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Highly Accessed Review

Osteoimmunology and osteoporosis

Piet Geusens12* and Willem F Lems3

Author affiliations

1 Department of Internal Medicine, Subdivision of Rheumatology, Maastricht University Medical Center, P. Debyelaan 25 Postbus 5800, 6202 AZ Maastricht, The Netherlands

2 Biomedical Research Institute, University of Hasselt, Belgium

3 Department of Rheumatology, 3A61 VU Medical Center, Postbox 7057, 1007 MB Amsterdam, The Netherlands

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Citation and License

Arthritis Research & Therapy 2011, 13:242  doi:10.1186/ar3375

Published: 30 September 2011

Abstract

The concept of osteoimmunology is based on growing insight into the links between the immune system and bone at the anatomical, vascular, cellular, and molecular levels. In both rheumatoid arthritis (RA) and ankylosing spondylitis (AS), bone is a target of inflammation. Activated immune cells at sites of inflammation produce a wide spectrum of cytokines in favor of increased bone resorption in RA and AS, resulting in bone erosions, osteitis, and peri-inflammatory and systemic bone loss. Peri-inflammatory bone formation is impaired in RA, resulting in non-healing of erosions, and this allows a local vicious circle of inflammation between synovitis, osteitis, and local bone loss. In contrast, peri-inflammatory bone formation is increased in AS, resulting in healing of erosions, ossifying enthesitis, and potential ankylosis of sacroiliac joints and intervertebral connections, and this changes the biomechanical competence of the spine. These changes in bone remodeling and structure contribute to the increased risk of vertebral fractures (in RA and AS) and non-vertebral fractures (in RA), and this risk is related to severity of disease and is independent of and superimposed on background fracture risk. Identifying patients who have RA and AS and are at high fracture risk and considering fracture prevention are, therefore, advocated in guidelines. Local peri-inflammatory bone loss and osteitis occur early and precede and predict erosive bone destruction in RA and AS and syndesmophytes in AS, which can occur despite clinically detectable inflammation (the so-called 'disconnection'). With the availability of new techniques to evaluate peri-inflammatory bone loss, osteitis, and erosions, peri-inflammatory bone changes are an exciting field for further research in the context of osteoimmunology.