%0 Journal Article
%T The use of glucocorticoids in rheumatoid arthritis - no 'rational' approach yet
%A Sonali P Desai
%A Daniel H Solomon
%J Arthritis Research & Therapy
%D 2010
%I BioMed Central
%R 10.1186/ar3035
%X In the previous issue of Arthritis Research and Therapy, Ibanez and colleagues [1] report on the 'rational' use of glucocorticoids (GCs) in the management of early arthritis. This article concludes that GCs cause minimal variation in bone mineral density (BMD) at multiple skeletal sites, and in fact may increase BMD at the ultradistal forearm, a juxta-articular site. Although this article is notable for examining the effect of GCs on BMD at five anatomic sites, a 'rational' use of GCs for rheumatoid arthritis (RA) is still elusive. To grasp the complex relationship between GCs and both localized (juxta-articular, bony erosions) and systemic (osteoporosis) bone loss in RA, we need to first step back and appreciate the interplay of the immune system and bone metabolism.The osteoclast plays a central role at the site of inflamed joints and is critical in the pathogenesis of joint erosions in RA [2]. Receptor activator of nuclear factor-kappa B ligand (RANKL), expressed by TH1 and TH17 T cell subsets, is a potent inducer of osteoclast differentiation. Additionally, an array of pro-inflammatory cytokines such as TNF, IL-1, IL-6 and IL-17 can stimulate RANKL expression [3] (Figure 1). GCs, in turn, directly affect both osteoblast and osteoclast activity, and indirectly exert many effects on bone metabolism, leading to an increased fracture risk [4] (Figure 2).How should the relationship between the bone biology in RA and the effects of GCs translate into the use of GCs in clinical practice? The COBRA trial provides a rationale for the use of GCs in combination with other disease modifying anti-rheumatic drugs (DMARDs) to significantly reduce RA disease activity [5]. A subsequent review demonstrates that GCs (mean cumulative dose of 2,300 mg prednisone equivalent over the first year), when used in combination with traditional DMARD therapy, can decrease the rate of radiographic progression in RA [6]. The effect of GCs on bone mass, among non-RA patients, has been evaluated
%U http://arthritis-research.com/content/12/3/127