by Eileen J. Lydon, ANP-BC, NYU Hospital for Joint Diseases, Updated by C.H. Weaver M.D. 7/2021
Osteoporosis occurs when bones become weak due to loss of bone tissue. Osteoporotic bone is thinner and full of holes, and there is less of it. As a result, the bone fractures easily, even due to simple everyday activities like a minor stumble, lifting a child, or even sneezing. Unfortunately, osteoporosis is a “silent disease,” meaning it often exists without any symptoms or warning signs until it is revealed through a bone fracture. A fracture can cause significant pain, loss of independence, and other serious health consequences, including a shorter life expectancy.1
Osteoporosis affects women in much greater numbers than men. In fact, 80% of people with osteoporosis are women. It is estimated that about 50 percent of women over age 50 will break a bone because of this condition. One reason is the smaller frame of many females, but by far the most common reason is the drop of estrogen that occurs during menopause—a woman may lose up to 20% of her bone mass in the first five to seven years after menopause. Additional risk factors specific to women include early menopause and the absence of menstrual periods, often because of anorexia nervosa.1-3
Rheumatoid arthritis (RA), a chronic inflammatory autoimmune disease, is also a risk factor for osteoporosis. With RA the body’s immune cells release chemicals that cause inflammation and attack healthy tissues. This condition most commonly affects the joints by causing pain, stiffness, and swelling; it may also limit their motion. If left untreated, RA may result in permanent joint damage. More than 1.3 million people in the United States are affected by RA, and approximately 75% are women. Women are two to three times more likely than men to develop RA. In fact, 1 to 3 percent of women will get rheumatoid arthritis in their lifetime.4-6
Women living with RA have a greater risk of osteoporosis due to several factors. First, the symptoms of RA can make it difficult for some women to move because of the pain and lack of joint motion, and this state of inactivity can lead to bone loss. Second, the inflammatory cells that cause pain and swelling of the joints can deplete the minerals in the bone (calcium), which can also result in bone weakness. Finally, glucocorticoids (prednisone and other steroids), which are commonly used to help manage RA, may induce osteoporosis.5
Being aware of the increased risk of osteoporosis and taking steps to proactively address bone health are important for women living with RA. Early detection, prevention, and effective treatment of osteoporosis are key to managing this condition. Being armed with knowledge can help make a positive impact on bone health and quality of life. The following strategies are a good place to start.
Bone Heath Strategies for Women with RA
Get Enough Calcium: Adult women age 19 to 50 should aim for 1,000 milligrams (mg) of calcium per day, and women older than 50 should get 1,200 to 1,500 mg each day. Incorporating calcium-rich foods into your diet is an ideal way to reach these targets: milk, cheese, broccoli, and almonds are all great sources. Look at food labels to see how much calcium food sources have. If your diet alone is not providing you with the recommended daily calcium, speak to your healthcare provider about adding a calcium supplement.7
Get Enough Vitamin D: The body needs adequate vitamin D to absorb calcium; therefore it is very important to be sure you’re getting enough vitamin D each day. The National Osteoporosis Foundation recommends 800 to 1,000 international units (IU) of vitamin D daily. Vitamin D can be absorbed through the skin from the sun and is also available through food sources (egg yolks, saltwater fish, liver, and fortified milk). Your healthcare provider may need to prescribe additional supplements to ensure that you are getting what you need.7
Get Enough Exercise: Bone is a living tissue, and it can become stronger with exercise just like muscles can. The most effective exercises for bone health are weight bearing, such as walking, stair climbing, and weight training.8 It is recommended that you exercise for 30 minutes per day. To avoid injury be sure to discuss with your healthcare provider which types of exercise are safe for you.8
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Avoid Smoking Cigarettes: Studies have shown a link between bone loss and cigarette smoking. If you’re a smoker, quitting can reduce your risk of osteoporosis, no matter your age.9
Limit Alcohol Intake: Heavy drinking can increase bone loss and increase the risk of falling, which can lead to a fracture. The National Osteoporosis Foundation recommends no more than two drinks per day.10
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Limit Steroid Use: Glucocorticoid Therapies Glucocorticoids (GCs) have been a mainstay of treatment for RA due to their efficacy as disease-modifying therapies. Their use however is implicated in the most common form of secondary osteoporosis, which develops through the mechanisms of increased bone resorption as well as reduced bone formation. These effects occur early in the treatment period and have been associated with an increased risk for fracture after 6 months of use. These findings have influenced proposed changes to the guidelines in 2021 for treatment of RA inflammation in a direction that favors limiting the use of GCs in RA.13
Ask Your Healthcare Provider If You Need a Bone-Density Test
A bone-density test measures the amount of minerals in the bones and is the best way to asses bone strength. The National Osteoporosis Foundation recommends a bone-density test for people in the following categories and studies suggest that women with RA are significantly under screened.
