with late RA also had significantly
lower hand BMC than controls (P = 0.0001 and P =
0.0002) after correction for age and height in male
subjects and for weight in female subjects. Hand BMC
of premenopausal female patients, both in the early
and the late RA groups, was not significantly different
from that of premenopausal controls (P = 0.2 and P =
Controls
Males (9)
Females (28)
Early RA
Males (17)
Females (25)
Late RA
Males (16)
Females (23)
* IQR = interquartilie range; RA = rheumatoid arthritis.
t Paired difference between hand bone mineral content at study
entry and at 1 year, by Wilcoxon matched pairs test.
0.8). However, the numbers of premenopausal patients in both groups were small.
Twelve-month assessment. Controls. Over the
12-month study period, neither the male nor the female
control group had any significant change in hand BMC
(Table 4 and Figure 2). When the female control
population was divided according to menopausal status, the postmenopausal group was found to have lost
a significant amount of hand BMC over 1 year (P =
0.001).
Overall R A patient group. Both the cohort of
male patients and the cohort of female patients showed
improvement in some parameters of disease activity at
the 12-month assessment. Male patients showed improvement in the swollen joint count (P = 0.01),
50.01
45
0
I
~
z
a
~
~
4o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
m
0
Table 3. Disease characteristics of the late rheumatoid arthritis
group (n = 39) at study entry and at 1 year
=i
~
35 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
3o o . . .
..
. . .
.
.
,
.
\.
. .p-----9
,
. . .
,
. . .
Median (interquartile range)
25.0'
Characteristic
Entry
stiffness, minutes
RAI
No. of swollen joints
HAQ score
CRP, mg/dl
Plasma viscosity, units
Larsen score
Hand BMC, gm
30 (90)
10 (14)
3 (3)
1.5 (1.3)
14 (43)
1.78 (0.26)
25 (30)
30 (16)
AM
1 year
30 (88)
10 (13)
3 (6)
1.6 (1.3)
14 (4)
1.77 (0.16)
29 (37)
31 (15)
* See Table 2 for explanations and abbreviations.
P*
0.2
0.6
0.5
0.01
0.2
0.1
0.001
0.17
20.01
BYC 1
BYC2
Figure 2. Changes in hand bone mineral content (BMC) over 1 year
in controls and rheumatoid arthritis (RA) patients. BMCl = baseline; BMC2 = 1-year assessment; 1 = male controls; 2 = male
patients with early RA; 3 = male patients with late RA; 4 = female
controls; 5 = female patients with early RA; 6 = female patients
with late RA.
DEODHAR ET AL
1208
2oi
.
10
-201
I
m
-30L
-40
K
-
-
M
PRE
EARLY RA
POST
M
PRE
P:ST
LATE RA
Figure 3. Percent changes in hand bone mineral content over a
1-year period in patients with rheumatoid arthritis (RA).M = male
patients; Pre = premenopausal female patients; Post = postmenopausal female patients.
plasma viscosity (P = 0.002), and CRP (P = 0.04), and
female patients showed improvement in early morning
stiffness (P = 0.01) and plasma viscosity (P = 0.005).
In both sexes, however, the Larsen score worsened
over this period (P = 0.02 in male patients, P = 0.001
in female patients). Patients also lost hand BMC over
the 1-year period. In male patients, the median loss
was 1.33 gm, or 3.25% (95%CI for median percent loss
0.67, 5.64) (P= 0.001). In female patients, the median
loss was 0.42 gm, or 1.46%(95% CI for median percent
loss -1.88, 5.14) (P = 0.05).
Early RA group. Over the study period, patients in the early RA group showed overall improvement in disease activity (Table 2), with decreases in
the duration of early morning stiffness, the Ritchie
articular index, the swollen joint count, plasma viscosity, and the CRP level and improvement in grip
strength, although the HAQ improved in male patients
only (P = 0.03). The Larsen score on hand radiographs
had worsened significantly at 1 year. As a group, the
patients with early RA lost a significant amount of
hand BMC over 12 months. In male patients, the
median loss was 2.45 gm, or 5.26% (95% CI for percent
loss 1.89, 9.6) (P = 0.007). In female patients, the
median loss was 0.73 gm, or 2.14% (95% CI for percent
loss -2.1, 6.9) (P = 0.03) (Table 4 and Figure 2). The
rate of change varied between individuals, however,
from an 11% gain to a 22% loss (Figure 3). The overall
percent loss of hand BMC correlated with baseline
CRP (r = 0.32, P = 0.05) and inversely with disease
duration (r = -0.67, P < 0.001), with greater loss
occurring predominantly in patients who had disease
duration of < 1 year at study entry (Figure 4).
