Pharmacological treatment for managing bone health in axial spondyloarthropathy: systematic review and meta-analysis

Rheumatol Int. 2020 Sep;40(9):1369-1384. doi: 10.1007/s00296-020-04623-3. Epub 2020 Jun 16.


Axial spondyloarthropathy (axSpA) is associated with an increased prevalence of osteoporosis, but no recommendations exist to guide management. This systematic review and meta-analysis aim to assess the efficacy of pharmacological and non-pharmacological interventions on bone mineral density (BMD) in axSpA. Electronic databases were searched from inception to June 2019 for randomised controlled trials (RCTs) and quasi (q)-RCTs with pharmacological and non-pharmacological interventions. Independent reviewers undertook screening, and risk of bias and quality assessments. Primary outcomes of interest were BMD at spine and hip. Eight studies (two RCTs and six qRCTs) were included (602 participants). Moderate level evidence favoured alendronate over placebo at femoral neck [mean difference (MD) 2.01, 95% CI 0.67 to 3.35], but there was low-level evidence showing no effect at the spine. There was moderate level evidence showing no effect of tumour necrosis factor inhibitors (TNFi) on BMD at total hip (MD - 0.01, 95% CI - 0.06 to 0.04). Very low-level evidence demonstrated no effect of TNFi on spine or femoral neck. Moderate level evidence favoured neridronate over infliximab at the spine (MD 3.26, 95% CI 1.14 to 5.38), but low-level evidence showed no effect at the total hip (MD 2.75, 95% CI - 0.21 to 5.71). There were no eligible studies investigating the efficacy of non-pharmacological interventions. We conditionally recommend alendronate for management of low BMD in axSpA. The balance of evidence does not recommend the use of TNF-inhibitors for treating low BMD. There is a lack of high-quality evidence guiding clinicians treating osteoporosis in axSpA.

Keywords: Axial spondyloarthropathy; Meta-analysis; Osteoporosis; Systematic review.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adult
  • Bone Density / drug effects
  • Bone Density Conservation Agents / therapeutic use*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Osteoporosis / complications
  • Osteoporosis / drug therapy*
  • Randomized Controlled Trials as Topic
  • Spondylarthritis / complications*
  • Tumor Necrosis Factor Inhibitors / therapeutic use*


  • Bone Density Conservation Agents
  • Tumor Necrosis Factor Inhibitors