How can I protect my bone health as a 65-year-old woman with RA?

Question

Hello doctor,

I am a 65-year-old female recently diagnosed with osteoporosis after a DEXA (Dual-energy X-ray) scan showed a T-score of - 2.9 at the lumbar spine and - 2.6 at the hip. I also have had longstanding rheumatoid arthritis (RA) for the past 12 years and have been on low-dose Prednisone (5 milligrams daily) and Methotrexate (15 milligrams per week) to control my joint symptoms.

Over the past year, I have had two fractures, one at the wrist and a recent vertebral compression fracture that happened with minimal trauma. My calcium level is 8.7 milligrams per deciliter, and vitamin D is borderline at 22 nanograms per milliliter.

I am now being advised to start either Denosumab or Teriparatide, but I am worried about how these will interact with my current RA medications and immune system. I am also experiencing daily back pain and stiffness. Please tell me.

Is it safe to continue steroids when they worsen bone loss?
Can biologics for RA affect my bone density?
Should I change my RA treatment plan to protect my bones better?
How do I manage pain without worsening bone health?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and can understand your concern.

You are dealing with severe osteoporosis (T-score -2.9 spine, -2.6 hip) and rheumatoid arthritis (RA). Also, two fractures, as your bones are fragile and need urgent treatment. The treatment options that you have are:

Denosumab (a human monoclonal antibody): It slows bone loss and is safe with RA medicines, given every six months.
Teriparatide (a form of parathyroid hormone): It builds bone and is better for spinal fractures. A daily injection for two years is needed.

Both are safe with Methotrexate (a chemotherapy agent) and Prednisone (a steroid), but vitamin D (currently low at 22 nanograms per milliliter) and calcium must be corrected first. Prednisone worsens bone loss, even at low doses. Aim to reduce or stop it, but Methotrexate is bone-safe.

Biologics (like TNF (tumor necrosis factor) or IL-6 (interleukin) blockers) may help both RA and bone health. You can ask your rheumatologist if you can switch. For pain management, you can use Acetaminophen (a painkiller) or short-term Calcitonin (a hormone) spray for back pain. You should avoid long-term NSAIDs (non-steroidal anti-inflammatory drugs). Start gentle physical therapy for strength, posture, and stiffness.

You should focus on the replenishment of vitamin D and calcium. Start Denosumab or Teriparatide. Discuss with your doctor about biologic RA therapy and tapering the dose of steroids.

I hope this information helps you.

Feel free to ask further queries.

Thank you.