Rheumatoid Arthritis and Osteoporosis: Preventing and Managing Thinning Bones

  • Rheumatoid arthritis.
    Sedentary lifestyle.
    Being low on vitamin D.


    All are risk factors for developing osteoporosis. Although being a postmenopausal woman tends to be one of the more familiar risk factors, men, children and young adults are vulnerable, too. If you feel as if a heavy sack of doom just snuck onto your shoulders, you're not alone.


    What is osteoporosis? What can you do to prevent it? What can you do if you have it? Pam Flores from our Osteoporosis site is here to answer all these questions.


    What is osteopenia and osteoporosis?
    Osteopenia is a normal age-related form of bone loss. Osteopenia is the pre-cursor to osteoporosis and it's not a disease. If your DXA scan - explained in the next question - shows that you have osteopenia, your score will be between (-1.0 and -2.5).

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    Osteoporosis is an abnormal loss of protein and mineral content resulting in weak bone that is prone to fracture, generally in post-menopausal woman, but also men and younger women. Osteoporosis, is diagnosed with a DXA score below (-2.5) and it's a disease of low bone density or porous bone.


    How are osteopenia and osteoporosis diagnosed?

    Both osteopenia and osteoporosis can be diagnosed with a dual energy x-ray absorptiometric (DXA) scan. This test is very simple and takes no more than 15 minutes to complete at an imaging center. For follow-up scans always use the same scanner and technician, if you can, due to the variability of these tests.


    What is it like to live with these conditions?

    Both osteopenia and osteoporosis are silent diseases meaning they have no outward symptoms, until you've fracture a bone. Once a fracture occurs, then it can be very painful.


    Stress is normal with this diagnosis, but with time it will dissipate.


    If you decide to take one of the FDA approved medications, there can be side effects, but not all patients will experience them.


    We are often told that diet can play a role in preventing osteoporosis. What do you need to include in your diet to strengthen your bones? What if you can't have dairy products due to e.g., lactose intolerance or milk allergy?

    A diet rich in fruits, vegetables, protein, dairy and bone building supplements are crucial to our bone health.


    If you are lactose intolerant or have a milk allergy, substitute green leafy vegetables, high in calcium, to offset the exclusion of dairy products. Also, many foods are now fortified with calcium and D, so look for those that you like which could include, cereals, fruit juices, yogurt (if tolerated) and many other fortified food items.


    Vitamin D is important for a number of bodily processes, including heart health. As well, recent studies have shown that people living with RA often have a vitamin D deficiency and that there is a connection between chronic pain and low vitamin D. Many rheumatologists are therefore prescribing increased doses of vitamin D for their patients. What role does this vitamin play in preventing/managing osteoporosis and what can you do to increase it?

  • Vitamin D is vital to good strong healthy bones, because without it we can't absorb calcium properly. When we don't get enough vitamin D, we can lose more bone. Since there is a correlation between RA and vitamin D deficiency, then it's even more important to get the correct amount. If your D score is extremely low, your rheumatologist may prescribe a therapeutic dose of D2 (50,000-150,000 I U's or more) for a period of a few months to raise your score.


    Vitamin D recommendations from the National Osteoporosis Foundation (NOF) are 800-1,000 IU's of D3 a day, for those over 50 and 400-800 for those under 50. Many D experts feel this recommendation is extremely low, so check with your doctor for his or her advice based on your vitamin D test scores.

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    Ask your doctor to test your vitamin D levels so you'll know how much you need to take daily to increase your score. A 25 hydroxyvitamin D blood test will tell your doctor how much vitamin D you have stored.


    Calcium and other bone building supplements are also very important to include in your diet as well. The current RDA for calcium from the NOF is 1,000-1,200 milligrams (mg's) a day in divided doses of 500 mg's at each serving-for those over 50. The other necessary supplements are magnesium, phosphorous and vitamin K2.


