European Journal of Pediatrics

, Volume 166, Issue 8, pp 775–784 | Cite as

Osteoporosis in juvenile idiopathic arthritis- a practical approach to diagnosis and therapy

  • Johannes Roth
  • Susanne Bechtold
  • Gudrun Borte
  • Frank Dressler
  • Hermann J. Girschick
  • Michael Borte


In all subgroups of juvenile idiopathic arthritis, a decrease in bone mass has been described in a high percentage of children. Recently, new pathogenetic concepts have identified muscle mass as the strongest predictor of bone mass and bone is now recognized as part of the musculoskeletal system. In addition, the sophisticated use of bone densitometry in pediatrics, including new measurement techniques, has provided the tools for a reliable assessment. A standardized diagnostic approach to the musculoskeletal system, including prophylaxis and therapy, is, therefore, mandatory in all children with JIA who do not achieve rapid remission. In this review, diagnostic and therapeutic options are being described and possibilities to incorporate them into clinical practice are suggested.


Juvenile idiopathic arthritis Osteoporosis Bone densitometry Musculoskeletal system Osteoporosis therapy 


  1. 1.
    American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis (2001) Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis 2001 update. Arthritis Rheum 44:1496–1503CrossRefGoogle Scholar
  2. 2.
    Bechtold S, Ripperger P, Dalla Pozza R, Schmidt H, Hafner R, Schwarz HP (2005) Musculoskeletal and functional muscle-bone analysis in children with rheumatic disease using peripheral quantitative computed tomography. Osteoporosis Int 16:757–763CrossRefGoogle Scholar
  3. 3.
    Bianchi ML, Cimaz R, Galbiati E, Corona F, Cherubini R, Bardare M (1999) Bone mass change during methotrexate treatment in patients with juvenile rheumatoid arthritis. Osteoporosis Int 10:20–25CrossRefGoogle Scholar
  4. 4.
    Burnham JM, Shults J, Weinstein R, Lewis JD, Leonard MB (2006) Childhood onset arthritis is associated with an increase risk of fracture: a population based study using the General Practice Research Database. AnnRheum Dis 65:1074–1079CrossRefGoogle Scholar
  5. 5.
    Chan YY, Bishop NJ (2002) Clinical management of childhood osteoporosis. Int J Clin Pract 56:280–286PubMedGoogle Scholar
  6. 6.
    Cimaz R (2002) Osteoporosis in childhood rheumatic diseases: prevention and therapy. Best Pract Res Clin Rheumatol 16:397–409PubMedGoogle Scholar
  7. 7.
    Dunlop DJ, Soukop M, McEwan HP (1990) Antenatal administration of aminopropylidene diphosphate. Ann Rheum Dis 49:955PubMedCrossRefGoogle Scholar
  8. 8.
    Eastell R, Reid DM, Compston J, Cooper C, Fogelman I, Francis RM, Hosking DJ, Purdie DW, Ralston SH, Reeve J, Russell RG, Stevenson JC, Torgerson DJ (1998) A UK consensus group management of glucocorticoid-induced osteoporosis: an update. J Intern Med 244:271–292PubMedCrossRefGoogle Scholar
  9. 9.
    Elsasser U, Wilkins B, Hesp R, Thurnham DI, Reeve J, Ansell BM (1982) Bone rarefication and crush fractures in juvenile chronic arthritis. Arch Dis Child 57:377–380PubMedCrossRefGoogle Scholar
  10. 10.
    Falcini F, Trapani S, Civinini R, Capone A, Ermini M, Bartolozzi G (1996) The primary role of steroids on the osteoporosis in juvenile rheumatoid arthritis patients evaluated by dual energy x-ray absorptiometry. J Endocrinol Invest 19:165–169PubMedGoogle Scholar
