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Ossific (Bone) Density and Rheumatoid Arthritis

Posted on April 01, 2021
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Candace Crowley, Ph.D.

What Is Osteoporosis? | Causes | RA & Osteoporosis Link | Assessing Risk | Management | Support

People with rheumatoid arthritis (RA), an inflammatory disease of the joints, have a higher risk of developing osteoporosis, a condition that causes bones to become weak over time. The condition can have adverse effects, including a higher risk of broken bones.

Rheumatoid arthritis is an inflammatory autoimmune condition in which the body’s immune system attacks the joints, resulting in symptoms such as pain, swelling, and deformity. If you have been diagnosed with RA, it’s important to understand how the condition can impact ossific (bone) density and how to manage the risk.

What Is Osteoporosis?

Osteoporosis is a metabolic bone disease that causes bones to weaken gradually, leading to an increased risk of a fracture. Over 53 million people in the U.S. have osteoporosis or osteopenia — a condition where the body doesn't make new bone as quickly as it reabsorbs old bone — which can increase the risk of developing osteoporosis. Osteoporotic bones have a low mass and density. In people older than 65, most density loss occurs in cortical bone, the hard outer layer of bones.

Clinically, osteoporosis is defined as the presence of low bone mineral density (BMD). In osteoporosis, BMD is commonly measured in the proximal femur (top part of the leg bone) or lumbar spine (lower part of the spine).

What Causes Osteoporosis?

In the body, bone normally is continually formed and broken down in a process called bone remodeling or bone metabolism. Several cell types are involved in this process. Osteoclast cells break down bone, while osteoblast cells form new bone (a process called ossification, or bone formation). Osteoporosis occurs when the body makes too little bone or loses too much bone, resulting in low bone density.

Low bone density results in unstable, fragile bones that are prone to breakage. The most common fracture locations in people with osteoporosis are the hip, vertebral region (spine), and wrist. Fractures can cause significant pain and disability.

Risk factors for low BMD include both biological and environmental factors. They include:

  • Being underweight
  • Being overweight
  • Smoking
  • Drinking alcohol
  • Not exercising enough
  • Having a family history of osteoporosis
  • Taking certain medication

Additionally, women, particularly postmenopausal women, have an increased risk of low bone mass.

The Link Between Rheumatoid Arthritis and Osteoporosis

Studies show osteoporosis is twice as common in people with RA than people of the same age and sex who do not have RA. The prevalence of bone fractures is also double in people with RA compared to those without. People with rheumatoid arthritis are at increased risk of bone fragility for several reasons.

Risk From Disease Activity

Chronic inflammation, particularly surrounding joints, characterizes rheumatoid arthritis. This inflammation can lead to cartilage damage and bone erosion. Inflammation can also affect the bones themselves, contributing to the loss of bone minerals and bone density. Cells involved in the inflammatory response make proteins called cytokines. These cytokines activate osteoclasts (cells that break down bone). As a result, bone loss is higher in areas surrounding the joints affected by RA, studies show.

Risk From Treatment

Some medications used to treat RA, such as corticosteroids (also called glucocorticoids or steroids), can trigger significant bone turnover and bone loss. Longer treatment with steroids, such as prednisone, are associated with more bone loss and higher osteoporosis risk.

Risk From Inactivity

Regular physical activity is vital for maintaining bone density and overall bone health. People with RA often experience joint pain and joint-function loss, making regular exercise difficult. The resulting inactivity can weaken bones and increase osteoporosis risk.

Assessing Osteoporosis Risk in People With RA

People with RA, especially those who have been taking steroids for a long time, should talk to their doctor about whether a BMD test is needed. In some cases, doctors may order a dual-energy X-ray absorptiometry (DXA) scan to measure bone density in different body parts.

DXA scans are quick, painless, and use low doses of radiation. These scans can be used to monitor people with RA for low bone density or bone abnormalities. DXA scans are also used to track treatment progress in people already receiving osteoporosis treatment.

Managing Osteoporosis Risk

There are many ways for people with rheumatoid arthritis to manage osteoporosis risk. Strategies and treatments — including lifestyle changes and medications — can help alleviate osteopenia and osteoporosis by strengthening bones, limiting bone loss, and stimulating bone mineralization. Following a rheumatologist’s treatment plan is important for limiting inflammation and maintaining bone health for people with RA. Confer with your doctor before trying any new treatments.

Nutrition

Calcium and vitamin D are critical for maintaining healthy bones and managing osteoporosis risk. You can find these nutrients in dietary sources or supplements.

The National Institutes of Health recommends a daily calcium intake of 1,000 milligrams for people up to age 50. Women over 50 (particularly postmenopausal women) and men over 70 should increase intake to 1,200 milligrams daily.

Dietary calcium sources include:

  • Dairy products, such as milk, yogurt, and cheese
  • Dark green, leafy vegetables
  • Calcium-fortified foods and beverages, such as plant-based milk

Recommendations for vitamin D intake range from 600 to 1,000 international units per day. Although sunlight is a source of vitamin D, many people cannot get sufficient levels from the sun and diet alone and must take supplements. Annual blood tests commonly measure vitamin D levels and can help determine if supplements are needed.

Dietary vitamin D sources include:

  • Tuna, mackerel, and salmon
  • Liver
  • Egg yolks
  • Vitamin-D fortified foods and beverages, such as some cereals and orange juices

Exercise

Regular exercise is important for increasing bone density, improving balance, and preserving joint mobility. However, exercising can be difficult for people with RA due to joint pain and stiffness. Those with RA should balance exercise with rest during flare-ups.

Two types of activities — weight-bearing and resistance exercise — are particularly recommended to maintain bone density and limit bone loss. Other exercises, such as yoga and tai chi, can improve balance, helping prevent falls and fractures.

Weight-bearing exercises place force on the bones. Such exercises include:

  • Walking
  • Climbing stairs
  • Dancing
  • Jumping rope
  • Skipping
  • Using an elliptical machine

Resistance exercises can also strengthen bones. Resistance exercises include:

  • Using stretch bands
  • Using light weights with multiple repetitions
  • Doing pilates

Healthy Lifestyle and Diet

Smoking and alcohol can block calcium absorption, increase bone mineral loss, and increase osteoporosis risk. Limiting alcohol intake and avoiding smoking are important for maintaining bone health. Obesity is also linked to osteoporosis risk due to enhanced inflammation in the body. Maintaining a healthy weight can help manage risk, and following an anti-inflammatory diet can help.

Medication

Several medications are available to prevent and treat osteoporosis by increasing the formation of new bone or decreasing bone breakdown. Some drugs are taken orally, while others are injected into the body.

Medications used to prevent or treat osteoporosis include:

  • Bisphosphonates
  • Calcitonin
  • Estrogen (hormone therapy)
  • Selective estrogen receptor modulators
  • Parathyroid hormone analogs
  • RANK ligand (RANKL) inhibitors

Several studies suggest that by blocking inflammatory cytokines, some RA therapies can also increase bone mass and bone strength. For example, systemic biologic medications (such as Etanercept) may positively affect bone synthesis and bone mineral density.

Talk With Others Who Understand

By joining myRAteam — the social network for people with rheumatoid arthritis and their loved ones — you can connect with more than 146,000 other members who understand life with RA. Every day, members come together to ask questions, give advice, and share their stories.

Have you used physical therapy to manage your RA? Share your experience in the comments below, or share your story on your myRAteam.

All updates must be accompanied by text or a picture.
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.
Candace Crowley, Ph.D. received her doctorate in immunology from the University of California, Davis, where her thesis focused on immune modulation in childhood asthma. Learn more about her here.

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