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Rheumatoid Arthritis and Osteoporosis: Is There a Connection?

Posted on December 20, 2021
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Joan Grossman

Osteoporosis may be connected to rheumatoid arthritis (RA) in some people. People with RA are at a higher risk of developing osteoporosis than the general population due to several factors. Inflammation from RA disease activity, prolonged use of corticosteroids for RA symptoms, and a sedentary lifestyle can all contribute to a prevalence of osteoporosis with RA. Women with RA have a greater risk of developing osteoporosis than men with the condition.

RA is a chronic inflammatory autoimmune condition that causes swelling, pain, and damage in joints due to disorders in the immune system. RA may affect other organs and tissues of the body in some people, including the eyes, lungs, and blood vessels. Osteoporosis is a common comorbidity of RA. When two or more conditions occur at the same time, the secondary condition is called a comorbidity.

Osteoporosis occurs when loss of bone mass, also known as bone mineral density (BMD), causes bones to become brittle and weak. The word “osteoporosis” means “porous bones,” and the disease causes abnormal holes or spaces within bone structure. Osteoporosis increases the risk for bone fracture.

MyOsteoTeam members have shared their experiences with osteoporosis and RA. “I have rheumatoid arthritis and Sjögren’s syndrome, and I had a low-impact fall back in February. Broke my wrist in multiple places, plus my sacrum,” one member wrote. “This led to a DEXA scan that showed severe osteoporosis.”

Another member explained their condition: “I was first diagnosed with rheumatoid arthritis. I’m now 53, I have had 14 orthopedic surgeries so far, and I found out in January 2018 that I now have advanced-stage osteoporosis.”

About 30 percent of people with RA develop osteoporosis, which is approximately two times the rate of the general population. Postmenopausal women with RA have an even higher risk. Osteoporosis with RA can be challenging, but recognizing the connections between osteoporosis and RA can help you manage your condition better.

Causes and Risk Factors

The exact causes of RA are not fully understood, but a combination of genetic and environmental factors are believed to trigger it. Viral or bacterial infections can be a trigger. Smoking, being overweight, and having a family history of RA are also risk factors in developing RA. The condition is more prevalent among women and typically begins in middle age.

Risk factors for osteoporosis generally include:

  • Smoking
  • Weight loss
  • Sedentary lifestyle
  • Poor diet
  • Vitamin D deficiency
  • Family history of osteoporosis or bone fractures
  • Female sex
  • Aging

A number of health conditions can also lead to osteoporosis, including hormonal dysfunction, digestive disorders, and neurological conditions. Autoimmune diseases like RA, ankylosing spondylitis, and lupus are also associated with osteoporosis.

Inflammation and Bone Loss

With RA, inflammation from the condition can impact bones and increase the risk of osteoporosis. Joint damage from RA can affect bone tissue next to affected joints and cause local bone erosion. Systemic inflammation from RA can cause more general bone loss.

Inflammation from RA is also linked to sarcopenia, which is characterized by a loss of muscle mass and strength. Weakened muscles can decrease BMD, and sarcopenia is a risk factor for reduced bone mass and osteoporosis. When both sarcopenia and osteoporosis occur at the same time, the condition is known as osteosarcopenia.

Research indicates that treating inflammation in RA can help reduce the risk of developing osteoporosis. Biologic and synthetic disease-modifying antirheumatic drugs (DMARDs) have been shown to protect bones against mineral loss in people with RA. These anti-inflammatory medications target proinflammatory proteins, or cytokines, that attack healthy tissue in people with RA due to immune system dysfunction.

Some RA treatments that may protect against BMD loss include:

  • Actemra (tocilizumab)
  • Enbrel (etanercept)
  • Humira (adalimumab)
  • Kevzara (sarilumab)
  • Remicade (infliximab)

Methotrexate, another common treatment for RA inflammation, may reduce bone density in high doses. However, research shows that low doses of the drug do not damage bones.

Corticosteroid-Induced Osteoporosis

Corticosteroids, also called glucocorticoids, are often used to treat RA and are linked to a higher risk of osteoporosis. Corticosteroids cause a decrease in bone formation and bone turnover, which is a natural process of bone resorption and remodeling. Corticosteroids are the leading cause of secondary osteoporosis, or osteoporosis that is caused by another disease. Among the general population, corticosteroids are the most common cause of osteoporosis in people under age 50.

Corticosteroids reduce the absorption of calcium, which is necessary for healthy bone formation. Studies show that people who take corticosteroids, even in small doses, may benefit from calcium and vitamin D supplements. Vitamin D is needed for calcium absorption.

If you take steroids, ask your health care providers about adding vitamin D and calcium supplements to your treatment plan. Be sure you understand proper dosage for these supplements, as they can have adverse effects if taken in excess amounts.

