| Abstract | Reumatoidni artritis (RA) jedna je od najčešćih kroničnih upalnih reumatskih bolesti koja primarno zahvaća zglobove, ali može se očitovati i izvanzglobnim manifestacijama bolesti. Osteoporoza je česta izvanzglobna komplikacija RA. Smanjena mineralna gustoća kosti i osteoporoza nalaze se u 30-50% pacijenata s RA. U osoba s RA prevalencija osteoporoze je 2 puta veća, a prijelomi su 1,5 do 2 puta češći u odnosu na opću populaciju, a najčešće se radi o asimptomatskim prijelomima trupa kralješka. Kako su osteoporotski prijelomi povezani sa smanjenjem kvalitete života i povećanim mortalitetom, osteoporoza ima velik utjecaj na kvalitetu života osobe, medicinske troškove te na obitelj i cjelokupno društvo. Gubitak kosti u RA zbiva se na tri razine: intrartikularno u obliku erozija s gubitkom prvo kortikalne kosti, periartikularno s gubitkom trabekularne kosti i sustavno na aksijalnom i apendikularnom skeletu sa sljedstvenim razvojem osteoporoze neovisno o spolu i dobi. Najvažniji rizični čimbenici povezani s RA koji pogoduju razvoju osteoporoze su kronična upala (proupalni citokini IL-1, IL-6, TNF-α) koja potiče razgradnju i inhibira izgradnju kosti, upotreba glukokortikoida, tjelesna neaktivnost i sarkopenija. Uz specifične rizične čimbenike za osteoporozu u RA bitni su i klasični rizični čimbenici kao što su naslijeđe, starija životna dob, pušenje, prekomjerno konzumiranje alkohola, nedostatak vitamina D, prijevremena menopauza i udružene bolesti povezane sa sekundarnom osteoporozom. Obzirom da je osteoporoza obično asimptomatska bolest do pojave prvog prijeloma, s ciljem prevencije i rane dijagnoze, preporuča se redoviti probir denzitometrijom kosti, izračunom rizika za prijelome pomoću upitnika FRAX te standardnom radiološkom obradom grudne i slabinske kralježnice. U osoba s RA i denzitometrijskim nalazom osteoporoze ili visokim rizikom za nastanak prijeloma upitnikom FRAX ili prevalentnim osteoporotičnim prijelomom indicirano je liječenje ciljanim lijekovima za liječenje osteoporoze, tj. antiresorptivnim lijekovima ili osteoanabolicima. U svrhu liječenja i prevencije osteoporoze preporuča se i adekvatan unos kalcija, suplementacija vitamina D, prevencija pada, provođenje redovite tjelesne aktivnosti te prestanak pušenja i konzumacije alkohola. U liječenju RA cilj je postići remisiju ili nisku aktivnost bolesti kako bi se uklonio ili umanjio utjecaj kronične sustavne upale na razvoj osteoporoze, spriječio razvoj erozija i deformacija zlobova te time očuvala funkcionalna sposobnost i sljedstveno spriječila tjelesna neaktivnost što sve zajedno umanjuje rizik nastanka osteoporoze. Terapija glukokortikoidima treba se provoditi u najmanjoj mogućoj dozi i u što kraćem vremenu. Biološki bolest modificirajući antireumatski lijekovi (bDMARD) prema istraživanjima pokazuju pozitivne učinke na očuvanje mineralne gustoće kostiju. |
| Abstract (english) | Rheumatoid arthritis (RA) is one of the most common chronic inflammatory rheumatic diseases that primarily affects the joints but it can also be manifested by extra-articular manifestations of the disease. Osteoporosis is a common extra-articular complication of RA. Decreased bone mineral density and osteoporosis are found in 30-50% of RA patients. In people with RA the prevalence of osteoporosis is 2 times higher and fractures are 1.5 to 2 times more common than in the general population with asymptomatic fractures of the vertebral body being the most common type of osteoporotic fractures. As osteoporotic fractures are associated with reduced quality of life and increased mortality, osteoporosis has a major impact on a person's quality of life, medical costs and the family and society as a whole as well. Bone loss in RA occurs at three levels: intraarticular in the form of erosions with loss of cortical bone first, periarticular with loss of trabecular bone and systemically on the axial and appendicular skeleton with consequent development of osteoporosis regardless of gender and age. The most important risk factors associated with RA that favor the development of osteoporosis are chronic inflammation (pro-inflammatory cytokines IL-1, IL-6, TNF-α) that promotes bone resorption and inhibits bone formation, glucocorticoid use, physical inactivity and sarcopenia. In addition to specific risk factors for osteoporosis in RA, classic risk factors such as heredity, older age, smoking, excessive alcohol consumption, vitamin D deficiency, premature menopause and the presence of diseases associated with secondary osteoporosis are also important. Considering that osteoporosis is usually an asymptomatic disease until the appearance of the first fracture, with the aim of prevention and early diagnosis, regular screening with bone densitometry, fracture risk calculation using the FRAX questionnaire and standard radiological examination of the thoracic and lumbar spine is recommended. In people with RA and a densitometric finding of osteoporosis or a high risk of fracture using the FRAX questionnaire or a prevalent osteoporotic fracture, treatment with targeted drugs for the treatment of osteoporosis, i.e. antiresorptive drugs or osteoanabolics, is indicated. In order to treat and prevent osteoporosis, adequate calcium intake, vitamin D supplementation, fall prevention, regular physical activity, and cessation of smoking and alcohol consumption are recommended. In the treatment of RA, the goal is to achieve remission or low disease activity in order to remove or reduce the impact of chronic systemic inflammation on the development of osteoporosis, prevent the development of erosions and joint deformities, thereby preserving functional ability and consequently preventing physical inactivity, which all together reduces the risk of osteoporosis. Glucocorticoid therapy should be carried out in the smallest possible dose and in the shortest possible time. According to research, biological disease-modifying antirheumatic drugs (bDMARDs) show positive effects on the preservation of bone mineral density. |
