Background Patients suffering from rheumatoid arthritia (RA) may feature significant loss of bone mineral density (BMD). early aggressive treatment and sometimes low corticosteroids doses are required; however, long term effects on bone are not extensively characterised.

Objectives To assess the effects of 10 mg prednisone daily + 7.5 mg methotrexate (MTX) on BMD in patients with early active and severe RA.

Methods 32 patients with active RA, with a disease duration less than 2 years, without prior treatment with any disease modifying antirheumatic drugs were randomised to receive either MTX and prednisone or sulphasalazine alone. Osteoporosis treatment was not permitted. Disease activity and BMD were monitored at baseline, 6, 12 and 24 months; BMD was determined by quantitative ultrasound at the calcis bone and was appreciated as broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI). BMD loss was calculated in% of baseline. Subgroup analysis (high and low disease activity) was performed upon ESR and CRP values.

Results After 6 and 12 months of treatment mean% BUA has decreased significantly (p < 0.05) compared to baseline in both study groups, but greater in patients with high disease activity; after 24 months BMD has fallen significantly more in the combination group in patients with severe RA (- 3.5%) compared to monotherapy group in patients with mild disease (+0.07%, p < 0.05). Change in BMD correlates more closely with measure of inflammation than with administration of prednosone and MTX.

Conclusion High disease activity is closely associated with bone loss in early active severe RA compared to bone loss due to aggressive therapy including MTX and low doses prednisone.