Sedentary Lifestyle, Rheumatoid Arthritis, and Osteoporosis

People with RA frequently have physical limitations due to fatigue, pain, and stiffness. A lack of physical activity can increase the risk for osteoporosis. Weight-bearing exercise has been shown to preserve bone mass and stimulate bone formation in some people with osteoporosis or those at risk of developing osteoporosis.

Weight-bearing aerobic exercise, resistance training, and strengthening exercise are particularly good for bone health for people with osteoporosis or RA. Many people with these conditions may be wary of exercise because they worry it may cause pain or flare-ups. Fortunately, studies indicate that safe exercise does not increase disease activity in RA or osteoporosis.

One MyOsteoTeam member discussed their approach to staying fit: “I also have rheumatoid arthritis. I went to physio yesterday for an exercise regime, so I will try the resistance exercises the physiotherapist has given me to do. I try to walk daily.”

Exercise can strengthen bones, increase muscle mass, improve range of motion, and improve balance, all of which can help prevent falls and the risk of osteoporotic fractures. Talk to your doctor about getting a referral for physical therapy to learn exercises that are appropriate for you.

You can find out more about exercising with RA.

Living With Osteoporosis and RA

For people with osteoporosis and RA, treatment initially aims at decreasing RA disease activity to lessen the effect of inflammation on bones. Maintaining an RA treatment plan is important for bone health. Your treatment plan may include a combination of anti-inflammatory drugs, methotrexate, or sulfasalazine, plus biologic drugs that are taken by injection or infusion.

Osteoporosis is typically managed with exercise and mineral and vitamin supplements. People with osteoporosis should also avoid smoking and drink little to no alcohol. In more acute cases, treatment may include drugs such as bisphosphonates, hormone therapy, or biologics. Forteo (teriparatide), a synthetic parathyroid hormone, and Prolia (denosumab), a monoclonal antibody, are some of the newer drugs used for osteoporosis. Depending on the drug, medications for osteoporosis are taken orally or by injection or infusion.

If you are living with osteoporosis and RA, it’s important to be sure your health care team is coordinated so that you avoid treatments that may impact your bone health.

“I have been on lots of meds for 38 years for rheumatoid arthritis, but I’m so grateful for the normal life they have given me,” one MyOsteoTeam member wrote.

Lifestyle Changes

Regular exercise, good nutrition, and effective stress management can help manage the challenges of living with osteoporosis and RA. A healthy lifestyle can also help reduce RA disease activity.

Talk to your doctors about referrals for physical therapists, occupational therapists, nutritionists, or counselors. By working with your health care team and making healthy lifestyle choices, you can reduce the risk of fractures, improve your quality of life, and feel your best.

Talk With Others Who Understand

On MyOsteoTeam, the social network for people with osteoporosis, more than 60,000 members come together to ask questions, give advice, and share their stories with others who understand life with osteoporosis.

Are you living with osteoporosis and have questions about rheumatoid arthritis? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Osteoporosis in Rheumatic Diseases — International Journal of Molecular Sciences
  2. Osteoporosis, Rheumatoid Arthritis, and Women: Knowledge Is Power — The Arthritis Connection
  3. Rheumatoid Arthritis – Mayo Clinic
  4. Osteoporosis — Mayo Clinic
  5. Osteoporosis in Rheumatoid Arthritis: Dangerous Liaisons — Frontiers in Medicine
  6. A Comprehensive Overview on Osteoporosis and Its Risk Factors — Therapeutics and Clinical Risk Management
  7. What Is Osteoporosis and What Causes It? — Bone Health & Osteoporosis Foundation
  8. 8 Osteoporosis Risk Factors and Causes Arthritis Patients Need To Know About — CreakyJoints
  9. Osteosarcopenia in Rheumatoid Arthritis Treated With Glucocorticosteroids — Essence, Significance, Consequences — Reumatologia
  10. The Impact of Long-Term Biologics/Target Therapy on Bone Mineral Density in Rheumatoid Arthritis: A Propensity Score-Matched Analysis — Rheumatology (Oxford)
  11. Rheumatoid Arthritis Medications — CreakyJoints
  12. Methotrexate in the Treatment of Rheumatoid Arthritis. II. In Vivo Effects on Bone Mineral Density — Rheumatology
  13. Glucocorticoid-Induced Osteoporosis — RMD Open
  14. Glucocorticoid‐Induced Osteoporosis in Rheumatic Diseases — Clinics (Sao Paulo)
  15. The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients — BioMed Research International
  16. Benefits of Exercise in Rheumatoid Arthritis — Journal of Aging Research
  17. Exercising With Osteoporosis: Stay Active the Safe Way — Mayo Clinic
  18. Rheumatoid Arthritis Treatment — Johns Hopkins Arthritis Center
  19. Pharmacological Management of Osteoporosis in Rheumatoid Arthritis Patients: A Review of the Literature and Practical Guide — Drugs and Aging
Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Joan Grossman is a freelance writer, filmmaker, and consultant based in Brooklyn, NY. Learn more about her here.

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