One of the challenges in trying to improve BMD in patients with osteopenia or osteoporosis is that most of the individuals who we would want to treat are asymptomatic and have not yet had an event. It is much like the tale of “the axe in the ceiling.” The axe is going to fall from the ceiling, but when? It can become a significant problem, and we have never been as successful in treating patients as we would have liked.

The risks associated with glucocorticoids really deserve special emphasis. Even low doses over a long period are really bad for bone health, and once you start a patient with RA on steroids, it can be difficult to taper them off. An alternative is joint injections to help patients get through tough times and flares. However, in addition to reducing the dose of glucocorticoids or getting patients off of them completely, we also need to consider our treatments for RA. It is a good idea to use a biologic because you do not get that bone-protective effect from methotrexate or leflunomide.

With respect to antiresorptive therapies, the oral bisphosphonates may be difficult to tolerate. Additionally, there was a tremendous amount of bad press on bisphosphonates and quite a bit of fear regarding atypical femoral fractures and osteonecrosis of the jaw, and, although very rare, patients have oftentimes heard more about these risks than the benefits of the drugs. The availability of zoledronic acid that is administered once yearly for 3 years is good to have, although the benefit is not as complete as we would like when patients do not receive their third dose. The other issue with antiresorptive therapies is that they have a limited use because you are not building normal bone. So, after 3 or 5 years of use, you should stop using them, and you need to switch to an alternative, which underscores the need for additional therapies. Denosumab has shown promise for slowing radiographic damage in RA and improving BMD in patients with RA, and it is easy to administer every 6 months and has benefit in terms of joint erosions in addition to treating the osteopenia or osteoporosis. Teriparatide is also a very good agent, but it requires daily injections, and, unless the patient has had a fracture and/or they are highly motivated, I think that the preference would be for less-frequent dosing. Adequate vitamin D, calcium supplementation, and estrogen may be helpful, but none of these interventions on their own achieve the magnitude of fracture risk reduction that is desirable in high-risk patients.