When you think about who’s at risk for osteoporosis, a stereotypical portrait probably comes to mind: a thin Caucasian or Asian woman who’s over age 50. But if you have rheumatoid arthritis (RA), add yourself to that picture. Women—and men—with RA also have a significantly increased risk of osteoporosis and for fractures, not only of the hip, but also the arms, legs, pelvis, and spine.
In fact, according to a 2006 British study, people with RA are 50% more likely to develop osteoporosis and bone fractures than those who don’t have RA. Women face the greatest odds: They are two to three times more likely to have RA than men and have four times the risk of osteoporosis. The study of about 30,000 people with RA and 91,000 without it found that the risk existed even if no other risk factors for osteoporosis, such as the long-term use of corticosteroids, smoking, and being thin, were present. In fact, the risk posed by RA alone was as great as the risk caused by taking corticosteroids.
What Raises the Risk of Osteoporosis?
Although scientists are still trying to sort out why people with RA are more likely to develop osteoporosis than others, they do know some of the factors that heighten risk.
Disease activity
In addition to the joint damage that the disease’s chronic inflammation may cause, RA itself appears to trigger bone loss in the affected joint as well as other bones throughout the body. Some studies suggest that proteins that control inflammation (cytokines) also regulate cells called osteoclasts that are responsible for breaking down bone.
Corticosteroids
These medications are frequently prescribed to slow the progress of RA. Examples of medications in this category include prednisone, prednisolone, dexamethasone, and cortisone. Unfortunately, corticosteroids (also called glucocorticoids) jumpstart bone loss by suppressing bone formation and increasing bone breakdown. They also interfere with the way the body uses calcium and lower the levels of sex hormones (estrogen and testosterone), both of which add to bone loss. Although shortterm use doesn’t appear harmful to bones, anyone taking corticosteroids for more than three months raises his or her risk of osteoporosis.
Lack of exercise
The pain and damage caused by RA can limit both your ability and your desire to exercise. But making the effort to do some exercise is important: The tug of muscles on bones whenever you move strengthens your bones.
How Strong Are Your Bones?
To find out, you will need to undergo a simple, painless test called dual energy x-ray absorptiometry (DXA). It uses low doses of radiation (lower than a regular x-ray) to measure your bone density in comparison to that of young, healthy people without osteoporosis or RA. If your score (called a T-score) is less than -2.5 you have osteoporosis. A score of -1 to -2.5 means you have osteopenia, the first stage of bone loss.
Doctors generally recommend a baseline DXA scan for anyone planning to take corticosteroid therapy for six months or more. At Johns Hopkins, people with or at risk for osteoporosis are usually advised to get a scan every 18–24 months to monitor changes and the effect of any treatment. The cost of a DXA scan ranges from about $125–350; Medicare and most private insurers will pay for testing every two years.
Proven Ways To Prevent Bone Loss
You can take steps to help prevent or halt bone loss and, hopefully, keep your T-score out of the danger zone. If you use corticosteroids, studies show that most bone loss occurs in the first months of treatment—followed by slower continuous loss. Therefore, beginning a prevention program when you start taking the medication is best. Even if you aren’t a long-term corticosteroid user, if you have RA it’s still a smart move to follow these recommendations for osteoporosis prevention.
Take calcium and vitamin D supplements
Calcium helps develop and maintain bone structure, and vitamin D helps the bones absorb calcium and hold onto minerals. The higher a bone’s mineral content, the stronger it is. Your doctor can check your vitamin D level to make sure that you are not deficient. In general, women and men should take 1,500 mg of calcium and 800 international units (IU) of vitamin D daily. Again, check with your rheumatologist to see what dose he or she recommends for you. You can also boost the amounts of vitamin D and calcium you get by eating low-fat dairy products, dark green leafy vegetables, and calcium-fortified foods and drinks. A walk in the sunshine will also boost your vitamin D: The skin produces vitamin D from ultraviolet light.
Get some weight-bearing exercise
Weight-bearing exercise like walking, climbing stairs, and lifting weights forces muscles to push against bone and to work against gravity, which strengthens bones. Movement also helps keep muscles flexible and improves balance so that you’re less likely to fall and break a bone.
Take medications
Studies show that several medications can help prevent or halt bone loss.
Bisphosphonates
Risedronate (Actonel), approved in 2000 for the prevention of osteoporosis in women using orticosteroids and for the treatment of postmenopausal osteoporosis, was also approved for use in men at risk for corticosteroid-induced osteoporosis in 2006. Actonel is from a class of drugs called bisphosphonates, the leading treatment for osteoporosis. Alendronate (Fosamax) and ibandronate (Boniva) are two other commonly prescribed bisphosphonates for osteoporosis prevention and treatment. These medications slow the breakdown of bone and improve bone density.
Bisphosphonate use has been associated with osteonecrosis of the jaw—a serious condition in which bone cells in the jaw die because of decreased blood flow, most often following a dental extraction or some other trauma to the jaw. While reports of this condition in people taking bisphosphonates are uncommon, it is advisable to get regular dental checkups and let your dentist know if you are taking a bisphosphonate.
Hormone replacement therapy
(HRT) Hormonal replacement with estrogen or estrogen plus progestin also slows bone loss in postmenopausal women. However, HRT is controversial because it increases the risk of estrogen-fed breast cancer and, in women over age 60, heart disease.
An alternative is raloxifene (Evista), one of a new class of drugs called selective estrogen receptor modulators (SERMs) and the only one approved for the prevention and treatment of postmenopausal osteoporosis. SERMs appear less risky than traditional estrogen replacements—and in some women may actually lower breast cancer risk—but they are not as effective for osteoporosis prevention as either bisphosphonates or HRT.
In men, abnormally low levels of the hormone testosterone can cause osteoporosis. For men with this problem, testosterone replacement therapy (TRT)— available in injection, patch, and gel formulations—helps preserve bone mass by increasing testosterone to normal levels. However, high levels of testosterone are associated with an increased risk of prostate cancer. If you have a documented testosterone deficiency and are considering TRT, discuss the risks versus the benefits with your doctor.
Calcitonin
This natural hormone is involved in regulating calcium and bone metabolism and has also been approved for the treatment of osteoporosis, but not prevention. Although it is not considered as effective as bisphosphonates, it may be a reasonable option if you can’t or don’t want to take that type of medication. Calcitonin can be taken as a nasal spray or as an injection.
Forteo (Teriparatide)
Approved by the FDA in 2002, this synthetic form of the parathyroid hormone (PTH) is the first medication approved for osteoporosis that stimulates the formation of new bone. It’s given by self-injection in the thigh or stomach once or twice daily, but it is reserved for the treatment of people with severe osteoporosis and fractures.
Stop smoking
Last, but certainly not least, if you smoke, quit. Not only is it harmful for your heart and lungs, but it’s also bad for your bones. Smoking can trigger early menopause, which in turn ups bone loss, and it interferes with calcium absorption. Coupled with RA, that’s “a perfect storm” for osteoporosis.
Source: F. Burki Desproges-Gotteron R.
