Bone Health in Rheumatoid Arthritis: An Update

Rheumatoid arthritis (RA) affects approximately 1% of the global population and is the most common inflammatory arthritis in adults. RA is well established as a significant risk factor for secondary osteoporosis (OP). Bone loss in RA occurs at three anatomically distinct levels: periarticular osteopenia, marginal erosions at the joint periphery, and generalised systemic OP. Understanding the complex mechanism underlying osteoclast-mediated bone loss in RA is essential for the development of targeted interventions, while identification of individuals at risk of OP and fracture remains paramount. This review will highlight recent advances in these areas.

The cornerstone of bone loss management and prevention in RA remains disease activity control and reduction of inflammation. In this review, we will discuss the most recent advances in understanding the mechanism of bone loss in RA, the skeletal effects of current RA and anti-OP therapies in the RA population. We also highlight areas where future research may be focused to inform best management of bone health in these patients. RA associated bone loss remains a substantial contributor to morbidity, highlighting the need for improved fracture risk stratification, optimisation of therapeutic approaches, and greater standardisation of monitoring strategies. Critical evidence gaps persist, including the absence of validated RA specific fracture risk thresholds to guide treatment decisions and the lack of prospective randomised trials comparing bone protective agents in RA associated osteoporosis. Data in men with RA remain limited, and further work is required to delineate the relative skeletal effects of biologic therapies. Additionally, optimal DXA monitoring intervals for patients with stable disease on DMARD therapy are not well defined, contributing to considerable variation in clinical practice. Addressing these unmet needs will be essential to advancing bone health management and reducing fracture burden in individuals with RA.