Osteoporosis — thinning and weakening of the bones — is a relatively common problem with age, especially in postmenopausal women. The main complication of osteoporosis is an increased tendency to fracture, especially fracture of the hip, which can lead to disability and complications that result in death for about 30 percent of the patients within the first year of the injury. To help prevent osteoporosis and even strengthen osteoporotic bones, daily calcium and vitamin D supplements are recommended, along with weight-bearing exercises such as walking or jogging.
Although osteoporosis is a common problem among women around menopause and even affects men in later life, it is even more prevalent in people with rheumatoid arthritis.
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So how common is osteoporosis in people with RA and how does it compare with the incidence in the general population?
The journal “Rheumatology” recently published a single-center study of adults referred for bone mineral density testing in which osteoporosis prevalence was compared in 304 RA patients with 903 otherwise healthy people. The study found that 30 percent of RA patients met the criteria for osteoporosis compared with 17.4 percent of age- and gender-matched controls.
“Every patient with RA is considered at risk for osteoporosis, particularly those with risk factors such as increased age, female gender, postmenopausal state or family history of osteoporosis,” says Dr. Ashira Blazer, an instructor of internal medicine at NYU Langone Health in New York.
Women, especially, are in double jeopardy, says Dr. Sharad Lakhanpal, a clinical professor of internal medicine at UT Southwestern Medical Center in Dallas. First, RA affects three times as many women as men. Second, most women get RA when they are already perimenopausal or have already gone through menopause, a time when women are particularly prone to losing bone through osteoporosis. “For most women, RA and osteoporosis peak at about the same age,” Lakhanpal says, “so women have a double whammy.”
RA is an incurable, autoimmune disorder in which the body’s immune system mistakenly begins attacking healthy tissue. Although most people think of RA as a disease that causes pain and disfigurement of the joints, the inflammation produced by the disease attacks myriad organ systems throughout the body, including the heart, lungs, skin, eyes and bones.
“People don’t often think of the bones as being an organ system, but they comprise an extremely active and very important organ,” Lakhanpal emphasizes.
“Bones produce two kinds of cells — osteoblasts, which form new bone, and osteoclasts, which break down old bone — allowing new bone to form in a process call remodeling,” says Lakhanpal, who is also the current president of the American College of Rheumatology. Red blood cells are also produced in the bone marrow.
The inflammatory proteins, called cytokines, produced by RA directly inhibit the process of bone formation, according to Lakhanpal, increasing the incidence of osteoporosis, and by extension, the risk of fracture.
“People with RA have a 30 percent increased risk of any major osteoporotic fracture, and a 40 percent increased risk of hip fracture,” Blazer says.
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Decreased bone formation due to the action of inflammatory cytokines is not the only reason why people with RA are more prone to osteoporosis than the general public.
“The increased risk of osteoporosis in people with RA is the result of a number of factors,” Blazer says. “Rheumatoid arthritis patients often move and walk less than other people due to pain,” Blazer says. “Normal weight bearing provides the signals the body needs to build stronger bones; avoiding weight bearing also means the body gets fewer of these signals.”
“Also, the medicines we use to treat RA, particularly glucocorticoids or steroids, can thin the bones, especially with prolonged use,” she adds. Disease-modifying anti-rheumatic drugs such as methotrexate can also affect bone formation, Lakhanpal says. In addition, people with RA often take nonsteroidal anti-inflammatory drugs such as ibuprofen for pain, and they frequently take them with a class of medications called proton pump inhibitors, like Prilosec, to reduce stomach acid and protect against some of the harmful effects of NSAIDs on the stomach. “Proton pump inhibitors can interfere with the absorption of calcium,” Lakhanpal says, further increasing the risk of osteoporosis.
Because people with RA are considerably more prone to osteoporosis than the general public, it is very important to screen for osteoporosis. “Osteoporosis is a silent disease” Lakhanpal says.
Blazer agrees. “Osteoporosis generally has no symptoms until there is a fracture. Even many vertebral fractures may be ‘silent,’ causing no pain.”
One hallmark of osteoporosis is loss of height over time. Everyone shrinks somewhat with age as the vertebrae dehydrate and compress on each other. People with RA and osteoporosis shrink much faster than the general public. To determine if a person with RA is losing too much height, Lakhanpal assesses his patients’ height at each visit.
He also orders a baseline bone density scan, a special kind of bone densitometry X-ray called a DEXA scan, that looks at the lower spine and hip and measures bone loss. The baseline DEXA scan is typically followed by additional DEXA scans every two years, especially if your rheumatologist determines that your osteoporosis may be proceeding despite treatment.
Blazer believes DEXA scans are important even for those people with RA who do not show signs of osteoporosis. “Follow-up DEXA scanning in RA patients who do not meet criteria for osteoporosis should be done every two years,” she says.
Another means of determining your overall risk of fracture is the Fracture Risk Assessment Tool, or FRAX, which estimates the 10-year probability of a major osteoporotic fracture.
When treating osteoporosis in people with RA, it is essential to manage medications. If possible, the use of corticosteroids and methotrexate should be curtailed or the dose adjusted.
When a DEXA scan shows the presence of osteoporosis, or if a person suffers an osteoporotic fracture, pharmacologic therapy, usually in the form of bisphosphonates, should be initiated. Bisphosphonates are drugs like Actonel and Fosamax, which are taken orally, by injection or even intravenously, to promote the formation of bone in people with osteoporosis.
“Treatment should focus on preventing bone loss due to RA, and initiating bisphosphonate therapy, which promotes bone formation, is the first line of therapy,” Blazer says.
Other medications can be used in people who cannot tolerate these drugs, or in those for whom bisphosphonates are ineffective. These include synthetic parathyroid hormones to stimulate new bone growth or certain monoclonal antibodies that prevent bone breakdown by osteoclasts.
[See: How to Practice Yoga When You Have Arthritis or Another Chronic Condition.]
“Lifestyle modifications, such as healthy diet, exercise focusing on weight bearing (walking, jogging) and smoking cessation can help protect the bones,” Blazer says. “Some patients may benefit from calcium and vitamin D supplements as well.”
“It is important to balance the trade-offs between improved physical activity with improved medical management and side effects,” Blazer says. “For example, when using low-dose prednisone (less than 7.5 mg), the risk of bone loss due to prednisone itself is largely offset by bone gained due to increased patient physical activity.”
If you have RA and osteoporosis, the outlook is not all bad.
“With early recognition and treatment, the prognosis in osteoporosis is very good,” Blazer says. “Fragility fractures can be effectively prevented in most people with the current medications.”
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People With Rheumatoid Arthritis Are at an Increased Risk of Osteoporosis originally appeared on usnews.com
