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Pathogenic Bone Loss in Rheumatoid Arthritis: Mechanisms and Therapeutic Approaches

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Pathogenic Bone Loss in Rheumatoid Arthritis: Mechanisms and Therapeutic Approaches Review Pathogenic bone loss in rheumatoid arthritis: mechanisms and therapeutic approaches Rheumatoid arthritis (RA) is a systemic inflammatory disorder with progressive joint destruction being its hallmark feature. Conventional treatments, such as DMARDs, aim to inhibit the inflammation; however, over the past decade, major advances in our understanding of bone metabolism has given us the ability to directly treat the bone loss in RA. Although modern anti-inflammatory therapies, such as anti-TNF-a treatment, have resulted in a remarkable improvement in the treatment of RA, these treatments do not directly target bone destruction in the joint. The aim of this review is to demonstrate that antiresorptive therapies can prevent structural joint destruction, particularly in the early stages of anti-inflammatory treatment. A number of novel approaches targeting bone resorption are also becoming available. 1 KEYWORDS: anti-inflammatory treatments n antiresorptive treatments n B ligand Melissa D Cantley , n NFATc1 n nuclear factor of activated T cells n osteoclasts receptor activator of Malcolm D Smith2 & nuclear factor n rheumatoid arthritis David R Haynes1† †Author for correspondence: Rheumatoid arthritis (RA) is a systemic inflam- joints in the hands and feet as well as the knees. 1Discipline of Pathology, School matory disorder characterized by destruction of Other synovial joints such as the ankles, hips, of Medical Sciences, University the joint, and this has a major impact on its func- elbows and shoulders are relatively spared of Adelaide, Adelaide, South tion. Progressive joint destruction is the hall- and the spine is rarely affected, apart from the Australia, 5005, Australia mark feature of RA. The disease is characterized atlanto-axial joint in the cervical spine. RA Tel: +61 883 033 180 by joint inflammation, synovial hyperplasia and rarely, if ever, affects distal interphalaengeal Fax: +61 883 034 408 associated destruction of bone and cartilage [1]. joints even though these are synovial joints. [email protected] It is the most common autoimmune disease in It is unclear why RA affects some synovial- 2Rheumatology Research Unit, Australia and currently affects 1% of the world’s lined joints frequently and others rarely or Repatriation General Hospital, population [201]. Despite the prevalence of this never. The primary joints affected include the Adelaide, 5041, South disease, complete understanding of the disease metacarpo-phalangeal, proximal interphalan- Australia, Australia process is still lacking. Most studies have focused geal, mid-carpal, radio-carpal and distal radio- on inflammation in the soft tissues; however, ulnar joints in the hands [2]. In the feet, the research is now focusing on preventing bone and target sites include the metatarso-phalangeal, cartilage destruction. Conventional treatments proximal interphalangeal and the intertarsal for RA aim to inhibit the inflammation; how- joints [2]. The disease results in pain, stiffness ever, over the past decade, major advances in our and swelling of the joints, which impacts on understanding of bone metabolism have enabled their functional capacity. Recurring inflam- us to identify the mechanisms of joint destruc- mation leads to bone and cartilage destruction, tion in RA. This knowledge, in combination affecting the individual’s physical functioning, with the recent development of therapies inhib- and causes both short and long-term morbid- iting bone loss, gives us the ability to directly ity [3]. The synovium is the major target for the treat the bone loss in RA. Although modern inflammatory process where infiltration of the anti-inflammatory therapies have resulted in a tissue occurs with multiple immune cells and remarkable improvement in the treatment of cytokines resulting in tissue inflammation. The RA, this review aims to demonstrate that anti- synovial tissue expands and forms a pannus that resorptive therapies, in combination with mod- invades the bone and cartilage, destroying the ern anti-inflammatory treatments, are needed to tissue as it proceeds [4]. The inflammation of the better prevent structural joint destruction and synovial tissues promotes osteoclastogenesis that disease progression in RA. leads to both focal articular bone erosion at the Rheumatoid arthritis presents clinically as site of pannus formation as well as systemic bone a symmetrical polyarthritis that targets many loss, similar to osteoporosis [4,5]. The invasion of part of joints in the body. RA only affects synovial- inflammatory tissue into the subchondral bone lined joints and predominantly affects peripheral involves many cell types including