Rheumatoid Arthritis, Bone Health and Osteoporosis: What You Need to Know

Summary of a presentation to the Early RA Support and Education Program

by Patricia Donohue, ACNP-BC, ONP-c

People with rheumatoid arthritis (RA) have a greater-than-average risk of developing osteoporosis. Learn about the relationship between RA and osteoporosis, as well as ways to mitigate your own risks.

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is a chronic systemic illness. It affects the whole body, especially the joints. RA is also an autoimmune disease, which means that the immune system in the body, usually responsible for fighting off infections, instead begins to attack healthy tissue.

RA affects just over one million people in the United States; about 70% of them are women. Most people are between the ages of 30 and 50 when they are diagnosed with RA.

Inflammation, which is a major feature of rheumatoid arthritis contributes to joint pain and swelling, and cartilage damage, which then leads to erosion into the bone around the around the joint. Inflammation also affects bones, including contributing to the loss of bone mineralization. Bone mineralization is the ongoing process of absorption of minerals, and requires adequate intake of vitamin D, calcium and other nutrients – including iron, phosphorus and zinc – which are needed to build and maintain healthy bones. Inflammatory processes in the bone near the joints – as well as in bone erosions and large cysts around the joint – can decrease the mineral content of the bone. This can lead to the development of osteopenia (moderately low bone density) as well as osteoporosis (significantly low bone density).

What is osteoporosis?

Osteoporosis is a “silent” skeletal disorder caused by the loss of bone mineral content. It is marked by low bone mass and density, microscopic deterioration within the bone, an increase in bone fragility, and increasing risk of fracture. Osteoporosis occurs when your body makes too little bone (formation), loses too much bone (resorption), or a combination of both of these factors.

Normal bone growth cycle

Bone is living tissue and even as adults, we are constantly remodeling our whole skeleton! In the normal bone growth cycle, our bodies continually:

  • make new bone (although less so as we age)
  • maintain bone homeostasis (resting bone state)
  • remove older fatigued bone

The body tries to replace old bone that it has removed. However, the amount of bone replaced is reduced as we age and in people with certain diseases such as rheumatoid arthritis.

The good news is that we can do things to make bones healthier, stimulate bone formation and slow down bone remodeling. Bone remodeling is the body’s way of breaking down weak bone and rebuilding stronger bone. At around age 27 to 30, our bones are strongest and at peak mineral density. However, after this age, there is a slow and steady decline in bone strength, accompanied by an increased risk of developing osteopenia and osteoporosis.

Who is at risk for osteoporosis?

According to estimates of the US Department of Health and Human Services (HHS) Healthy People 2020 Initiative:

  • 5.3 million people in the US over the age of 50 have osteoporosis.
  • In addition, 34 million have osteopenia (moderately low bone mass). This condition affects:
    • 30% to 40% of women over the age of 50
    • 5% to 10% of men over the age of 70

At the same time, some young persons in their teens and twenties (particularly those with a history of bone fracture, eating disorders or excessive use of corticosteroid drugs), are also diagnosed with osteopenia and osteoporosis.

What are the biological risk factors of osteoporosis?

  • race/gender/age: Caucasian and Asian postmenopausal women over the age of 65; men over the age of 70
  • low body mass index or obesity
  • small, thin frame
  • family history of osteoporosis and/or hip fracture
  • diabetes
  • hyperthyroidism (Grave’s disease)
  • rheumatoid arthritis
  • lupus
  • renal (kidney) disease
  • malabsorption disorders (in which a person's body does not correctly absorb nutrients such as carbohydrates, proteins, fats, vitamins or minerals), for example:
    • celiac disease
    • irritable bowel disease
    • complications or side effects of bariatric surgery
  • congenital (since birth) bone and collagen disease

Although you can’t change the risk factors above, you can have some control over other risk factors. There are several bone-healthy lifestyle choices that can have a significant, positive impact.

Which risk factors for osteoporosis can I change?

For people with RA, the main treatment approach emphasizes controlling inflammation and preventing joint damage. There are other things you can do to reduce your risk of developing osteoporosis. These include:

Lifestyle choices

  • reducing your caffeine intake
  • avoiding smoking
  • moderating your alcohol consumption
  • applying good nutrition and caloric intake, and supplementing with vitamins and minerals, if needed, to address:
    • eating disorders, low body weight or obesity
    • inadequate calcium and vitamin D intake
  • controlling gastrointestinal issues such as celiac disease, which inhibit calcium absorption
  • exercising – in particular, weight-bearing and muscle-building exercises (as opposed to aerobic exercise)

Medication changes

  • avoiding long-term use of prednisone and other corticosteroids when possible

Tips for a bone-healthy lifestyle

Food, calcium and vitamin D

The preferred approach now favors obtaining the calcium one needs through eating a healthy, well-balanced diet, and adding calcium supplements if needed to make up for any shortfalls. For postmenopausal women (who are most at risk for developing osteoporosis and fractures), the recommendations are for 1,200 mg per day of calcium. For premenopausal women and men, the recommendation is for 1,000 mg per day.

Good calcium-rich food sources include:

  • low-fat milk, yogurt, cheese and other dairy products
  • almond milk and other plant-based milk beverages
  • green leafy vegetables
  • broccoli
  • salmon and tuna

Below are daily requirements of calcium and vitamin D3 – from both diet (food sources) and dietary supplements.