  11. 11.
    Fricke O, Weidler J, Tutlewski B, Schoenau E (2006) Mechanography- a new device for the assessment of muscle function in pediatrics. Pediatr Res 59:46–49PubMedCrossRefGoogle Scholar
  12. 12.
    Frost HM, Schoenau E (2000) The “Muscle Bone Unit” in children and adolescents: a 2000 overview. J Ped Endocr Metab 13:571–590Google Scholar
  13. 13.
    Häkkinen A, Sokka T, Kautiainen H, Kotaniemi A, Hannonen P (2004) Sustained maintenance of exercise induced muscle strength gains and normal bone mineral density in patients with early rheumatoid arthritis: a 5 year follow up. Ann Rheum Dis 63:910–916PubMedCrossRefGoogle Scholar
  14. 14.
    Henderson CJ, Cawkwell GD, Specker BL, Sierra RI, Wilmott RW, Campaigne BN, Lovell DJ (1997) Predictors of total body bone mineral density in non-corticosteroid treated prepubertal children with juvenile rheumatoid arthritis. Arthritis Rheum 40:1967–1975PubMedCrossRefGoogle Scholar
  15. 15.
    Henderson CJ, Specker BL, Sierra RI, Campaigne BN, Lovell DJ (2000) Total body bone mineral content in non-corticosteroid treated postpubertal females with juvenile rheumatoid arthritis. Arthritis Rheum 43:531–540PubMedCrossRefGoogle Scholar
  16. 16.
    Hochberg Z, Bereket A, Davenport M, Delemarre-Van de Waal HA, De Schepper J, Levine MA, Shaw N, Schoenau E, van Coeverden SC, Weisman Y, Zadik Z, European Society for Paediatric Endocrinology (ESPE) Bone Club (2002) Consensus Development for the supplementation of vitamin D in childhood and adolescence. Horm Res 58:39–51PubMedCrossRefGoogle Scholar
  17. 17.
    Hofbauer LC, Schoppet M (2004) Clinical implications of the osteoprotegerin/RANKL/RANK system for bone and vascular diseases. JAMA 292:490–495PubMedCrossRefGoogle Scholar
  18. 18.
    Homik J, Suarez-Almazor ME, Shea B, Cranney A, Wells G, Tugwell P (2004) Calcium and Vitamin D for corticosteroid-induced osteoporosis (Cochrane Review). In: The Cochrane Library, Issue 3. Wiley, Chichester, UKGoogle Scholar
  19. 19.
    Illidge TM, Hussey M, Godden CW (1996) Malignant hypercalcaemia in antenatal administration of intravenous pamidronate. Clin Oncol 8:257–258CrossRefGoogle Scholar
  20. 20.
    de Jong Z, Munneke M, Lems WF, Zwinderman AH, Kroon HM, Pauwels EK, Jansen A, Ronday KH, Dijkmans BA, Breedveld FC, Vliet Vlieland TP, Hazes JM (2004) Slowing of bone loss in patients with rheumatoid arthritis by long-term high-intensity exercise: results of a randomized, controlled trial. Arthritis Rheum 50:1066–1076PubMedCrossRefGoogle Scholar
  21. 21.
    Kotaniemi A, Savolainen A, Kroger H, Kautiainen H, Isomaki H (1999) Weight-bearing physical activity, calcium intake, systemic glucocorticoids, chronic inflammation and body constitution as determinants of lumbar and femoral bone mineral in juvenile chronic arthritis. Scand J Rheumatol 28:19–26PubMedCrossRefGoogle Scholar
  22. 22.
    Kotaniemi A, Savolainen A, Kautiainen H, Kroeger H (1993) Estimation of central osteopenia in children with chronic polyarthritis treated with glucocorticoids. Pediatrics 91:1127–1130PubMedGoogle Scholar
  23. 23.
    Lien G, Flato B, Haugen M, Vinje M, Sorskaar D, Dale K, Johnston V, Egeland T, Forre O (2003) Frequency of osteopenia in adolescents with early-onset juvenile idiopathic arthritis. Arthritis Rheum 48:2214–2223PubMedCrossRefGoogle Scholar
