Rheumatoid arthritis & Osteoporosis
13 Oct 2020Rheumatoid arthritis and osteoporosis are two distinct conditions with differing mechanisms of onset. However, there are links between the two conditions, patients with RA are at an increased risk of developing osteoporosis. Both conditions can impede locomotion and compromise an individual’s ability to care for themselves if their conditions are severe
Rheumatoid arthritis is a long-term condition that affects the joints of the body. It causes inflammation, pain and loss of motion. It is a progressive condition which seriously impacts on quality of life. It is an autoimmune disease which is caused by the body attacking the lining of joints. Its exact causation is currently unknown but it is thought to involve genetic and environmental factors.
It can impede the ability of an individual to use medical devices themselves which can cause exacerbations of other conditions that the patient may suffer from. An example of this could be the successful use of inhalers to manage asthma or COPD.
Symptoms of rheumatoid arthritis can also include lethargy, fever, sweating, poor appetite and weight loss. It can contribute to the development of other conditions such as depression, cardiovascular disease and infections.
Medicinal intervention aims to relieve suffering caused by the disease and to modify the progression of the disease. Non-steroidal anti-inflammatory drugs are useful as analgesia to manage the pain associated with rheumatoid arthritis, they can also alleviate some of the stiffness experienced from this condition.
Aspirin and ibuprofen are commonly used to provide pain relief for sufferers of rheumatoid arthritis. Non-steroidal anti-inflammatory drugs may have side-effects including gastrointestinal discomfort, hypersensitivity, rash and skin reactions. Aspirin can cause bleeding due to its anti-coagulant effect and patients should be adequately counselled so that they understand this risk. Patients must understand that these drugs will only treat the symptoms of the condition and are not associated with an improvement in the progression of the disease.
Methotrexate, sulfasalazine, leflunomide and hydroxychloroquine are first-line treatments for the slowing of the progression of rheumatoid arthritis. These drugs are classified as disease modifying anti-rheumatic drugs (DMARD). They do not treat symptoms but they do slow the progression of the disease. As rheumatoid arthritis is a long-term progressive condition this can improve quality of life by reducing the rate at which symptoms worsen.
Methotrexate is most commonly used of these and is often given in combination with biological treatments if it does not achieve adequate clinical effect as a monotherapy. Blood tests must be done regularly when taking methotrexate. A weekly dose of methotrexate is given on the same day each week. Folic acid is often given as a co-medication on the days in which methotrexate is not taken.
Side effects of methotrexate treatment can include anaemia, diarrhoea, drowsiness, fatigue, gastrointestinal discomfort and increased risk of infection. Patients must be counselled adequately and understand that they must immediately report signs of blood disorders, liver toxicity and respiratory effects. These can be life-threatening complications of methotrexate treatment.
Sulfasalazine is another non-biological treatment option for the management of rheumatoid arthritis. Compliance can be an issue with this medication as it takes many months of treatment before the emergence of clinical effect. Side effects of this medication can include gastric disturbance, nausea, diarrhoea, dizziness, fever, headache, skin reactions and vomiting.
Biological treatments are newer developments in the treatment of rheumatoid arthritis. These are complex medicinal products that act specifically on biological processes to achieve their clinical effect. Infliximab is a monoclonal antibody which is used in the treatment of rheumatoid arthritis. A monoclonal antibody is a manufactured protein which provides a targeted response. Infliximab is used in the treatment of rheumatoid arthritis because it inhibits the actions of a protein called tumour necrosis factor alpha. This is a cell signalling protein which is responsible for the mediation of a number of cell functions that lead to cell death. Blockade of this protein with infliximab is associated with impeded disease progression and a reduction in symptoms of the disease.
As infliximab is a chimeric monoclonal antibody it can generate a dangerous immune response in patients that it is given to. Patients are more susceptible to infection when they are receiving treatment with infliximab and they must report any signs of infection to a doctor immediately.
Osteoporosis is a disease characterised by a reduction in bone density which increases the risk of fractures. The disease is typically diagnosed after a minor fall in which a fracture occurs. It is a disease that is associated with advanced age and occurs with more frequency as age increases.
Women are at a higher risk of osteoporosis as oestrogen affects the development of bone. Following menopause, and the associated drop in oestrogen production, there is a more rapid loss of bone. Other potential contributing factors can include smoking, alcohol, hyperthyroidism, genetic causes, long-term treatment with some medications, eating disorders and a sedentary lifestyle. The presence of the disease can be confirmed by measuring the bone density of a patient and comparing this to the bone density of a healthy adult. This scan is called a DEXA scan and utilises low energy x-rays.
There are a number of medications that are used in the treatment of osteoporosis. Vitamin D and calcium are necessary for adequate bone density. Dietary and lifestyle factors increase a patient’s risk of developing osteoporosis through the deficiency of one, or both, of these substances.
Colecalciferol can be given to increase the levels of vitamin D in the patient. This is especially useful if a patient is unable to adequately access the sun as the body synthesises this substance when exposed to sunlight. Older people in care home settings may not have adequately access to the outdoors and using this medication can avoid the development of vitamin D deficiency which can lead to osteoporosis. Side effects of this medication can include abdominal pain, headache, hypercalcaemia, hypercalciuria, nausea and skin reactions.
Calcium supplementation can form an important response to osteoporosis. If dietary intake of calcium is insufficient then osteoporosis will develop due to the body’s diminished ability to replace lost bone. This deficiency can be tackled with medication such as calcichew tablets. These are tablets which contain calcium and can be used to replenish low levels of this substance in the body. Side effects of these medications may include constipation, diarrhoea, hypercalcaemia and nausea.
Biphosphonate medications can be taken to slow the rate of bone loss and try to prevent fractures and progression of osteoporosis. Risedronate can be taken once weekly as a tablet. Patients must be adequately counselled with this medication as it can cause irritation to the oesophagus if taken incorrectly. Patients must be told to sit upright or stand for 30 minutes after taking the medication. They should not take any food or water for between 30 minutes and 2 hours after taking the medication.
Denosumab is a monoclonal antibody that prevents the formation of osteoclasts which decreases the rate at which bone is lost. It is a subcutaneous injection that is given infrequently to treat osteoporosis. It is regarded as a safe medication and reduces risk of fracture and improves bone density. Side effects can include skin infections and low blood calcium levels.
A doctor will assess the suitability of different treatment options for each patient and develop a plan in consultation with other healthcare professionals to treat osteoporosis.