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Prevention and Management of Bone Erosion with Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease that causes joint pain, stiffness, and damage throughout the body. The joint damage caused by this condition usually occurs on both sides of the body. This chronic disease not only causes joint inflammation, but it can also cause damage and deformity of the joints. The damage is the result of bone erosion. Bone erosion is one of the main features of rheumatoid arthritis. While there is no cure for rheumatoid arthritis, there are treatments available to manage and slow down the progression of bone erosion. Here’s everything you need to know about the prevention and management of bone erosion with rheumatoid arthritis.

Rheumatoid Arthritis and Bone Erosion

Rheumatoid arthritis is a type of autoimmune disorder that causes joint pain, stiffness, and damage throughout the body. According to the American College of Rheumatology, this chronic inflammatory disease affects over 1.3 million people in the United States alone.(1,2,3) In rheumatoid arthritis, your immune system starts to mistakenly attack the body’s tissues and cells. This condition is different from other immune disorders in that it tends to primarily affect the lining of the joints. The joint damage caused by rheumatoid arthritis tends to happen equally on both sides of the body. This means that if a joint is affected in one of your legs or arms, the same joint in the other leg or arm will also be affected. This is one of the main distinguishing features of rheumatoid arthritis from other types of arthritis, such as osteoarthritis.(4,5,6)

Being a progressive disease, rheumatoid arthritis not only causes inflammation of the joints, but it can also cause damage and deformity of the joints. Damage caused to the joints is usually a result of erosion of the bones.

In fact, bone erosion is one of the main features of rheumatoid arthritis. The risk of bone erosion increases as the disease becomes more severe and can eventually be characterized by the loss of bone in various parts of the body.(7,8)

While there is still no cure for rheumatoid arthritis, there are many treatments that help you manage and even slow down the progression of bone erosion caused by this condition.

Why Does Bone Erosion Happen In Rheumatoid Arthritis?

Rheumatoid arthritis is known to cause chronic inflammation in the body, which is what is believed to leads to the gradual erosion of your bones. Some of the typical symptoms of rheumatoid arthritis include:

  • Joint Stiffness
  • Joint Pain
  • Swollen Joints
  • Loss of Joint Function and Deformities

Many people also experience loss of appetite and fatigue. The symptoms of rheumatoid arthritis can vary from being mild to severe. It is essential that you do not ignore your signs, even if they tend to come and go. Being aware of and recognizing the early symptoms of rheumatoid arthritis can help you and your doctor better treat your condition and slow down bone erosion.(9)

Rheumatoid arthritis tends to usually affect the smaller joints of the body like your feet, hands, and fingers. So, bone erosion is also likely to occur in these joints itself. However, this does not mean that rheumatoid arthritis cannot affect other joints of the body. It can also impact your elbows, hips, knees, and shoulders.

Bone erosion in rheumatoid arthritis is believed to happen because of chronic inflammation that stimulates osteoclasts in the body. Osteoclasts are cells that are responsible for breaking down bone tissue. This leads to bone resorption.(10,11)

Bone resorption is part of the body’s normal regulatory process of minerals that are needed to balance repair, maintenance, and remodeling of bones. This process, though, becomes unbalanced in people who have rheumatoid arthritis, leading to a rapid breakdown of mineralized tissue within the body.

Bone erosion in rheumatoid arthritis can also happen when there is a massive number of inflammatory cytokines in the body. Your cells start releasing small proteins known as cytokines to boost the immune system to fight against diseases. In some cases, though, the body releases a huge amount of cytokines, which can lead to swelling and inflammation. Over a period of time, this can eventually lead to bone, joint, and tissue damage.(12,13)

Management of Bone Erosion in Rheumatoid Arthritis

There is no time frame for when bone erosion can occur in people with rheumatoid arthritis. It can develop quite early on and get progressively worse over time. In some people, erosion of the bones can begin within just weeks of getting a diagnosis of rheumatoid arthritis. Nearly 20 percent of people who are diagnosed with rheumatoid arthritis start having bone erosion after eight weeks. After a period of one year, almost 60% of people begin experiencing bone erosions.(14)

Due to the fact that progressive erosion of the bones can lead to disability, slowing down or at least healing the erosion can help improve your quality of life to a great extent. However, once bone erosion occurs, it is usually not reversible. However, it is not impossible.