  24. 24.
    Lovell DJ, Glass D, Ranz J, Kramer S, Huang B, Sierra RI, Henderson CJ, Passo M, Graham B, Bowyer S, Higgins G, Rennebohm R, Schikler KN, Giannini E (2006) A randomized controlled trial of calcium supplementation to increase bone mineral density in children with juvenile rheumatoid arthritis. Arthritis Rheum 54:2235–2242PubMedCrossRefGoogle Scholar
  25. 25.
    Munns CF, Rauch F, Ward L, Glorieux FH (2004) Maternal and fetal outcome after long-term pamidronate treatment before conception: a report of two cases. J Bone Miner Res 19:1742–1745PubMedCrossRefGoogle Scholar
  26. 26.
    Murray KJ, Boyle RJ, Woo P (2000) Pathological fractures and osteoporosis in a cohort of 103 systemic onset juvenile idiopathic arthritis patients. Arthritis Rheum 43:S119Google Scholar
  27. 27.
    Parfitt AM (1990) Bone-forming cells in clinical conditions. In: Hall BK (ed) The osteoblast and osteocyte. Telford Press, Caldwell, NJ, pp 351–429Google Scholar
  28. 28.
    Parfitt AM (1997) Vitamin D and the pathogenesis of rickets and osteomalacia. In: Feldman D, Glorieux FH, Pike W (eds) Vitamin D. Academic Press, San Diego, pp 645–662Google Scholar
  29. 29.
    Parfitt AM, Drezner MK, Glorieux FH (1987) Bone histomorphometry: standardization of nomenclature, symbols, and units. Report of the ASBMR Histomorphometry Nomenclature Committee. J Bone Miner Res 2:595–610PubMedCrossRefGoogle Scholar
  30. 30.
    Pepmueller PH, Cassidy JT, Allen SH, Hillman LS (1996) Bone mineralization and bone mineral metabolism in children with juvenile rheumatoid arthritis. Arthritis Rheum 39:746–757PubMedCrossRefGoogle Scholar
  31. 31.
    Rauch F, Schoenau E (2001) Changes in bone density during childhood and adolescence: an approach based on bone’s biological organisation. J Bone Miner Res 16:1–8Google Scholar
  32. 32.
    Rauch F, Glorieux F (2004) Osteogenesis imperfecta. Lancet 363:1377–1385PubMedCrossRefGoogle Scholar
  33. 33.
    Rauchenzauner M, Schmid A, Heinz-Erian P, Kapelari K, Falkensammer G, Griesmacher A, Finkenstedt G, Hoegler W (2007) Sex- and age-specific reference curves for serum markers of bone turnover in healthy children from 2 months to 18 years. J Clin Endocrinol Metab 92:443–449PubMedCrossRefGoogle Scholar
  34. 34.
    Reed A, Haugen M, Pachman LM, Langman CB (1991) 25-Hydroxyvitamin D therapy in children with active juvenile rheumatoid arthritis: short term effects on serum osteocalcin levels and bone mineral density. J Pediatrics 119:657–660CrossRefGoogle Scholar
  35. 35.
    Roth J, Palm C, Scheunemann I, Ranke MB, Schweizer R, Dannecker GE (2004) Musculoskeletal abnormalities of the forearm in patients with juvenile idiopathic arthritis relate mainly to bone geometry. Arthritis Rheum 50:1277–1285PubMedCrossRefGoogle Scholar
  36. 36.
    Roth J, Tzaribachev N, Linge M, Kuemmerle-Deschner J (2005) The muskuloskeletal system in juvenile arthritis, a 4-year follow up. Arthritis Rheum 20:Suppl S92Google Scholar
  37. 37.
    Sambrook PN (2001) Therapy and prophylaxis of corticosteroid induced osteoporosis. Z Rheumatol 60:120–122PubMedCrossRefGoogle Scholar
  38. 38.
    Scheunemann I, Dannecker G, Roth J (2006) Phalangeal bone ultrasound is of limited value in patients with juvenile idiopathic arthritis. Rheumatology 45:1125–1128PubMedCrossRefGoogle Scholar
  39. 39.