Late RA group. Over the study period, there
was no significant change in most of the disease
activity parameters measured in the late RA group
(Table 3), although the Larsen score and the HAQ
score worsened significantly. There was a trend toward loss of hand BMC after 1 year in male patients,
but the change did not reach statistical significance
(median loss 0.94 gm, or 2.24% [95% CI for percent
loss -0.86,4.1]) (P= 0. I), and there was no significant
change in female patients (median loss 0.03 gm, or
0.11% [95% CI for percent loss -4.52, 5.141) (P= 0.2)
(Table 4 and Figure 2). The individual rate of change in
the late RA group vaned, however, between 8% gain
and 33% loss, with greatest losses in some of the
postmenopausal female patients (Figure 3). There was
no correlation between change in hand BMC and
parameters of disease activity. The number of patients
who had previously taken corticosteroids was too
small to enable examination of the effect of past use of
these drugs on hand BMC.
Effect of menopause on hand BMC. To investigate whether menopausal status affected hand BMC at
baseline and its rate of loss over 1 year, ANCOVA was
used, with presence of RA and menopause as 2 separate risk factors after correction for confounders such
as age, height, and weight. In female patients with
early RA, menopausal status (P = O.OOOl), but not the
presence of disease (P = O.l), was the important
determinant of hand BMC at baseline, whereas in
female patients with late RA, both the presence of the
disease (P < 0.0001) and menopausal status (P =
0.007) were determinants of hand BMC at baseline.
PERCENT LOSS
. .
15
1
-10
-15'
0
r =-0.67
~
2
4
6
8
10
12
~
14
16
18
DURATION IN MONTHS AT ENTRY
20
22
24
EARLY RA
p<O.OOl
Figure 4. Percent changes in hand bone mineral content over a
1-year period in patients with rheumatoid arthritis (RA), and correlation with disease duration at study entry.
HAND BMC IN RA
With regard to the rate of loss of hand BMC, the
presence of RA (P = 0.03) was the sole determinant in
female patients with early RA; menopausal status was
not a significant factor (P = 0.2). In female patients
with late RA, however, menopausal status (P = 0.01)
was the main determinant of the rate of loss of hand
BMC, and presence of the disease was not significant
(P= 0.8). In summary, therefore, presence of RA was
found to be the sole determinant of the rapid loss of
hand BMC in female patients with early RA, but in
female patients with late RA, the changes in hand
BMC were not solely disease dependent.
Comparison between early RA and late RA
groups. Among male patients, there was no significant
difference in hand BMC between the early RA and late
RA groups after correction for age (P = 0.1). The rate
of loss of hand BMC, however, was significantly
greater in men in the early RA group than in men in the
late RA group after correction for age (P = 0.01)
(Figure 2).
Women in the late RA group had significantly
lower hand BMC than women in the early RA group
after correction for height, weight, and age (P= 0.0004
at entry, P = 0.01 at 1 year) (Figure 2). Women in the
early RA group lost more bone than the women in the
late RA group, but this difference in the rate of loss of
hand BMC did not reach statistical significance.
DISCUSSION
Rheumatoid arthritis is characterized radiologically by periarticular osteoporosis, joint space narrowing, and erosions. This joint damage is generally
irreversible and correlates with declining functional
capacity over the long term (15).
