Measures to Reduce Bone Loss in Rheumatoid Arthritis
Inflammatory conditions such as rheumatoid arthritis can cause bone loss, which can lead to osteoporosis. The use of prednisone further increases the risk of bone loss, especially in postmenopausal women. It is important to do risk assessment and address risk factors that can be changed in order to help prevent bone loss. Patients may do the following to help minimize the bone loss associated with steroid therapy:
- Therapy for RA has improved greatly in the past 30 years. Current treatments give most patients good or excellent relief of symptoms and let them keep functioning at, or near, normal levels. With the right medications, many patients can achieve “remission” — that is, have no signs of active disease.
- There is no cure for RA. The goal of treatment is to lessen your symptoms and poor function.
- Doctors do this by starting proper medical therapy as soon as possible, before your joints have lasting damage.
- No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime.
- Good control of RA requires early diagnosis and, at times, aggressive treatment.
- Thus, patients with a diagnosis of RA should begin their treatment with disease-modifying antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the disease.
- Often, doctors prescribe DMARDs along with nonsteroidal anti-inflammatory drugs or NSAIDs and/or low-dose corticosteroids, to lower swelling, pain and fever.
- DMARDs have greatly improved the symptoms, function and quality of life for nearly all patients with RA. Common DMARDs include methotrexate, leflunomide, hydroxychloroquine and sulfasalazineAn improvement in symptoms may require four to six weeks of treatment with methotrexate. Improvement may require one to two months of treatment with sulfasalazine and two to three months of treatment with hydroxycholoroquine.
Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” Usually they are reserved for patients who do not adequately respond to DMARDs, or if adverse prognostic factors:
- They can target the parts of the immune system and the signals that lead to inflammation and joint and tissue damage. FDA-approved drugs of this type include abatacept (Orencia), adalimumab (Humira), anakinra,certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab and tocilizumab (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.
- DMARDs and biologic agents interfere with the immune system’s ability to fight infection and should not be used in people with serious infections.
- Testing for tuberculosis (TB) is needed before starting DMARD and antiTNF therapy.
- People who have evidence of prior TB infection should be treated for TB because there is an increased risk of developing active TB while receiving antiTNF therapy.
- AntiTNF agents are not recommended for people who have lymphoma or who have been treated for lymphoma in the past. People with rheumatoid arthritis specially those with severe disease have an increased risk of lymphoma regardless of what treatment is used.
- Janus kinase (JAK) inhibitors are another type of DMARD. People who cannot be treated with methotrexate alone may be prescribed a JAK inhibitor such as tofacitinib (Xeljanz).
- The best treatment of RA needs more than medicines alone.
- You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications.
- You likely also will need to repeat blood tests and X-rays or ultrasounds from time to time.
When bone damage from the arthritis has become severe or pain is not controlled with medications, surgery is an option to restore function to a damaged joint.
Living With Rheumatoid Arthritis:
- Research shows that people with RA, mainly those whose disease is not well controlled, have a higher risk for heart disease and stroke. Talk with your doctor about these risks and ways to lower them.
- It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares.
- In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range-of-motion exercises, such as stretching. This will keep the joint flexible.
- When you feel better, do low-impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints.
- A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.
- Finding that you have a chronic illness is a life-changing event. It can cause worry and sometimes feelings of isolation or depression. Use the lowest possible dose of glucocorticoids for the shortest possible time, when possible, to minimize bone loss.
- Consume an adequate amount of calcium and vitamin D, either in the diet or by taking supplements.
Dr. Gaurav Seth