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.
