Osteoporosis in Rheumatic Diseases: Risk Factors and Prevention

Introduction

The chronic inflammation and damage to different bodily parts are caused by rheumatoid arthritis, lupus, and other rheumatic disorders. They may have an impact on soft tissues, muscles, and bones. People with rheumatic disorders frequently have osteoporosis, a condition where bones weaken and break easily. A test for bone density is used to diagnose osteoporosis. Because it can result in fractures, it is a major problem. Long-term conditions, including osteoporosis and cardiac difficulties, are common in people with rheumatic disorders. Through inflammation, a number of risk factors, and drugs, particularly steroids, these disorders can weaken bones. Although osteoporosis does not often have noticeable symptoms, it nonetheless lowers the quality of life. Many people with rheumatoid arthritis have osteoporosis that is brought on by drugs. Even so, the majority of them receive inadequate diagnosis and care.

What Is the Relationship Between Osteoporosis and Systemic Lupus Erythematosus (SLE)?

• Differences in Prevalence and Gender: SLE is a multi-organ illness that is complex. Bone problems are common in SLE patients. Research indicates that compared to healthy persons, SLE patients experience a higher frequency of bone loss. Both osteopenia (weaker bones than usual) and osteoporosis (OP) are common. Patients with low body mass, long-term disease damage, and steroid treatment who are premenopausal SLE women are at risk. OP is prevalent in postmenopausal SLE patients who have taken steroids for a long time. The findings of various studies vary when it comes to men with SLE. While some exhibit little bone loss, some do, particularly in the femoral neck and spine, show lower bone density. Children with SLE are particularly vulnerable, as they have a greater chance of developing OP in their early adult years.

• Risk Factors for SLE-Related Osteoporosis: OP in SLE is caused by a number of reasons, including immunological reactions, inflammation, metabolic problems, and pharmaceutical side effects.

  • Inflammation: Bones are affected by inflammation brought on by active SLE. Bone loss is caused by inflammatory markers such as IL-6 and TNF-α. Osteoclast cells that break down bone activate more when these indicators are present at higher levels in SLE patients.

  • Immune Responses: In people with SLE, autoantibodies may deteriorate bone density. Anti-SSA and anti-Sm antibodies, for example, have been connected to bone loss. Reduced bone density is correlated with increased disease activity.

  • Metabolic Factors: Less thyroid function, elevated homocysteine levels, and a lack of vitamin D all contribute to bone loss in SLE. Many SLE patients lack enough vitamin D because of things like medication use and avoiding the sun.

  • Conventional Factors: Postmenopausal state, low body weight, and age all raise the risk of osteoporosis. Depending on the race, ethnicity may also be important. Bone density is influenced by hormonal variables, particularly low levels of dehydroepiandrosterone sulfate.

  • Medication: Although steroids (GCs) are frequently used to treat SLE, they can cause bone loss. GCs have two effects: they both reduce inflammation and weaken bones. The use of Hydroxychloroquine (HCQ) affects vitamin D levels. Other medications that can deteriorate bone health include Tacrolimus, Methotrexate, Cyclosporine A, and certain anticoagulants.

How Does Osteoporosis Manifest in Rheumatoid Arthritis (RA)?

• Gender Variations in Rheumatoid Arthritis (RA) Patients' Prevalence: RA is a chronic inflammatory disease that mostly affects the joints and can cause damage to them. Different aspects of RA damage bones, such as broad bone weakening and localized bone loss close to inflamed joints. The prevalence of RA is higher in women aged 20 to 70, with a twofold increase in risk. Osteoporosis (OP) is frequent in RA, with rates as high as 31.5 percent in women between the ages of 60 and 70. In comparison to women, men with RA also have a modest decrease in bone density, particularly as they age.

• RA Patients' Risk Factors for Osteoporosis

  • Factors Associated with Disease: Inflammation and bone loss are associated with RA. Proinflammatory cytokines that are generated during inflammation, such as TNF-α, IL-1, and IL-6, promote bone resorption and are linked to osteoporosis. Bone loss in RA is a consequence of autoantibodies such as RF and ACPA. The course and intensity of the disease also affect bone loss; active RA is associated with a greater decrease in bone density.

