• 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.