    Schiessl H, Frost HM, Jee WS (1998) Estrogen and bone-muscle strength and mass relationships. Bone 22:1–6PubMedCrossRefGoogle Scholar
  40. 40.
    Specker BL, Schoenau E (2005) Quantitative bone analysis in children: current methods and recommendations. J Pediatr 146:726–731PubMedCrossRefGoogle Scholar
  41. 41.
    Schoenau E, Saggese G, Peter F, Baroncelli GI, Shaw NJ, Crabtree NJ, Zadik Z, Neu CM, Noordam C, Radetti G, Hochberg Z (2004) From bone biology to bone analysis. Horm Res 61:257–269PubMedCrossRefGoogle Scholar
  42. 42.
    Schoenau E, Neu CM, Beck B, Manz F, Rauch F (2002) Bone mineral content per muscle cross-sectional area as an index of the functional muscle-bone unit. J Bone Min Res 17:1095–1101CrossRefGoogle Scholar
  43. 43.
    Schoenau E, Rauch F (1997) Markers of bone and collagen metabolism- problems and perspectives in paediatrics. Horm Res 48 (suppl 5):50–59Google Scholar
  44. 44.
    Singh-Grewal D, Wright V, Bar-Or O, Feldman BM (2006) Pilot study of fitness training and exercise testing in polyarticular childhood arthritis. Arthritis Rheum 55:364–372PubMedCrossRefGoogle Scholar
  45. 45.
    Srivastava T, Alon US (2003) The role of bisphosphonates in diseases of childhood. Eur J Pediatr 162:735–751PubMedCrossRefGoogle Scholar
  46. 46.
    Takken T, Hemel A, van der Net J, Helders P (2002) Aerobic fitness in children with juvenile idiopathic arthritis: a systematic review. J Rheumatol 29:2643–2647PubMedGoogle Scholar
  47. 47.
    Thornton J, Ashcroft DM, Mughal MZ, Elliott RA, O’Neill TW, Symmons D (2006) Systematic review of effectiveness of bisphosphonates in treatment of low bone mineral density and fragility fractures in juvenile idiopathic arthritis. Arch Dis Child 91:753–761PubMedCrossRefGoogle Scholar
  48. 48.
    Wallace CA, Ruperto N, Giannini E, Childhood Arthritis and Rheumatology Research Alliance, Pediatric Rheumatology International Trials Organization, Pediatric Rheumatology Collaborative Study Group (2004) Preliminary criteria for clinical remission for select categories of juvenile idiopathic arthritis. J Rheumatol 31:2290–2294PubMedGoogle Scholar
  49. 49.
    WHO Study Group (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Tech Rep Ser 843:1–129Google Scholar
  50. 50.
    Woo SB, Hellstein JW, Kalmar JR (2006) Systematic review: bisphosphonates and osteonecrosis of the jaw. Ann Intern Med 144:753–761PubMedGoogle Scholar
  51. 51.
    Zak M, Hassager C, Lovell DJ, Nielsen S, Henderson CJ, Pedersen FK (1999) Assessment of bone mineral density in adults with a history of juvenile chronic arthritis. Arthritis Rheum 42:790–798PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Johannes Roth
    • 1
    • 7
  • Susanne Bechtold
    • 2
  • Gudrun Borte
    • 3
  • Frank Dressler
    • 4
  • Hermann J. Girschick
    • 5
  • Michael Borte
    • 6
  1. 1.Department of Pediatric Pneumology and ImmunologyCharite University MedicineBerlinGermany
  2. 2.Children’s Hospital University of MunichMunichGermany
  3. 3.Department of Diagnostic and Interventional RadiologyUniversity of LeipzigLeipzigGermany
  4. 4.Children’s Hospital MHHHannoverGermany
  5. 5.University Children’s HospitalWuerzburgGermany
  6. 6.Municipal Hospital“St. Georg” Leipzig, Children’s HospitalLeipzigGermany
  7. 7.SPZ RheumatologyCharite Virchow KlinikumBerlinGermany

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