Osteoporosis and risk of fracture

Osteoporosis is a common comorbidity that affects both women and men with RA, but particularly women after menopause.

In the general population, the period shortly before menopause (1.5 years before) and the period following menopause are associated with loss of bone, with bone density decreasing on average at a rate of 2.5% yearly before and during menopause and at a slower rate (about 1%) after menopause. Among post-menopausal Caucasian women in the general population, 35% will develop osteoporosis.¹

Women with RA, who already face a risk of bone loss associated with chronic inflammation, face additional increased risk of osteoporosis from menopause. This places post-menopausal women with RA at extremely high risk for fractures and other complications associated with continued bone loss.¹

However, osteoporosis and bone loss can affect women with RA well before they reach menopause. Results from a study of 394 female RA patients ranging in ages from 20 to 70 years found that bone mineral density was reduced throughout the study population and that osteoporosis occurred at double the rate for the entire group of female RA patients compared with a healthy control group of females without RA.²

Increased risk of fracture

Osteoporosis is a health concern primarily because of increased risk of fracture. A large study conducted in the UK including over 30,000 RA patients and over 90,000 normal non-RA controls, found that the RA group had increased risk for fractures of the hip, pelvic, spine, humerus (upper arm), and tibia/fibula (lower leg). The group of RA patients had twice the risk for hip fractures and over twice the risk for fractures of the spine compared with an age matched group in the general population.³

Reducing your risk for bone loss

Because RA itself is a risk factor for bone loss (reduced bone mineral density), if you have RA and you are above the age of 50 years (for both men and women), you should have your bone mineral density monitored. Bone loss associated with RA occurs as a result of inflammation. For this reason and many others, it is important for you to work with your doctor to control the inflammation associated with RA by using one of the many effective treatment options. Treatment with a variety of agents has been shown to slow down or stop damage to joints and related structures.⁴

In addition to RA treatment, you should make sure you are getting the proper amount of calcium in your diet. Common dietary sources of calcium include dairy products, dark green leafy vegetables, calcium fortified foods and drinks, including orange juice, soy beverages, tofu products, cereal, and breads, and nuts, such as almonds. Remember that vitamin D plays an important role in bone health. Your body needs vitamin D in order to absorb calcium (this is why milk is typically fortified with vitamin D).

There are few dietary sources of vitamin D. Your body, itself, actually makes vitamin D when it is exposed to sunlight, so make sure you get a proper amount of sun exposure. However, be aware that some medications such as methotrexate can cause photosensitivity and severe skin reactions. Check with your doctor to make sure that you have adequate amounts of vitamin D. Specific blood tests are available to monitor serum levels of vitamin D.

Depending on your calcium intake and vitamin D levels, consider taking a calcium supplement and vitamin D for prevention of osteoporosis and fracture. There is some evidence that vitamin D levels may be low in patients with RA due to the RA disease process. In addition to helping with bone health, vitamin D may also have some benefits for immune system function.⁴ As vitamin D is fat-soluble, look for a supplement which comes in liquid capsule form or take the supplement with food containing a little bit of oil or fat for optimum absorption.

Corticosteroids and bone health

There is a definite link between corticosteroid use and increased risk for fractures in patients with RA. However, the debate about what constitutes a safe corticosteroid dose with respect to bone health is still ongoing. Therefore, if you are at increased risk for bone loss, it makes sense to limit the amount of corticosteroids that you use to control inflammation and pain associated with RA.  Use of other effective treatments (DMARDs and biologics), not linked to bone loss, may help you to control RA symptoms by treating the disease directly.⁴

For RA patients who are receiving corticosteroids, as well as those who are not and who have osteoporosis, supplementation with calcium and vitamin D, and use of a bisphosphonate (a class of drugs used to prevent bone loss) is a standard approach to treatment.⁴