fibroblasts, 10.2217/IJR.09.42 © 2009 Future Medicine Ltd Int. J. Clin. Rheumatol. (2009) 4(5), 561–582 ISSN 1758-4280 561 Review Cantley, Smith & Haynes Pathogenic bone loss in rheumatoid arthritis: mechanisms & therapeutic approaches Review lymphocytes and monocytes. Monocytes are fracture [17]. It is important to note that other the precursors of osteoclasts that resorb bone factors may contribute to the increased risk of through the acidic disillusion of bone mineral fracture such as the development of osteoporosis and enzymatic destruction of bone matrix [6]. owing to decreased mobility of the RA patient. Resorption of the unmineralized cartilage does not appear to directly involve osteoclasts Mechanisms of disease but seems to be due to proteases that are syn- A major hallmark of inflammatory bone loss thesized by the synovial fibroblasts, neutrophils diseases, such as RA, is enhanced osteo clastic and the chondrocytes [7]. The articular cartilage bone resorption without a corresponding is avascular and nonmineralized, consisting of increase in bone formation. Osteoclasts are the chondrocytes that are embedded in the extra- multinucleated cells derived from the mono- cellular matrix. The extracellular matrix con- cyte/macrophage hematopoietic lineage that sists of a type II collagen network that forms are responsible for resorbing bone [18–20]. The the structural backbone of the matrix along with essential role that osteoclasts play in bone loss other proteins [7]. There is a large amount of in RA has been demonstrated in animal studies proteoglycan in cartilage that binds water and showing that mice without osteoclasts are resis- functions as a mechanical shock absorber [7]. tant to arthritis-induced bone loss [21,22]. The The cartilage damage in RA can be attributed crucial role of osteoclasts in RA bone loss is also to a number of catabolic factors, such as pro- supported by studies of human tissue obtained inflammatory cytokines, aggrecanases, matrix from patients with RA [23–26]. In animal models metalloproteinases and nitric oxide. The syno- of RA, and in human RA, large multinucleated vial fibroblasts express large amounts of matrix- osteoclastic cells resorbing subchondral bone degrading enzymes that invade the articular have been detected at sites of bone erosion in the cartilage resulting in cartilage destruction [7]. joints [27,28]. These osteoclasts form as a result of Many of the factors produced by the inflamed exposure to inflammatory cytokines present in synovium that are involved in the bone destruc- synovial tissue, and understanding this process tion also have an effect on chondrocyte func- is the key to developing treatments for bone loss tioning [8]. Inflammatory cytokines, IL-1 and in RA. Figure 1 demonstrates the inflammatory TNF-a are thought to play a major role in car- cytokines involved in both localized bone loss tilage loss [8]. Many studies have demonstrated within the joint and generalized bone loss. that IL-1 stimulates chondrocytes to increase production of matrix metalloproteinases that nOsteoimmunology degrade the cartilage [9,10]. The involvement of the immune system is fun- While the localized destruction of the joint is damental to the progression of RA. In recent the major focus of treatment, generalized bone decades the involvement of the immune system loss, known as osteopenia, results in a loss of in bone metabolism has become apparent (as bone mineral density (BMD) and elevates the reviewed by Takayanagi et al. [29]). Therefore, risk of osteoporotic fractures in patients with it is not surprising that bone loss in RA appears RA [11]. Clinical studies have evaluated BMD to be controlled by immune factors and cells. in the hands of patients with early RA and found This relationship between the immune system an association between reduction in BMD and and bone metabolism has been termed ‘osteo- disease severity [12,13]. This increased systemic immunology’, and an understanding of osteo- bone loss is attributed to the effects of pro- immunology is vital for developing ways of inflammatory cytokines released from the site preventing bone loss in RA. of synovial inflammation that act systemically and result in a generalized bone loss [14–16]. RA nMacrophage colony has also been demonstrated to have an impact stimulating factor on increasing the risk of fractures as a result of Macrophage colony stimulating factor (M-CSF) the associated generalized bone loss. One study was one of the first factors to be recognized as found an increased risk of fracture, especially of playing an essential role in the process of osteo- the hip (relative risk: 2.0) and the spine (relative clast development. It is normally produced by risk: 2.4), in RA patients compared with age and osteoblasts or bone marrow stromal cells and sex-matched controls. Predictors included a long transmits its signal
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