Some studies have linked the use of a class of drugs known as disease-modifying antirheumatic drugs (DMARDs) with the capability to reduce the progression or advancement of bone erosion.(15)

It is essential to realize that any chance you may have of healing or repairing bone erosion needs to begin with controlling the inflammation inside the body. DMARDs are usually the first line of treatment for rheumatoid arthritis. Unlike pain medication that can only treat the symptoms of rheumatoid arthritis like joint stiffness and pain, DMARDs are medications that target certain cells in the immune system that are known to promote inflammation.(16)

Treating rheumatoid arthritis with DMARDs can help the disease enter a phase of remission and, therefore, also slow down the progression of the disease. These medications are also used for stopping bone erosion and for repairing any existing bone erosion. However, DMARDs or any other drugs are unlikely to ever fully repair any damaged bones.

The conventional DMARDs are made up of injectable and oral medications such as methotrexate.(17) If DMARDs fail to control inflammation and you do not experience much difference in your condition, your doctor may decide you switch you to a biologic drug. Biologics are a different form of DMARD, and some of the common biologics used to treat rheumatoid arthritis include:

  • Abatacept (brand name: Orencia)
  • Adalimumab (brand name: Humira)
  • Certolizumab (brand name: Cimzia)
  • Etanercept (brand name: Enbrel)
  • Golimumab (brand name: Simponi)
  • Infliximab (brand name: Remicade)

Apart from continuing to target the specific cells in the immune system that cause inflammation, biologics also block the production of chemicals like cytokines that promote or signal inflammation within the body.

In people with rheumatoid arthritis, once the inflammation is under control, it is possible to slow down and even heal bone erosion. Controlling inflammation is also necessary because less inflammation in the body helps lower the stimulation of osteoclasts, which is also known to slow down bone erosion.

In some cases, doctors also recommend therapy to suppress these osteoclasts. This may include anti-resorptive drugs that help treat bone loss and other bone-related problems. Examples include bisphosphonates and denosumab (brand names: Xgeva and Prolia).(18,19)

Is it Possible to Prevent Bone Erosion in Rheumatoid Arthritis?

Bone erosion is one of the main characteristics of rheumatoid arthritis, and unfortunately, it might not always be possible to fully prevent bone erosion. However, if you treat inflammation at an early stage, it increases the chances of protecting your joints. If you experience symptoms like joint pain and stiffness, chronic fatigue, weight loss, redness, or even a low-grade fever that tends to persist, you should not waste time in consulting a doctor.(20)

At the same time, studies have shown a link between bone erosion and having low bone mineral density. This is why taking care of yourself and maintaining healthy bones is very important in preventing or slowing down bone erosion.

Here are some ways in which you can strengthen your bones:

Exercise Regularly: Regularly exercise or physical activity will help strengthen your muscles and also strengthen your bones. However, don’t strain yourself all at once. Instead, you should begin slow and try to do a mix of cardio exercises and other strength-training activities. Even low-impact exercises like swimming, yoga and walking are good options to start with.

Take Calcium and Vitamin D Supplements: On average, adults need around 1000 milligrams of calcium every day and 600 international units (IU) of vitamin D every day. However, never start taking any supplements without consulting your doctor.

Get Your Medications Adjusted: If you are using certain medicines for treating inflammation for a long time, this may also cause damage to your bones. These include drugs like methotrexate and prednisone. You should talk to your doctor about lowering your dose or even switching to other medications once the inflammation has been managed effectively.

Quit Smoking and Drinking Alcohol: Tobacco use has been found to weaken your bones. Drinking too much alcohol also has the same effect on your bones.(21) You should seriously consider quitting smoking and reducing your alcohol intake. Men should restrict their alcohol intake to two drinks a day, while women should not have more than one drink in a day. You can always ask your doctor for help to quit smoking.


Bone erosion is a key feature of rheumatoid arthritis, and people living with this disease often develop erosion of their bones. Reducing inflammation that too at an early stage can help you not only feel better but also delay the progression of bone erosion. Starting treatment for rheumatoid arthritis as early as possible will help improve the quality of your life and also reduce the risk of joint deformation and disability.