Women
Premenopausal
1,000 mg calcium
600 international units vitamin D3

Postmenopausal
1,200 mg calcium
800 international units vitamin D3

Men
Up to age 70
1,000 mg calcium
600 international units vitamin D3

Over Age 71
1,200 mg calcium
800 international units vitamin D3

 

Supplemental calcium is best absorbed when taken in amounts of 500 mg to 600 mg or less, preferably with a meal.

It tends to be difficult to receive enough vitamin D through exposure to sunlight or food. Recommendations for vitamin D intake range from 600/800 international units to 1,000 international units per day. It is a good idea to have your doctor check your vitamin D level with annual blood tests.

Good sources of vitamin D-rich foods include:

  • tuna, mackerel, salmon
  • egg yolks
  • certain fortified products, including orange juice, soy milk and cereal

Exercise

Numerous studies have shown that bones like to be mechanically “loaded,” that is, engaged in weight-bearing activities that help the bones get stronger. Any activity that places force on the bone may increase your bone mineral density in your hip and spine.

Bone-loading/weight-bearing exercises include:

  • walking
  • jumping rope
  • skipping
  • working out on an elliptical machine

Studies have shown the benefits of exercise in the prevention of hip fracture in older women, and reduced overall occurrence of fractures in older adults. (Kemmler, 2013, Feskanish, 2002, Greg, 1998.)

Resistance exercises are also beneficial. Examples include resistance using stretch bands or light weights with multiple repetitions. Pilates is another example of a type of exercise that uses resistance of gravity. And practices such as yoga and T’ai chi have been shown to improve balance – helping to prevent falls and fractures.*

What is the relationship between rheumatoid arthritis and osteoporosis?

Individuals with RA are at increased risk of developing osteoporosis. Chronic inflammation associated with RA, medications used to treat the disease, particularly prednisone and other corticosteroid (“steroids”) drugs, all contribute to this risk.

In addition, inadequate intake or absorption of bone-building calcium, and less exercise due to fatigue and pain, may contribute to reduction in bone formation, bone mineral density loss – and increased risk of fractures. People with RA have a 30% higher rate of fractures due to osteoporosis than the average population, as well as a 40% increase in hip fractures, as well as loss of height and periodontal bone loss (loss of bone around the teeth in the jaw and skull).

How rheumatoid arthritis affects bone mineralization

Rheumatoid arthritis has an impact on bone mineralization. This is the body’s ability to absorb and make use of bone-building minerals, including calcium and phosphorous. People with RA may experience the following:

  • joint destruction at the wrist
  • osteoporosis of the hip or lumbar spine
  • loss of height
  • vertebral compression fractures
  • periodontal bone loss
  • 40% increase in hip fractures
  • 30% increase in major osteoporotic fracture
  • long-bone fractures in the leg
  • stress fractures of metatarsals

How is osteoporosis diagnosed?

Since osteoporosis is a silent disease and is not associated with pain until you fracture a bone, it is important to have screening tests performed to look at the quality or mineralization of the bone.

  • Dual-energy X-ray absorptiometry (DEXA or DXA) is a low-dose ionizing radiation X-ray used to measure bone mineral content. Insurance will not pay for a yearly exam. Postmenopausal women are encouraged to have a bone density exam every two years after age 65 or older, as are men age 70 or older. People with risk factors or who have experienced fractures from low-energy activity or falls should begin having DEXA scans at an earlier age.
  • Trabecular bone score (TBS), obtained through DEXA imaging, is a diagnostic tool that measures bone architecture and fracture risk.
  • Quantitative CT scan: This measures the volume of bone mineral density in the spine. This is another radiology test that can be performed if you have had a CT scan of your lumbar spine. The test looks at the inside quality of the bone within a few vertebral bones in your spine.
  • Laboratory bone markers: Look at the rate of a person’s bone formation and loss. We can measure, in both blood and urine tests, bone markers that tell us how much bone your body is making at a certain point in time along with how much bone breakdown is occurring.
  • Frax scores: Developed by the World Health Organization (WHO), FRAX Analysis is a risk assessment test that estimates 10-year risk of hip fracture and major fractures overall, based on personal history and other risks.

How are osteoporosis and osteopenia treated?

Once one is diagnosed with osteoporosis or osteopenia, taking calcium alone is not adequate to restore bone density. Discussions with your healthcare provider will likely identify treatment options which include:

Antiresorptive medications – To decrease bone turnover

  • bisphosphonates
    • alendronate (Fosamax)
    • residronate (Actonel)
    • ibandronate (Boniva)
    • risedronic acid (Atelvia)
    • zoledronic acid (Reclast)
  • rank-L inhibitor
    • denosumab (Prolia)
  • sclerostin inhibitor (Romosozumab)
  • selective estrogen receptor modulators
    • raloxifene (Evista)
  • estrogen/progesterone
  • androgen/testosterone

Anabolic medications – To improve formation of new bone

  • teriparatide (Forteo)
  • abaloparitide (Tymlos)

Loss of bone mineral density occurs naturally with the normal aging process. Rheumatoid arthritis and its treatment with corticosteroids can increase an individual’s chance of developing a low bone mineral state such as osteopenia or osteoporosis.

Screening tests to identify poor bone mineralization are important along with treatment with medications, if indicated. Conservative measures such as diet, supplements, exercises and fall prevention are all important to include in a bone-healthy lifestyle.

References and resources

Original presentation given December 18, 2017.

Authors

Patricia Donohue, ACNP-BC, ONP-c
HSS Department of Medicine

 

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