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Diabetes Care 29:952 2006
DOI: 10.2337/diacare.29.04.06.dc06-0032
© 2006 by the American Diabetes Association
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Letters: Comments and Responses

Acute Neuropathic Joint Disease: A Medical Emergency?

Response to Jeffcoate et al.

Ai Lyn Tan, MRCP1,2 and Dennis McGonagle, PHD, FRCPI1,2

1 Academic Unit of Musculoskeletal Disease, Chapel Allerton Hospital, Leeds, U.K.
2 Department of Rheumatology, Calderdale Royal Hospital, Salterhebble, Halifax, U.K.

Address correspondence to Prof. Dennis McGonagle, Academic Unit of Musculoskeletal Disease, Chapel Allerton Hospital, 2nd Floor, Chapeltown Road, Leeds, LS7 4SA, U.K. E-mail: d.g.mcgonagle{at}leeds.ac.uk

We thank Jeffcoate et al. (1) for their comments on our article (2). To summarize, they agree that neuropathic joint disease (NJD) is indeed a medical emergency, but they disagree that bisphosphonates are of proven efficacy. One of the major problems for clinicians at the moment is the failure to recognize early NJD based on several considerations, including other possible diagnosis at presentation, the presence of pain, normal radiographs, and patients presenting to nonendocrinological specialists. Therefore, at the time of initiation of therapy, damage may already be well established and, furthermore, joint offloading with prolonged casting has several drawbacks (3).

It was not the intention of our article to convey the idea that the very early initiation of bisphosphonate therapy before radiographic damage would definitely halt disease. We agree with Jeffcoate et al. that further work needs to be done in this regard. However, given the data from trials in NJD, the safety profile and costs of bisphosphonate therapy, and ease of administration, it would seem reasonable to prescribe these.

It is interesting to note that bisphosphonates may have some structural modification properties in the more common garden variety of osteoarthritis (4) and also some evidence of symptom control (4,5). However, based on the magnetic resonance imaging (MRI) observations that the earliest stages of NJD is strikingly associated with bone edema, which is also a predictor of progressive osteoarthritis joint deterioration in other sites (6), besides the ankle and foot, then it would seem prudent that attempts to inhibit osteoclast function may be of use.

To summarize, we feel that the MRI features of early NJD will allow for early intervention, including those suggested by the authors, at a stage before irreversible joint damage to see whether ultimately progressive joint damage can be prevented. We feel that the MRI observations in early disease have broad implications for raising awareness of the potential for early NJD diagnosis and for monitoring potential therapies.

References

  1. Jeffcoate WJ, Game FL, Armstrong DG, Cavanagh PR: Acute neuropathic joint disease: a medical emergency? (Letter). Diabetes Care 29:951–952, 2006[Free Full Text]
  2. Tan AL, Greenstein A, Jarrett SJ, McGonagle D: Acute neuropathic joint disease: a medical emergency? Diabetes Care 28:2962–2964, 2005[Free Full Text]
  3. Eldor R, Raz I, Ben Yehuda A, Boulton AJ: New and experimental approaches to treatment of diabetic foot ulcers: a comprehensive review of emerging treatment strategies. Diabet Med 21:1161–1173, 2004[Medline]
  4. Carbone LD, Nevitt MC, Wildy K, Barrow KD, Harris F, Felson D, Peterfy C, Visser M, Harris TB, Wang BW, Kritchevsky SB: The relationship of antiresorptive drug use to structural findings and symptoms of knee osteoarthritis. Arthritis Rheum 50:3516–3525, 2004[Medline]
  5. Spector TD, Conaghan PG, Buckland-Wright JC, Garnero P, Cline GA, Beary JF, Valent DJ, Meyer JM: Effect of risedronate on joint structure and symptoms of knee osteoarthritis: results of the BRISK randomized, controlled trial [ISRCTN01928173]. Arthritis Res Ther 7:R625–R633, 2005[Medline]
  6. Felson DT, McLaughlin S, Goggins J, LaValley MP, Gale ME, Totterman S, Li W, Hill C, Gale D: Bone marrow edema and its relation to progression of knee osteoarthritis. Ann Intern Med 139:330–336, 2003[Abstract/Free Full Text]

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This Article
Right arrow Extract Freely available
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Google Scholar
Right arrow Articles by Tan, A. L.
Right arrow Articles by McGonagle, D.
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Right arrow Articles by Tan, A. L.
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