High incidence of antiresorptive agent-related osteonecrosis of the jaw in patients with rheumatoid arthritis
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LETTER TO THE EDITOR
High incidence of antiresorptive agent‑related osteonecrosis of the jaw in patients with rheumatoid arthritis Ryu Watanabe1 Received: 22 March 2020 / Accepted: 23 March 2020 © The Japanese Society Bone and Mineral Research and Springer Japan KK, part of Springer Nature 2020
Dear editor, I read with great interest the article by Fujieda et al. that was recently published in the journal [1]. In this study, the authors evaluated the prevalence and incidence of antiresorptive agent-related osteonecrosis of the jaw (ARONJ) in a total of 232 patients, including 125 with autoimmune disease (AID) and 107 with primary osteoporosis [1], and determined a higher incidence of ARONJ in the former group than in the latter. Among patients with AID, patients with rheumatoid arthritis (RA) had a strikingly high incidence of ARONJ than did those with other AIDs. Moreover, the authors showed that discontinuation of antiresorptive therapy before tooth extraction did not reduce the incidence of ARONJ. I would like to further discuss some aspects of this study, which certainly provided new insights into critical issues that directly affect daily clinical practice. First, earlier studies also reported that patients with RA are predisposed to osteonecrosis of the jaw (ONJ). However, it remains unclear whether RA disease activity is correlated with ONJ development. Although Furuya et al. demonstrated that patients with RA who required tooth extraction had a higher disease activity level than those who did not, the authors did not document disease activity at the time of ONJ onset [2]. Therefore, it remains unknown whether dental procedures should be postponed until RA is well controlled. Second, it remains unclear whether therapeutic agents other than glucocorticoids (GCs) affect the incidence of ARONJ in patients with RA. A recent systematic review suggested that anti-tumor necrosis factor-alpha inhibitor therapy increases the risk of ONJ [3]. Considering the introduction of a multitude of disease-modifying antirheumatic drugs, a large-scale study is needed to better characterize the This comment refers to the article available online at https://doi. org/10.1007/s00774-020-01089-y. * Ryu Watanabe [email protected] 1
Department of Rheumatology, Osaki Citizen Hospital, 3‑8‑1 Furukawa Honami, Osaki, Miyagi 989‑6183, Japan
association between non-GC treatment options and ARONJ development. Third, denosumab has been reported to efficiently suppress progression of joint damage in RA [4], and the use of this drug has increased in recent years. 99 out of 883 patients with RA who visited our hospital between April 2018 and March 2019 used denosumab. However, a recent metaanalysis revealed that denosumab might confer a higher risk of ONJ even than that associated with bisphosphonate [5]. Therefore, the incidence of denosumab-related ONJ may increase in the future. Despite these unsolved questions, the study by Fujieda and colleagues will certainly increase the awareness of ARONJ among rheumatologists and p
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