  • Medication and Therapy: When corticosteroids (GCs) are used to treat RA, bone loss may occur, particularly at high dosages. Low doses, however, help decrease inflammation even when they harm bone. Biological agents, in particular, are disease-modifying antirheumatic medications (DMARDs) that promote bone health by lowering bone resorption and managing inflammation. Although the overall effect of several classic DMARDs, such as MTX and LEF, on bone metabolism is complex, it is unclear how they affect OP in RA overall.

  • Conventional Risk Factors: Men and women with RA who are postmenopausal are susceptible to OP. Female gender, advancing age, postmenopausal status, low body mass index (BMI), low weight, and family history of OP are risk factors. These elements have a part in RA sufferers' weakening of the bones.

What Are the Key Aspects of Osteoporosis Development in Different Types of Spondyloarthritis (SpA)?

A collection of inflammatory conditions affecting the joints together, referred to as spondyloarthritis (SpA), include ankylosing spondylitis (AS), psoriatic arthritis, reactive arthritis, enteropathic arthritis, and undifferentiated spondyloarthropathy.

• Typical Features of SpA:

  • Common characteristics of these illnesses include comparable results from laboratory testing, clinical symptoms, and medical imaging.

  • To differing degrees, they can also impact the spine, peripheral joints, and sacroiliac joints.

• Prevalence and Variations by Gender:

  • The most prevalent kind of SpA, known as ankylosing spondylitis (AS), mostly affects the sacroiliac joints and spine.

  • Osteophytes, or new bone growth, are frequently caused by AS and might make it difficult to identify changes in bone mineral density (BMD).

  • Early AS can result in osteoporosis (OP), a low bone density disorder with variable prevalence rates.

  • AS mainly affects young men and can cause BMD to decline, especially in the femoral neck and spine.

• Risk Elements for OP in AS:

  • Proinflammatory cytokines contribute to bone resorption, and inflammation is a major factor in the development of OP in AS.

  • Important cytokines consist of TNF-α, IL-1, and IL-6.

  • OP is linked to variables such as the length of the disease, mobility (or immobility), and the production of syndesmophytes.

  • Moreover, established risk variables (such as age, race, family history, and dietary habits) and genetics play a role in OP in AS.

• Treatments for AS

  • Treatment for AS includes biological agents (for example, Infliximab, Etanercept, Adalimumab, Anakinra), corticosteroids, nonsteroidal anti-inflammatory medications (NSAIDs), and disease-modifying antirheumatic medicines (DMARDs).

  • Because NSAIDs prevent prostaglandin synthesis, which is important for bone development, they may have an impact on bone health.

  • TNF-α blockers help stop bone loss in AS patients that is linked to systemic inflammation.

  • Since corticosteroids are less frequently used for AS, little research has been done on how they affect bone density.

How Is Osteoporosis (OP) Manifested in Additional SpA Types?

• Bone alterations are also present in other types of SpA, such as psoriatic arthritis (PsA).

• PsA patients typically have higher bone mineral density (BMD) readings than individuals with rheumatoid arthritis, and they may undergo periarticular and total bone loss.

• Regarding bone turnover indicators and bone loss in PsA, there is contradicting evidence.

• According to certain research, OP is linked to a longer course of the disease and worse impairment in PsA patients.

• Ankylosing spondylitis (AS) is the most prevalent type of inflammatory joint disease under the umbrella of spondyloarthritis (SpA).

• Osteoporosis (OP) can result from several conditions that have similar symptoms, particularly in AS patients. Inflammation and genetics are two factors that affect OP in SpA. Medication choices for treating bone health issues include TNF-α blockers and NSAIDs. Changes in bone are also present in other kinds of SpA, such as psoriatic arthritis, with OP being more common in individuals with longer illness duration and disability.

Which Other Rheumatic Conditions May Exhibit Manifestations of Osteoporosis?

