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Women who have rheumatoid arthritis (RA) have about a 30 percent greater risk of developing osteoporosis of the hip and spine. But osteoporosis is not inevitable for women who have RA.

Anyone who has rheumatoid arthritis (RA) is at elevated risk for a long list of comorbid conditions. Men and women who are diagnosed with RA are also diagnosed with asthma, cancer, cardiovascular disease, infectious disease, and cancer more often than people who do not have RA. And women who have RA have about a 30 percent greater risk of developing osteoporosis.

Drugs for rheumatoid arthritis can cause osteoporosis

There are two ways in which RA predisposes women to develop osteoporosis. One major concern is the kinds of drugs used to treat RA. Glucocorticoid drugs like prednisone and prednisolone weaken bone. Depletion of bone mineral content can be detected as soon as six months after the beginning of treatment when the dosage of these drugs is more than 15 mg a day. But even low doses of glucocorticoids add up. Osteoporosis often can be detected when the cumulative dosage of glucocorticoids exceeds 5400 mg. If you are getting 10 mg of a steroid medication every day for your rheumatoid arthritis, you may experience detectable loss of bone mineral density in 540 days, about a year and a half.

Is your RA medication a glucocorticoid? Glucocorticoid medications include methylprednisolone (Medrol, Medrol Dosepak, DepoMedrol, SoluMedrol, A-Methapred), prednisolone (Orapred ODT, Pediapred), and prednisone (Prednisone Intensol, Raysol).

There are many other kinds of drugs for RA, including chelators, nonsteroidal analgesic (NSAIDs, such as ibuprofen and naproxen sodium), tetracyclines, opioid analgesics, other analgesics, and disease-modifying antirheumatic drugs (DMARDs). All of these drugs have side effects. Many of them are extremely expensive. But glucocorticoids are relatively cheap, and almost universally available. Sometimes they are the most practical treatment for RA. The problem is that they rob minerals from bone. But glucocorticoid medications are not the only culprit in osteoporosis in people who have RA.

Wasting and osteoporosis

An underappreciated complication of RA is metabolic wasting, also known by the medical term cachexia. Wasting is the second aspect of RA that leads to ostoporosis.

Women who have RA for a long time lose muscle mass. Wasting is the reason that RA makes you feel achy all the time. And because muscle wasting makes muscles burn sugar faster, women with RA-related cachexia  lose weight even though their bodies retain fat. 

You need healthy muscles to have healthy bones. Mineral density in bone increases in response to the mechanical load placed on the bone by muscles attached to it. When you just don't feel like doing anything, your bones don't get the hormonal stimulation they need to keep recycling old bone and remodeling with new bone. And as your muscles shrink, your bones deteriorate even more.

What can women with RA do to prevent osteoporosis?

If you have RA, the place to start to prevent osteoporosis is maintaining muscle mass. And about 50 percent of women who have RA have to deal with muscle wasting.

There is no easy answer for muscle wasting RA. Simply eating more is not the answer. Wasting muscles just don't absorb nutrients properly without a little help.

The kind of nutritional modification that helps women with rheumatoid arthritis restore muscle mass starts with avoiding excessive sodium. When muscle cells take excessive sodium in, they push some of the amino acids they need for new proteins out. Avoid salted fish, whole pickles, and heavily salted food. It's not necessary to go on a low-sodium diet, but you should avoid a high-sodium diet.

The next step to take in changing the diet to preserve muscle mass is avoiding an excess of inflammatory factors.  There are complicated approaches to reducing inflammation, but a a good place to start is getting the right balance of essential fatty acids. The body builds inflammatory hormones out of arachidonic acid (in egg yolks and red meat) and from n-6 essential fatty acids (which are abundant in cooking oils made from seeds, like safflower oil).

You don't have to avoid eggs, meat, or cooking oils as if they were poison. Your body actually needs some inflammatory hormones to power the immune system. But you need to balance inflammatory factors with anti-inflammatory factors. The body builds anti-inflammatory hormones from n-3 essential fatty acids. You can get n-3 essential fatty acids from some plant oils, but there are always more n-6 (pro-inflammatory acids) than n-3 (anti-inflammatory acids), except in flaxseed oil.

So to get the best ratio of n-6 to n-3 fatty acids you can:

  • Avoid corn, cottonseed, grapeseed, and peanut oil. They contain no or almost no n-3 fatty acids.
  • Use virgin olive oil in moderation. It's not a good source of anti-inflammatory acids, but it contains helpful antioxidants.
  • Favor hempseed, canola, and flaxseed oil. They approximate a healthy balance of anti-inflammatory and pro-inflammatory fatty acids.
These choices help you avoid making your condition worse. But to lessen inflammation in ways that actually improve muscle and joint health, consume fish or (if you are a vegan) microalgae oil. These products are expensive, but they provide n-3 fatty acids without the n-6's. The American College of Rheumatology confirms that these products can improve joint health in RA, although the benefits are modest (they aren't a cure for RA) and take several months.

Then, if you already have osteoporosis, you absolutely must start taking 400 to 1000 mg of supplemental calcium and 1000 IU of vitamin D every day. Calcium and vitamin D are the basics for maintaining bone mineral. To these supplements, add magnesium (400 to 600 mg a day) and vitamin K2 (45 milligrams per day). 

What about exercise?

Once you make the needed changes to your diet, and you get your doctor's OK, then it is time to make needed changes to your daily exercise routine to maintain muscle mass that helps you maintain healthy bones. The key to maintaining muscle mass is resistance. Muscles need to work against something to be stimulated to take in the nutrients and water they need to grow. So what kinds of exercise provide resistance?

Something as simple as stretching requires your muscles to work to resist gravity. You can also try dumbbells or light lifting or machines. Don't overdo it. A little exercise can make a big difference in recovering from muscle wasting. Exercise also helps you avoid the falls that can break your bones and decreases rheumatoid arthritis pain.

  • Compston J. Glucocorticoid-induced osteoporosis: an update. Endocrine. 2018 Jul. 61(1):7-16. doi: 10.1007/s12020-018-1588-2. Epub 2018 Apr 24. Review. PMID: 29691807.
  • El Maghraoui A, Sadni S, Rezqi A, Bezza A, Achemlal L, Mounach A. Does Rheumatoid Cachexia Predispose Patients with Rheumatoid Arthritis to Osteoporosis and Vertebral Fractures? J Rheumatol. 2015 Sep. 42(9):1556-62. doi: 10.3899/jrheum.141629. Epub 2015 Aug 1. PMID: 26233497.
  • Haugeberg G, Uhlig T, Falch JA, et al. Bone mineral density and frequency of osteoporosis in female patients with rheumatoid arthritis: results from 394 patients in the Oslo County Rheumatoid Arthritis register. Arthritis Rheum 2000.43:522–30.
  • Okano T, Inui K, Tada M, Sugioka Y, Mamoto K, Wakitani S, Koike T, Nakamura H. Loss of lean body mass affects low bone mineral density in patients with rheumatoid arthritis - results from the TOMORROW study. Mod Rheumatol. 2017 Nov. 27(6):946-952. doi: 10.1080/14397595.2017.1289645. Epub 2017 Mar 7. PMID: 2815051.
  • Photo courtesy of SteadyHealth

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