Osteoporosis in patients with rheumatoid arthritis: an update in epidemiology, pathogenesis, and fracture prevention

ABSTRACT

Introduction

Rheumatoid arthritis (RA) is a chronic disabling disease characterized by a symmetrical articular involvement due to ongoing joint inflammation, if left insufficiently treated. Local and generalized bone loss is one of the main extra-articular complications of RA and leads to an increased risk for fragility fractures, which further impair functional ability, quality of life, and life expectancy. Therefore, there is an urgent need for good fracture risk management in the vulnerable RA patient.

Areas covered

The authors review: the epidemiology and pathophysiology (i.e. risk factors) of osteoporosis (OP), fracture, and vertebral fracture risk assessment, the effects of anti-rheumatic drugs on bone loss, pharmacological treatment of OP in RA including both bisphosphonates (BP) and newer drugs including anti-resorptives and osteoanabolic treatment options.

Expert opinion

Patients with active RA have elevated bone resorption and local bone loss. Moreover, these patients are at increased risk for generalized bone loss, vertebral and non-vertebral fractures. Since general risk factors (such as low BMI, fall risk) and RA-related factors play a role, optimal fracture prevention in RA patients is based on optimal diagnostics based on both of these factors, and on the use of adequate non-medical and medical treatment options.

KEYWORDS:

• Fracture prevention
• osteoporosis
• rheumatoid arthritis

Article highlights

• Rheumatoid arthritis is not only characterized by general bone loss but also local peripheral bone loss at the site of inflammation and general bone loss.

• Vertebral and Non-vertebral Fracture risk is doubled in RA patients.

• Optimal fracture risk assessment should not only include BMD assessment but also vertebral fracture assessment and fracture risk evaluation (e.g. the use of FRAX tool).

• Treatment of osteoporosis in rheumatoid arthritis should include not only pharmacological treatment but also non-pharmacological treatment options.

• In every rheumatoid arthritis patient clinicians should aim at the lowest possible disease activity to prevent bone loss and to reduce fracture risk.

This box summarizes the key points contained in the article.

Declaration of interest

HG Raterman has received an educational grant from UCB Pharm as well as consultancy fees from AbbVie, Amgen, Celgene, and Sanofi Genzyme. IEM Bultink has received consultancy and/or speaker fees from Eli Lilly and Company, Merck Sharp and Dohme, Amgen, UCB Pharma, Roche, and Sanofi Genzyme. Finally, WF Lems has received a grant from Pfizer Inc as well as consultancy fees from Merck Sharp and Dohme, Amgen Inc, Eli Lilly and Company, Pfizer and UCB Pharma. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.