  1. Rheumatology.org. 2021. Statistics. [online] Available at: <https://www.rheumatology.org/Learning-Center/Statistics/Prevalence-Statistics> [Accessed 1 May 2021].
  2. Firestein, G.S., 2003. Evolving concepts of rheumatoid arthritis. Nature, 423(6937), pp.356-361.
  3. McInnes, I.B. and Schett, G., 2011. The pathogenesis of rheumatoid arthritis. New England Journal of Medicine, 365(23), pp.2205-2219.
  4. Bresnihan, B., 1999. Pathogenesis of joint damage in rheumatoid arthritis. The Journal of rheumatology, 26(3), pp.717-719.
  5. Scott, D.L., Coulton, B.L. and Popert, A.J., 1986. Long term progression of joint damage in rheumatoid arthritis. Annals of the Rheumatic Diseases, 45(5), pp.373-378. Scott, D.L., Smith, C. and Kingsley, G., 2003.
  6. Joint damage and disability in rheumatoid arthritis: an updated systematic review. Clinical and experimental rheumatology, 21(5; SUPP 31), pp.S20-S27.
  7. Schett, G. and Gravallese, E., 2012. Bone erosion in rheumatoid arthritis: mechanisms, diagnosis and treatment. Nature Reviews Rheumatology, 8(11), p.656.
  8. Gravallese, E.M., 2002. Bone destruction in arthritis. Annals of the rheumatic diseases, 61(suppl 2), pp.ii84-ii86.
  9. Steinbrocker, O., Traeger, C.H. and Batterman, R.C., 1949. Therapeutic criteria in rheumatoid arthritis. Journal of the American Medical Association, 140(8), pp.659-662. Schett, G., 2007. Cells of the synovium in rheumatoid arthritis. Osteoclasts. Arthritis research & therapy, 9(1), pp.1-6.
  10. Sato, K. and Takayanagi, H., 2006. Osteoclasts, rheumatoid arthritis, and osteoimmunology. Current opinion in rheumatology, 18(4), pp.419-426.
  11. McInnes, I.B. and Schett, G., 2007. Cytokines in the pathogenesis of rheumatoid arthritis. Nature Reviews Immunology, 7(6), pp.429-442.
  12. Brennan, F.M. and McInnes, I.B., 2008. Evidence that cytokines play a role in rheumatoid arthritis. The Journal of clinical investigation, 118(11), pp.3537-3545.
  13. Panagopoulos, P.K. and Lambrou, G.I., 2018. Bone erosions in rheumatoid arthritis: recent developments in pathogenesis and therapeutic implications. Journal of musculoskeletal & neuronal interactions, 18(3), p.304.
  14. Sokka, T. and Hannonen, P., 2000. Healing of erosions in rheumatoid arthritis. Annals of the rheumatic diseases, 59(8), pp.647-649.
  15. Gaffo, A., Saag, K.G. and Curtis, J.R., 2006. Treatment of rheumatoid arthritis. American journal of health-system pharmacy, 63(24), pp.2451-2465.
  16. Œwierkot, J. and Szechiñski, J., 2006. Methotrexate in rheumatoid arthritis. Pharmacological reports, 58(473), pp.473-492.
  17. Chiu, Y.G. and Ritchlin, C.T., 2017. Denosumab: targeting the RANKL pathway to treat rheumatoid arthritis. Expert opinion on biological therapy, 17(1), pp.119-128.
  18. Page, A.A., 2016. Denosumab-Prolia and Xgeva AHM.
  19. Panagopoulos, P.K. and Lambrou, G.I., 2018. Bone erosions in rheumatoid arthritis: recent developments in pathogenesis and therapeutic implications. Journal of musculoskeletal & neuronal interactions, 18(3), p.304.
  20. Voigt, L.F., Koepsell, T.D., Nelson, J.L., Dugowson, C.E. and Daling, J.R., 1994. Smoking, obesity, alcohol consumption, and the risk of rheumatoid arthritis. Epidemiology, pp.525-532.

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Pramod Kerkar, M.D., FFARCSI, DA
Pramod Kerkar, M.D., FFARCSI, DA
Written, Edited or Reviewed By: Pramod Kerkar, M.D., FFARCSI, DA Pain Assist Inc. This article does not provide medical advice. See disclaimer
Last Modified On:July 3, 2021

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