    Weight bearing exercises are known to be an important part of preventing osteoporosis. However, RA can significantly affect your ability to get enough exercise due to pain and fatigue. As well, many types of exercise put a lot of stress on joints that are already hurting. Can you suggest alternatives that can strengthen bones without increasing pain?

    Since each of you would have individual needs when it comes to exercise, I'll include the recommended high and low impact weight-bearing exercises and modifications for those who need it, due to limited mobility and pain. A physical therapist can provide modifications to all the exercises below (National Osteoporosis Foundation, exercises 2010).


    High and Low Impact Exercise 



    Walking (treadmill/outside)

    High-impact aerobics

    Tai Chi

    Hiking/Stair climbing

    Elliptical training machines


    Low impact aerobics

    Jumping rope

    Stair-step machines




    Modifications for weight-bearing exercises may be necessary, so one good way to get both weight-bearing and low joint impact is water therapy. Finding a good physical therapist to help you design a routine is the place to start. Shallow-water-walking is considered weight-bearing, so for those with joint limitations and pain, look into something like this. Here's a link from our Chronic Pain Site on Water Therapy for compromised joint structure and pain. Don't forget that the normal things you do during the day, while on your feet, are also considered weight-bearing exercise. Housework, gardening, caring for your children or anything you do while on your feet - like activities of daily living - is good exercise.


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    If you have osteopenia or osteoporosis, what can you do to manage these conditions? Are medications the only way? What are the side effects of these types of medications?

    Many patients who have osteopenia choose natural treatment, because diet, exercise and supplements can improve your t-scores. However, this advice would be based on your doctor's recommendation depending on your medical history and fracture risk determined by a FRAX© score.


    If you have rheumatoid arthritis and osteoporosis, you're probably trying to figure out what to do for treatment. There are many types of drugs and various ways of taking them. Here's a list of all the current drugs for the treatment of osteoporosis on the market now.

    Oral Bisphosphonates (BP's) and SERMs

    Side Effects


    Side Effects

    Actonel® (daily, weekly and monthly)




    Muscle, bone and joint pain, atrial fibrillation, GERD, espohagitis, rare incidence of osteonecrosis of the jaw (ONJ), and spontaneous fractures

    HRT (oral, patch and creams, etc.)

    Blood clots, heart and stroke warnings, contraindicated for estrogen + and female reproductive cancers

    Boniva® (daily and monthly)


    Muscle, bone and joint pain, atrial fibrillation, GERD...(see above)

    Calcitonin® (daily nasal spray)

    Nasal irritation, head ache, nose bleeds and sinus irritation

    Fosamax® (weekly)

    Muscle, bone and joint pain, atrial fibrillation, GERD...(see above)

    Fosteum® (oral twice daily medicinal food)

    Nausea and upset stomach

    Evista® (daily)

    Blood clots, stoke and edema

    Protelos® (daily, EU approved only)

    Blood clots and edema

    Intravenous  Bisphosphonates

    Side Effects

    Injectable Anabolic, Biologic, Antiresorptive

    Side Effects


    Reclast® (annual)



    Reclast® (bi-annual)



    Flu-like symptoms, bone, joint, and muscle pain, atrial fibrillation, (ONJ), and spontaneous fractures

    Forteo® (daily sub-q, 2 year limit)



    Dizziness, hypotension, site bruising, rare incidence of osteosarcoma



    Prolia® (twice yearly injection-biologic)

    Skin infections, pain, elevated cholesterol, rare incidence of spontaneous fractures and ONJ

    Boniva® (quarterly)

    Flu-like symptoms, bone, joint, and muscle pain, atrial fibrillation, (ONJ)...(see above)

    Calcitonin® (every other day injection)


    Nausea, vomiting and diarrhea


    **As always, check with your physician to see which medications are right for you.**


    I hope this article helps to explain bone loss and the various diet, supplements, exercise and medication treatments.


    Thank you Pam for sharing this valuable information!



    You can read more of Lene's writing on The Seated View.

Published On: July 28, 2010