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Pharmacological treatment for managing bone health in axial spondyloarthropathy: systematic review and meta-analysis

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Abstract

Axial spondyloarthropathy (axSpA) is associated with an increased prevalence of osteoporosis, but no recommendations exist to guide management. This systematic review and meta-analysis aim to assess the efficacy of pharmacological and non-pharmacological interventions on bone mineral density (BMD) in axSpA. Electronic databases were searched from inception to June 2019 for randomised controlled trials (RCTs) and quasi (q)-RCTs with pharmacological and non-pharmacological interventions. Independent reviewers undertook screening, and risk of bias and quality assessments. Primary outcomes of interest were BMD at spine and hip. Eight studies (two RCTs and six qRCTs) were included (602 participants). Moderate level evidence favoured alendronate over placebo at femoral neck [mean difference (MD) 2.01, 95% CI 0.67 to 3.35], but there was low-level evidence showing no effect at the spine. There was moderate level evidence showing no effect of tumour necrosis factor inhibitors (TNFi) on BMD at total hip (MD − 0.01, 95% CI − 0.06 to 0.04). Very low-level evidence demonstrated no effect of TNFi on spine or femoral neck. Moderate level evidence favoured neridronate over infliximab at the spine (MD 3.26, 95% CI 1.14 to 5.38), but low-level evidence showed no effect at the total hip (MD 2.75, 95% CI − 0.21 to 5.71). There were no eligible studies investigating the efficacy of non-pharmacological interventions. We conditionally recommend alendronate for management of low BMD in axSpA. The balance of evidence does not recommend the use of TNF-inhibitors for treating low BMD. There is a lack of high-quality evidence guiding clinicians treating osteoporosis in axSpA.

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Funding

There is no funding to report for this study.

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Authors and Affiliations

  1. School of Medicine, Trinity College Dublin, Dublin, Ireland

    Gillian E. Fitzgerald & Finbar D. O’Shea

  2. Department of Rheumatology, St. James’s Hospital, Dublin, Ireland

    Gillian E. Fitzgerald & Finbar D. O’Shea

  3. Independent Researcher, Dublin, Ireland

    Tom O’Dwyer

  4. John Stearne Library, Trinity Centre for Health Sciences, St. James’s Hospital, Dublin, Ireland

    David Mockler

  5. Discipline of Physiotherapy, Trinity College Dublin, Dublin, Ireland

    Fiona Wilson

Authors
  1. Gillian E. Fitzgerald
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  2. Tom O’Dwyer
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  3. David Mockler
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  4. Finbar D. O’Shea
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  5. Fiona Wilson
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Contributions

All authors contributed to the study conception and design. The literature search strategy was devised by David Mockler, with input from all authors, and performed by David Mockler. The literature review was performed by all authors. Data extraction was performed by Gillian Fitzgerald, Tom O’ Dwyer and Fiona Wilson. Data analysis was performed by Gillian Fitzgerald, Tom O’Dwyer, Finbar O’ Shea and Fiona Wilson. Gillian Fitzgerald wrote the first draft. All authors critically analysed and commented on all versions. All authors read and approved the final manuscript. All co-authors take full responsibility for the integrity of the review.

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Correspondence to Gillian E. Fitzgerald.

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Conflict of interest

Dr. Fitzgerald reports non-financial support from Pfizer Pharmaceuticals, non-financial support from AbbVie Pharmaceuticals, outside the submitted work. Mr. Mockler has nothing to disclose. Dr. O’ Dwyer has nothing to disclose. Dr. O’Shea reports personal fees from Lilly, personal fees from Abbvie, personal fees from Novartis, personal fees from Boheringer, personal fees from Gilead, personal fees from UCB, personal fees from Roche, personal fees from Sanofi, outside the submitted work. Dr. Wilson has nothing to disclose.

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Fitzgerald, G.E., O’Dwyer, T., Mockler, D. et al. Pharmacological treatment for managing bone health in axial spondyloarthropathy: systematic review and meta-analysis. Rheumatol Int 40, 1369–1384 (2020). https://doi.org/10.1007/s00296-020-04623-3

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  • DOI: https://doi.org/10.1007/s00296-020-04623-3

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