Long-term effects on bone mineral density after four years of treatment with two intensive combination strategies, including initially high-dose prednisolone, in early rheumatoid arthritis patients: the COBRA-light trial.

In this study, no difference in bone loss was observed between patients with early RA initially treated with COmbinatietherapie Bij Reumatoide Artritis (COBRA) (including initially 60 mg/day prednisolone) and patients treated with COBRA-light (including initially 30 mg/day prednisolone) during 4-year observation. PURPOSE: To assess changes in bone mineral density (BMD) after 4 years in early rheumatoid arthritis (RA) patients initially treated with COBRA-light or COBRA therapy. METHODS: In a 1 year, open-label, randomised, non-inferiority trial, patients were assigned to COBRA-light (methotrexate 25 mg/week plus initially prednisolone 30 mg/day) or COBRA (methotrexate 7.5 mg/week, sulfasalazine 2 g/day plus initially prednisolone 60 mg/day) therapy. After 1 year, antirheumatic treatment was at the discretion of treating rheumatologists. BMD was measured at baseline and after 1, 2 and 4 years at hips and lumbar spine with dual-energy X-ray absorptiometry. BMD changes between treatment strategies on average over time were compared with GEE analysis. RESULTS: Data from 155 out of 162 patients could be analysed: 68% were female with a mean age of 52 (SD 13) years. Both COBRA-light and COBRA therapy showed declines in BMD at the total hip of -3.3% and -1.7%, respectively (p = 0.12), and the femoral neck, -3.7% and -3.0%, respectively (p = 0.95). At the lumbar spine, both treatment groups showed minor decline in BMD over 4 years: -0.5% and -1.0%, respectively (p = 0.10). CONCLUSION: In a treat-to-target design in early RA, over 4 years, no differences between groups were found in change in BMD at total hip, femoral neck and the lumbar spine. At the hip, bone loss was around 3% in both groups, while mild bone loss was observed at lumbar spine, both in patients starting prednisolone 60 and 30 mg/day. These data suggest that the well-known negative effects of prednisolone can be modulated by modern treatment of RA.

Making the invisible visible: bioelectrical impedance analysis demonstrates unfavourable body composition in rheumatoid arthritis patients in clinical practice.

OBJECTIVES: To examine differences between the assessment of body composition by body mass index (BMI) and bioelectrical impedance analysis (BIA) in patients with rheumatoid arthritis (RA). METHOD: The body composition of RA patients was assessed during their visit to the outpatient department of a Dutch academic hospital using BMI, fat-free mass index (FFMI), and fat mass index (FMI). FFMI and FMI were determined by single-frequency BIA. RESULTS: Sixty-five consecutive RA patients (83% women, mean age 58 years, median disease duration 7 years) with moderately active disease [mean Disease Activity Score using 28 joint counts (DAS28) = 3.40; mean Rheumatoid Arthritis Disease Activity Index (RADAI) score = 3.49] and moderate disability [mean Health Assessment Questionnaire (HAQ) score = 0.87] were included. Based on BMI, 2% of our study population were underweight, 45% had a healthy body composition, and 54% were overweight or obese. Based on BIA, 18% of the patients showed a low FFMI and 74% had a high or very high FMI. Low FFMI was found in 44% of the women with a normal BMI, and high FMI was found in 40% of the women and 75% of the men with a normal BMI. CONCLUSIONS: A high frequency of unfavourable body composition, predominantly reduced FFMI and elevated FMI, was found in a cohort of RA patients with moderately active disease, turning BMI into an unreliable method for assessment of body composition in RA. BIA, however, might be the preferred method to assess FFMI and FMI in RA patients in clinical practice, as it is easy to use and relatively inexpensive.