Joints with persistent synovitis have a higher
risk of progressive bone damage than joints without
signs of inflammation (16). A goal of RA treatment is to
prevent this damage to the articular tissue by controlling synovitis. Assessment of bony changes detected
by radiographs has thus evolved as the “gold standard” for evaluating progression of RA. There are,
however, numerous problems with reproducibility and
sensitivity of the many radiologic assessment methods
that are presently available (17). Larsen’s method of
scoring hand radiographs is one such widely used and
validated method (14). This method requires assessment by a well-trained observer, but it can still be
inaccurate in monitoring the early changes of RA since
the determination of periarticular osteoporosis is subjective and depends heavily on the quality of the
1209
radiographs (17). Microfocal radiographs and magnetic
resonance imaging (MRI) scans can detect changes
earlier than conventional radiography, though the
changes on microfocal radiographs are not quantitative and in the case of MRI, the costs could be
prohibitive. Clearly a better tool is needed to quantitatively monitor the early bone changes in RA.
Hand BMC measurement with DXA provides
such a sensitive tool to measure this early loss of bone.
It has been previously shown to be a reproducible
method, which is free of observer bias and which has
the potential to be performed with standard equipment
available in many hospitals (10). It has a distinct
advantage over other x-ray scoring methods since the
precision of the method does not depend on the hand
position.
In this study, patients with RA had an average
of 7.6% less hand bone mass as compared with controls even at study entry, and on average lost a further
2.35% hand BMC over 1 year. RA is known to cause a
generalized skeletal effect, with bone loss in the femoral neck and lumbar spine (7,8); however, a recent
cross-sectional study has shown that changes in hand
bone mass are more dramatic than changes at other
sites (18), with a reduction in hand bone mineral
density of 23%, as compared with 16% at the femoral
neck and 11% at the lumbar spine (18). The loss of
hand bone mass in patients with RA therefore appears
to be a combined result of the generalized plus local
effects of the disease. Our longitudinal data demonstrate that the most rapid rate of loss of hand bone
density occurs very early in the disease (5.26% over 1
year in men with early RA and 2.14% in women with
early RA). Studies of bone density in the lumbar spine
and femoral neck of patients with RA have also shown
significant bone loss very early in the disease (73).
Long-term followup in these patients is needed to
determine whether the loss of hand BMC correlates
with future loss of function and overall poor outcome.
The annual rate of change of hand BMC in
patients with early RA varied from 11% to -22%, and
this correlated with the baseline CRP level but not
with indicators of hand function such as grip strength.
This loss occurred despite improvement in other validated measures of disease activity, indicating that
even though the current treatment of RA is successful
in improving symptoms and markers of inflammation,
it may not be very effective in controlling the early loss
of bone. It is possible that there is a lag period before
general clinical improvement is mirrored in the hand
1210
DEODHAR ET AL
BMC measurement; consequently, this study on patients with early RA is being extended.
Corticosteroids have a major effect on bone
density (19), although none of our patients received
corticosteroids during this study. Menopausal status
appears to be a cofactor for loss of hand BMC in
postmenopausal women with RA of longer duration,
but the rapid loss of hand BMC in early RA is
independent of menopausal status, Hormone replacement therapy (HRT) has recently been shown to
increase spinal bone density and maintain femoral
bone density in patients with RA (20). It would be
interesting to know whether HRT has a similar protective role on hand bone loss.
Proposed mechanisms of bone loss in RA are
many. It is postulated that this could be mediated
through cytokines such as interleukin-1 (IL-1), IL-6,
and tumor necrosis factor Q (21). Use of oral corticosteroids (19) and reduction in mobility (8) are also
implicated in the pathogenesis of generalized osteoporosis. The failure of presently accepted drug therapy
in controlling bone loss provides a rationale for consideration of either antiresorptive agents such as calcitonin or bisphosphonates or newer agents that block
the IL-1 receptor, to determine whether these strategies prevent hand bone loss.
Hand bone densitometry is an accurate, reproducible, and sensitive quantitative measure of bony
changes in the hand. It has the potential to be used as
a gold standard outcome measure in early stage of RA,
the very crucial time at which maximum damage to the
bones occurs. It also opens up new possibilities for
monitoring and evaluating newer therapies aimed at
preventing these early bone changes. Further longterm studies are required to clarify whether this rapid
and early loss of bone is clinically relevant to functional outcome.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
REFERENCES
Barwell R: Diseases of the Joints. London, Hardwicke, 1865
Compston JE, Crawley EO, Evans C, O’Sullivan MM: Spinal
trabecular bone mineral content in patients with non-steroid
treated rheumatoid arthritis. Ann Rheum Dis 47:66&664, 1988
Sambrook PN, Eisman JA, Champion GD, Yeates MG, Pocock
NA, Eberl S: Determinants of axial bone loss in rheumatoid
arthritis. Arthritis Rheum 30:721-728, 1987
Sambrook PN, Eisman JA, Yeates MG, Pocock NA, Eberl S,
20.
