People with rheumatoid arthritis (RA) have a higher risk of osteoporosis than the general population. Inflammation from RA itself, long-term use of corticosteroids taken for the treatment of RA symptoms, and a sedentary lifestyle among people with RA all contribute to the prevalence of osteoporosis with RA. Women have a greater risk of developing osteoporosis than men.

RA is a chronic inflammatory condition that is considered an autoimmune disease and causes pain, swelling, and damage in joints due to immune system dysfunction. RA can also affect other organs and tissues of the body. When two or more conditions occur together, the secondary condition is called a comorbidity, and osteoporosis is a common comorbidity with RA.

Osteoporosis occurs when bones become brittle and weak due to a loss of bone mass or bone mineral density (BMD), which can increase the risk for bone fracture. The word osteoporosis means “porous bones” and appears as abnormal holes or spaces within the bone structure.

Members of myRAteam frequently discuss their experiences with osteoporosis and RA. “I kept having back pain, and my doctor sent me for a test for osteoporosis, and sure enough, I have severe osteoporosis,” one team member wrote.

Another member explained her condition. “My worst pain is in my wrists, particularly my thumbs. I have had many X-rays of my wrists and they all show the same thing,” she said. “My osteoporosis has depleted my bones around the wrists so that they are practically bone on bone.”

Approximately 30 percent of people with RA develop osteoporosis, which is about twice the rate of the general population, and women at menopause and postmenopausal women with RA have an even higher risk. Osteoporosis can be challenging with RA, but understanding the connection between osteoporosis and RA may help you manage your condition better and help you prevent bone fractures.

Causes and Risk Factors

Risk factors in general for osteoporosis include sedentary lifestyle, smoking, weight loss, poor diet, vitamin D deficiency, family history of osteoporosis or bone fractures, gender, and aging.

Many health conditions can also cause osteoporosis, such as hormonal dysfunction, digestive disorders, neurological conditions, blood and bone diseases, as well as autoimmune diseases like RA, ankylosing spondylitis, and lupus. People with RA have particular risk factors that can be managed for potentially better outcomes.

Inflammation and Bone Loss

In people with RA, inflammation from the condition causes an increased risk of osteoporosis. Joint damage can affect bone near affected joints and cause local bone erosion. Systemic inflammation from RA can cause more general bone loss.

Inflammation in RA is also believed to cause sarcopenia, which is a loss of muscle strength and mass. Muscle strength has a significant correlation to BMD, and sarcopenia is a risk factor for osteoporosis and low bone mass. An occurrence of both sarcopenia and osteoporosis is sometimes called osteosarcopenia.

Treatment of inflammation in RA may reduce the risk of developing osteoporosis. Biologic and synthetic disease-modifying antirheumatic drugs (DMARDs), such as tumor necrosis factor α, interleukin-1, interleukin-6, or interleukin-17 inhibitors have been shown to protect against bone loss in people with RA. These anti-inflammatory drugs block proinflammatory cytokines, which are proteins in the immune system that attack healthy tissue in people with RA.

Biologic drugs and other DMARDs that are used in the treatment of RA may protect against BMD loss, including:

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

Methotrexate, another common treatment for inflammation in RA, may decrease bone mass in high doses, but research shows that the drug does not harm bones in low doses.

Corticosteroid-Induced Osteoporosis

Corticosteroids, also known as glucocorticoids, are frequently used to treat RA and are linked to an increased risk of osteoporosis due to a decrease in bone formation and bone turnover, which is part of the natural bone resorption and remodeling process. Corticosteroids are the leading cause of secondary osteoporosis, meaning osteoporosis that is the result of another disease. Corticosteroids are the most common cause of osteoporosis in people under 50 years old, among the general population.

One myRAteam member explained her experience with corticosteroids and RA. “I have been on prednisone now for over ten years every day. They alter my dosage depending on the severity of my illness,” she wrote. “At the moment, or since September, I am taking 15 milligrams a day. And yes, it has given me osteoporosis.”

Another member wrote, “I’ve been on prednisone for 18 months and didn’t realize it was doing so much damage. I’ve been diagnosed with osteoporosis, and prednisone doesn’t help. I wasn’t taking calcium or vitamin D.”

Corticosteroids inhibit the absorption of calcium, which is needed for bone formation. Research has indicated that people who take corticosteroids, even in small doses, may benefit from supplements of calcium and vitamin D, which is essential for calcium absorption.

If you take corticosteroids, talk to your rheumatologist about adding calcium and vitamin D to your treatment plan, and be sure you understand proper usage for these supplements, which shouldn’t be taken in excess of the recommended dosage.

Sedentary Lifestyle and Osteoporosis

People with RA often experience physical limitations due to pain, stiffness, and fatigue, and can be prone to a sedentary lifestyle, which is a risk factor for osteoporosis. Research shows that weight-bearing exercise can preserve bone mass and stimulate the formation of bone in some people with osteoporosis or at risk for developing osteoporosis.

Weight-bearing aerobic exercise, resistance training, and strengthening exercise are especially beneficial to bone health. Although it is common for people with RA to be wary of exercise because they are afraid it may cause a flare, there is no evidence that exercise increases disease activity. Exercise can strengthen bones, increase muscle mass, and improve range of motion and balance to help prevent falls and the risk of osteoporotic fracture.

People with RA can work with a physical therapist to determine exercises that are appropriate for your particular condition.

Read more about exercise for people with RA.

Living With RA and Osteoporosis

Osteoporosis is typically managed with exercise, mineral and vitamin supplements, avoidance of smoking, and little or no alcohol consumption. In more acute cases, treatment may include medication such as bisphosphonates, biologics, or hormone therapy. Newer drugs like Fortio (teriparatide), a synthetic parathyroid hormone, and Prolia (denosumab), a monoclonal antibody, are showing promising results in some people with osteoporosis. Medications for osteoporosis are taken orally, by injection, or administered by infusion, depending on the drug.

Treatment of osteoporosis in people with RA initially aims at reducing RA disease activity to minimize the impact of inflammation on bones. Maintaining your RA treatment plan is important for your bone health. Be sure you are getting regular bone density tests to check for osteoporosis and osteopenia, a condition of weakened bones that can develop into osteoporosis.

Lifestyle Changes

A healthy lifestyle that includes regular exercise and physical activity, a well-balanced diet, and techniques for managing stress can help reduce the risk of developing osteoporosis, and help manage the challenges of living with RA and osteoporosis. A healthy lifestyle can also help reduce RA disease activity.

Talk to your rheumatologist about referrals for physical therapists, occupational therapists, nutritionists, or mental health professionals, if you need help managing stress. By working with your health care team and making healthy lifestyle choices, you can reduce the risk of fractures, feel your best, and improve your quality of life.

Talk With Others Who Understand

On myRAteam, the social network for people with rheumatoid arthritis, more than 167,000 members come together to ask questions, give advice, and share their stories with others who understand life with rheumatoid arthritis.

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