- Women 65 and older regardless of risk factors
- Younger postmenopausal women with risk factors for fracture
- Women in the menopausal transition with risk factors for fracture
- Adults with a condition (such as RA) or who are taking medication (such as glucocorticoids) associated with low bone mass or bone loss.
Bone Mineral Density (BMD) screening is easily performed by DXA (dual-energy x-ray absorptiometry), and and individuals fracture risk can be calculated using FRAX (Fracture Risk Assessment Tool). Calculating a BMD-adjusted 10-year fracture risk using FRAX provides a foundation to discuss potential therapies.14
Ask Your Healthcare Provider If You Need Bone-Strengthening Medication
There are several medications approved by the US Food and Drug Administration to treat osteoporosis and help prevent fractures. Ask your healthcare provider if you are a candidate for medication.
Prevent Falls: Keeping your environment safe can reduce the risk of falling:
- Keep floors clear of clutter.
- Use a rubber mat in the shower.
- Be mindful of floors that are slippery.
- Wear shoes with good traction.
- Exercises such as tai chi, swimming, and stretching can help reduce falls by improving balance, flexibility, and strength.11
Osteoporosis Risk Factors
- Getting older
- Previous fracture from a minor incident (such as a fall from standing height)
- Women who are postmenopausal or had early menopause
- Absence of menstrual periods
- Family history of osteoporosis
- Weighing less than 127 pounds
- Cigarette smoking
- Excess alcohol intake
- Certain medical conditions such as rheumatoid arthritis
- Use of certain medications such as glucocorticoids, and proton pump inhibitors.1,12
Eileen J. Lydon, ANP-BC, has worked at the New York University Hospital for Joint Diseases as an adult nurse practitioner in the Department of Rheumatology for the past 13 years. She assists in evaluating hospital consults and oversees panels of patients with rheumatologic conditions in the outpatient ambulatory care clinic, including an osteoporosis clinic. She also provides educational presentations to patients and peers regarding rheumatologic conditions. She is the chapter development and governance chair of the Rheumatology Nurses Society.
- Fit to a T. US Bone and Joint Initiative website. Available at: Accessed January 14, 2017.
- National Osteoporosis Foundation. *Boning Up on Osteoporosis: A Guide to Prevention and Treatment.*Washington, DC: National Osteoporosis Foundation; 2008.
- Bone Health Basics: Get the Facts. National Osteoporosis Foundation website. Available at: www.nof.org/prevention/general-facts. Accessed January 14, 2017.
- Rheumatoid Arthritis. American College of Rheumatology website. Available at: www.rheumatology.org. Accessed January 14, 2017.
- What People with Rheumatoid Arthritis Need to Know About Osteoporosis. NIH Osteoporosis and Related Bone Diseases National Resource Center website. Available at: . Accessed January 14, 2017.
- 2013 Clinician’s Guide to Prevention and Treatment of Osteoporosis website. Available athttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4176573/. Accessed January 19, 2017.
- Calcium and Vitamin D: Important at Every Age. NIH Osteoporosis and Related Bone Diseases National Resource Center website. Available at: . Accessed January 14, 2017.
- Exercise for Your Bone Health. NIH Osteoporosis and Related Bone Diseases National Resource Center website. Available at: . Accessed January 14, 2017.
- Smoking and Bone Health. NIH Osteoporosis and Related Bone Diseases National Resource Center website. Available at: . Accessed January 14, 2017.
- What Is Own the Bone? American Orthopaedic Association website. Available at: . Accessed January 14, 2017.
- Preventing Falls and Related Fractures. NIH Osteoporosis and Related Bone Diseases National Resource Center website. Available at: . Accessed January 14, 2017.
- Abtahi S, Driessen JHM, Burden AM, et al. Concomitant use of oral glucocorticoids and proton pump inhibitors and risk of osteoporotic fractures in patients with rheumatoid arthritis: a population-based cohort study. Presented at: ASBMR 2020 Virtual Annual Meeting; September 11-15, 2020. Poster #P-546.
- Adami G, Rahn EJ, Saag KG. Glucocorticoid-induced osteoporosis: from clinical trials to clinical practice. Ther Adv Musculoskelet Dis. 2019;11:1759720X19876468. doi:10.1177/1759720X19876468
- Schmajuk G, Tonner C, Trupin L, Yazdany J. Variations in radiographic procedure use for Medicare patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2017;69(5):642-648. doi:10.1002/acr.22988