21.
Champion GD: Osteoporosis in rheumatoid arthritis: saftey of
low dose corticosteroids. Ann Rheum Dis 45:950-953, 1986
Reid DM, Kennedy NSJ, Smith MA, Tothill P, Nuki G: Total
body calcium in rheumatoid arthritis: effects of disease activity
and corticosteroid treatment. Br Med J 285:330-332, 1982
Verstraeten A, Dequecker J: Vertebral and peripheral bone
mineral content and fracture incidence in postmenopausal patients with rheumatoid arthritis. Ann Rheum Dis 4T852-857,
1986
Shenstone BD, Mahmoud A, Woodward R, Elvins D, Palmer R,
Ring EF, Bhalla AK: Longitudinal bone mineral density
changes in early rheumatoid arthritis. Br J Rheumatol 33541545, 1994
Gough AKS, Lilley J, Eyre S, Holder RL, Emery P: Generalised bone loss in patients with early rheumatoid arthritis.
Lancet 344:23-27, 1994
Flemming A, Crown JM, Corbett M: Early rheumatoid disease.
I. Onset. Ann Rheum Dis 35:357-360, 1976
Deodhar AA, Brabyn J, Jones PW, Davis MJ, Woolf AD:
Measurement of hand bone mineral content by dual energy
x-ray absorptiometry: development of the method, and its
application in normal volunteers and in patients with rheumatoid arthritis. Ann Rheum Dis 53:685490, 1994
Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF,
Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS,
Medsger TA Jr, Mitchell DM, Neustadt DH, Pinals RS, Schaller
JG, Sharp JT, Wilder RL, Hunder GG: The American Rheumatism Association 1987 revised criteria for the classification of
rheumatoid arthritis. Arthritis Rheum 31:315-324, 1988
Ritchie DM, Boyle JA, McInnes JM, Jasani MK, Dalakos TG,
Grieveson P, Buchanan WW: Clinical studies with an articular
index for the assessment of joint tenderness in patients with
rheumatoid arthritis. Q J Med 37:393406, 1968
Fries JF, Spitz P, Kraines RG, Holman HR: Measurement of
patient outcome in arthritis. Arthritis Rheum 23:137-145, 1980
Larsen A, Dale K, Eek M: Radiographic evaluation of rheumatoid arthritis and related conditions by standard reference films.
Acta Radio1 18:481-491, 1977
Scott DL, Symmons DPM, Coulton BL, Popert AJ: Long-term
outcome of treating rheumatoid arthritis: results after 20 years.
Lancet l:llO8-llll, 1987
Ingeman-Nielson M, Halskov 0, Hansen TM, Halberg P, Stage
P, Lorenzen I: Clinical synovitis and radiological lesions in
rheumatoid arthritis. Scand J Rheumatol 12:237-240, 1983
Brower AC: Use of the radiograph to measure the course of
rheumatoid arthritis: the gold standard versus fool’s gold.
Arthritis Rheum 33:316323, 1990
Peel NFA, Spittlehouse AJ, Bax DE, Eastell R: Bone mineral
density of the hand in rheumatoid arthritis. Arthritis Rheum
37~983-991, 1994
Laan RFJM, van Riel PLCM, van Erning LJThO, Lemmens
JAM, Ruijs SHJ, van de Putte LBA: Vertebral osteoporosis in
rheumatoid arthritis patients: effect of low dose prednisolone
therapy. Br J Rheumatol 31:91-96, 1992
Hall GM, Daniels M, Doyle DV, Spector TD: Effect of hormone
replacement therapy on bone mass in rheumatoid arthritis
patients treated with and without steroids. Arthritis Rheum
37:14%1505, 1994
Bhalla AK, Shenstone B: Bone densitometry measurements in
early inflammatory disease. Ballieres Clin Rheumatol 6:405414, 1992
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