Fractures, and bone loss

The inflammatory process that occurs in RA increases the risk of bone loss and fractures. Normally, the body maintains healthy bone by a process of repair (called remodeling) driven by two types of bone cells, osteoclasts, which are responsible for removing (resorption) of old existing bone, and osteoblasts, which are responsible for forming new bone. A balance between the activities of osteoclasts and osteoblasts keeps the overall mass of bone in the body constant. However, in RA this balance is upset. Bone loss is common and is associated with the severity of inflammation and the duration of the disease.1

 

Increased risk of fracture

Osteoporosis, with increased risk of fracture, commonly affects women with RA. This is especially true as this group reaches menopause and during the post-menopausal years, when the risk for osteoporosis is normally the highest. Women with RA, who already face a risk of bone loss associated with chronic inflammation, face additional increased risk of osteoporosis from menopause. This means that they are at extremely high risk for fractures and other complications associated with continued bone loss.2

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 normal control group (non-RA females).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.4

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.

 

Glucocorticoids and bone health

There is a definite link between glucocorticoid use and increased risk for fractures in patients with RA. However, the debate about what constitutes a safe glucocorticoid 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 glucocorticoids that you use, especially since there are other effective treatments (DMARDs and biologics) not linked to bone loss that you can use to control RA symptoms.4

For RA patients who are receiving glucocorticoids, and for those who have osteoporosis, supplementation with calcium and vitamin D, and use of a bisphosphonate (a class of drugs used to prevent bone loss) should be considered.4

Written by: Jonathan Simmons | Last reviewed: September 2013.