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Therapy Insight: osteoporosis and osteonecrosis in systemic lupus erythematosus

Nature Clinical Practice Rheumatology volume 2, pages 562–569 (2006)Cite this article

Abstract

Survival of patients with systemic lupus erythematosus (SLE) has improved over the past decade, thanks to improved treatment of the disease, which now results in fewer fatal complications. This improvement has allowed physicians to focus their attention on the prevention of organ damage caused by this chronic, inflammatory disease, and by the medications used to control the disease. Osteoporosis is common in SLE patients; risk factors for osteoporosis include prolonged use of glucocorticoids, cyclophosphamide and possibly gonadotropin-releasing-hormone agonists. In premenopausal women with SLE, inflammation or SLE-related medications can increase bone turnover, which eventually weakens bone architecture, then reduces bone strength and increases the risk of fracture. Prevention and treatment of osteoporosis in SLE patients should entail a multifaceted approach. Levels of calcium, vitamin D and homocysteine should be evaluated, and age-appropriate supplementation instituted. The bone loss that results from systemic inflammation should be treated by reduction of the inflammation with glucocorticoids, potent anti-inflammatory agents or antiresorptive agents. The efficacy of this therapy can be monitored using bone mineral density scans. This Review briefly discusses the pathophysiology of the localized and generalized osteoporosis and osteonecrosis in SLE patients and recommends therapies to both prevent and treat these unfortunate complications of this disease.

Key Points

  • Survival of patients with systemic lupus erythematosus has improved, such that treatment is now focused on minimizing the organ damage associated with either the disease itself or the medications used to treat it

  • Systemic inflammation increases osteoclast maturation and reduces osteoblast maturation and activity, such that rapid bone loss can occur

  • Compared with cortical bone, trabecular bone is more severely affected by systemic inflammation and other metabolic changes, owing to its high turnover rate

  • Patients should be carefully evaluated for bone health via measurement of bone mineral density, and laboratory evaluation of levels of calcium and vitamin D and biochemical markers of bone turnover

  • Prevention and treatment of bone loss in systemic lupus erythematosus is multifaceted and should include aggressive reduction of systemic inflammation, antiresorptive agents (if a patient has had a fracture or has a low bone mineral density), and appropriate supplementation of calcium and vitamin D

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Figure 1: Mechanisms of bone remodeling.
Figure 2: Risk factors for osteoporosis in patients with SLE.

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Author information

Authors and Affiliations

  1. Endowed Professor of Medicine and Rheumatology at the University of California, Davis Medical School, Sacramento

    Nancy E Lane

  2. Director of the Center for Healthy Aging,

    Nancy E Lane

  3. Vice-Chair for Research for the Department of Medicine at the University of California at Davis, CA, USA

    Nancy E Lane

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  1. Nancy E Lane
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Lane, N. Therapy Insight: osteoporosis and osteonecrosis in systemic lupus erythematosus. Nat Rev Rheumatol 2, 562–569 (2006). https://doi.org/10.1038/ncprheum0298

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