Response to: ‘Bone health, an often forgotten comorbidity in systemic lupus erythematosus: a comment on the new recommendations’ by Orsolini et al

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* Antonis Fanouriakis
* George Bertsias
* Dimitrios T Boumpas

*   systemic lupus erythematosus
*   disease activity
*   treatment

We thank Drs Orsolini *et al* for their interest in the updated European League against Rheumatism (EULAR) recommendations for the treatment of systemic lupus erythematosus (SLE),1 and we are grateful for bringing up a crucial aspect of the disease, namely osteoporosis and bone health in patients with this disease. Undoubtedly, prevention and treatment of osteoporosis represent a major challenge and a current unmet need in the holistic management of patients with lupus. The choice to omit the issue of bone health from the updated recommendations was only due to limited space in the manuscript; for this reason, a special focus was placed on infections and cardiovascular disease, as these currently represent two major causes of morbidity and mortality in lupus patients.

Importantly, as the authors emphasise, the increased risk for osteoporosis and fractures in SLE seems to be only in part associated with the chronic use of glucocorticoids (GC). Ongoing disease activity, premature menopause caused by use of gonadotoxic drugs and vitamin D deficiency represent additional factors that contribute to a reduced bone mineral density in SLE.2 The authors also correctly point out that an assessment tool for the evaluation of fracture risk customised for patients with SLE is lacking. The FRAX tool, which is recommended and widely used to calculate this risk,3 may indeed underestimate the actual risk in the context of SLE. To this end, it relies on physicians caring after lupus patients to provide patients with practical instructions in order to minimise the risk for fractures. Lifestyle modifications, such as exercise uptake and maintenance of a normal body mass index, are important, as are smoking cessation and reduction of alcohol consumption. For patients receiving GC, the recent guidelines of the American College of Rheumatology for the prevention and treatment of GC-induced osteoporosis should be followed.3 We fully agree with Orsolini *et al* that a future update of the EULAR recommendations for the management of SLE should include specific guidance regarding bone health.

## Footnotes

*   Handling editor Prof Josef S Smolen

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Patient consent for publication Not required.

*   Provenance and peer review Commissioned; internally peer reviewed.

## References

1.   Fanouriakis A , Kostopoulou M , Alunno A , et al . 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis 2019;78:736–45.[doi:10.1136/annrheumdis-2019-215089](http://dx.doi.org/10.1136/annrheumdis-2019-215089) 
    
    [Abstract/FREE Full Text](http://ard.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTE6ImFubnJoZXVtZGlzIjtzOjU6InJlc2lkIjtzOjg6Ijc4LzYvNzM2IjtzOjQ6ImF0b20iO3M6Mjg6Ii9hbm5yaGV1bWRpcy83OS8xMS9lMTUxLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.   Orsolini G , Bultink IEM , Adami G , et al . Bone health, an often forgotten comorbidity in systemic lupus erythematosus: a comment on the new recommendations. Ann Rheum Dis 2019;79:e150. [doi:10.1136/annrheumdis-2019-215896](http://dx.doi.org/10.1136/annrheumdis-2019-215896) pmid:http://www.ncbi.nlm.nih.gov/pubmed/31270109 
    
    [PubMed](http://ard.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fannrheumdis%2F79%2F11%2Fe151.atom) 

3.   Salman-Monte TC , Torrente-Segarra V , Vega-Vidal AL , et al . Bone mineral density and vitamin D status in systemic lupus erythematosus (SLE): a systematic review. Autoimmun Rev 2017;16:1155–9.[doi:10.1016/j.autrev.2017.09.011](http://dx.doi.org/10.1016/j.autrev.2017.09.011) 
    
    

4.   Buckley L , Guyatt G , Fink HA , et al . 2017 American College of rheumatology guideline for the prevention and treatment of Glucocorticoid‐Induced osteoporosis. Arthritis Care Res 2017;69:1095–110.[doi:10.1002/acr.23279](http://dx.doi.org/10.1002/acr.23279)