• Systemic sclerosis (SSc) and Osteoporosis: The disease known as systemic sclerosis (SSc) causes the skin to thicken and become harder. Diffuse and restricted cutaneous SSc are the two forms. According to studies, people with SSc are more likely to fracture and develop osteoporosis (OP). Bone loss in SSc is caused by a number of variables, including low BMI, menopause, age, and gender. The precise causes are still being investigated, though.

• Osteoporosis in Polymyositis and Dermatomyositis (DM and PM): Rashes and muscle weakness are symptoms of two uncommon muscle illnesses called dermatomyositis (DM) and polymyositis (PM). Adult DM or PM patients develop fractures and OP in about 25 percent of cases. Due to factors such as low body mass and specific therapies, children with juvenile diabetes mellitus frequently have reduced bone density, particularly in the hip.

• Behcet’s Disease Osteoporosis (BD): Multisystem vasculitis is what Behcet's Disease (BD) is. Research reveals contradictory findings about OP and BD. Some claim that BD patients have reduced bone density, particularly in the lumbar spine. It is possible that elevated cytokine levels in BD affect bone health, but additional research is required.

Patients who have BD, DM, PM, or SSc are more susceptible to osteoporosis and fractures. Age, body mass, and certain cytokines are among the variables that affect bone loss. The intricate connection between these rheumatic illnesses and osteoporosis is still being studied.

How to Prevent Osteoporosis in Rheumatic Diseases?

In those with rheumatic disorders, osteoporosis can be prevented by a combination of medicine, lifestyle changes, and routine monitoring. Due to inflammation, decreased physical activity, and the use of certain medications like corticosteroids, rheumatic disorders like lupus, ankylosing spondylitis, and rheumatoid arthritis might raise the risk of osteoporosis. The following are some methods to help people with rheumatic disorders avoid osteoporosis:

• Speak With a Rheumatologist:

  • Frequent Monitoring: Individuals with rheumatic diseases should see a rheumatologist on a regular basis so that they can monitor the disease's activity and prescribe the right drugs.

• Medication Management:

  • Vitamin D and Calcium Supplements: These are necessary for strong bones. To find the appropriate dosage, speak with a healthcare professional.

  • Bisphosphonates: These drugs have the ability to stop bone deterioration. They may be prescribed by the healthcare professional if needed.

  • Biologic Therapy: When compared to conventional treatments, several more recent therapies for rheumatic disorders may include a reduced risk of bone loss.

• Modifications to Lifestyle:

  • Frequent Exercise: Weight-bearing activities that build bones and enhance general health include dancing, walking, and resistance training. To develop a safe workout program, speak with a trainer or physical therapist.

  • Healthy Diet: It is important to have a balanced diet high in calcium and vitamin D. Add fish, almonds, leafy greens, and dairy products to the diet.

  • Give Up Smoking and Drink Moderately: Bone deterioration can result from heavy alcohol intake and smoking. Reduce alcohol consumption and give up smoking to support bone health.

  • Fall Prevention: Fractures from falls are more common in those with osteoporosis. To reduce falls, eliminate tripping risks at home, put in handrails, and use non-slip mats.

• Routine Bone Density Testing: To keep an eye on the condition of their bones, people with rheumatic disorders, particularly those undergoing long-term corticosteroid therapy, should have routine bone density examinations (DEXA scans).

• Control the Inflammation:

  • DMARDs, or Disease-Modifying Antirheumatic Medications: These drugs may lessen the risk of osteoporosis by lowering inflammation and delaying the development of rheumatic disorders.

  • Steroid Management: To reduce bone loss, healthcare professionals should use the lowest effective dose of corticosteroids for the shortest amount of time if they are required to manage symptoms.

• Regular Follow-Ups: To track the status of one's bone health and modify the treatment plan as needed, schedule routine follow-up visits with the rheumatologist and bone health specialist.

Conclusion

In several rheumatic disorders, including systemic sclerosis (SSc), dermatomyositis (DM), or polymyositis (PM), and Behcet's Disease (BD), osteoporosis is a prevalent problem. Osteoporosis and fractures are potential risks for patients with these disorders; age, body mass, and disease-specific variables such as cytokine levels can all play a role. It is obvious that bone health is important for people with certain rheumatic disorders, even if additional research is required to completely understand the relationships.