Common Questions
How do rheumatoid arthritis and other inflammatory diseases affect bone density?
Systemic inflammatory and autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus, scleroderma, mixed connective tissue disease, ulcerative colitis and Crohn's disease, have all been associated with decreased bone mineral density and increased fracture risk via multifactorial mechanisms (1-4). While corticosteroid use in all these diseases has been shown to decrease BMD, many pro-inflammatory cytokines have been shown to promote bone resorption. Hypogonadism and immobilization also contribute to decreased BMD in these diseases. Malabsorption, especially of vitamin D, affects BMD in inflammatory bowel disease.
Rheumatoid arthritis affects bone density through generalized osteopenia, as seen in other inflammatory diseases, periarticular osteopenia and focal subchondral erosions. The synovial tissue proliferation in rheumatoid arthritis promotes the development of osteoclast-like cells from mononuclear cell precursors, which then cause focal osteolysis at the articular surfaces. This inflammatory synovial process extends to the periarticular bone and marrow, promoting increased osteoclast activity and subsequent osteopenia along the periarticular surfaces (1).
Measures to prevent osteopenia and osteoporosis should be pursued in all patients with systemic inflammatory and autoimmune diseases as addressed by the American Gastroenterological Association and American College of Rheumatology guidelines (5,6).
- Favus M (ed). Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. Lippencott, Williams & Wilkins: Philadelphia 1999; Fourth ed.
- Boyanov M, Robeva R, Popivanov P. Bone mineral density changes in women with systemic lupus erythematosus. Clinical Rheumatology 2003; 22: 213-217.
- Bodolay E, Bettembuk P, Balogh �, Szekanecz Z. Osteoporosis in mixed connective tissue disease. Clinical Rheumatology 2003; 22: 213-217.
- Van Staa TP, Cooper C, Samuels Brusse L, Leufkens H, Javaid MK, Arden N. Inflammatory bowel disease and the risk of fracture. Gastroenterology 2003; 125;6: 1496-1503.
- American College of Rheumatology. Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis and Rheumatism 2001; 44;7: 1496-1503.
- American Gastroenterological Association. American Gastroenterological Association Medical Position Statement: Guidelines on osteoporosis in gastrointestinal diseases. Gastroenterology 2003; 124;3: 791-794.