Inflammation is Bad for Bone: Osteoporosis and Psoriatic Disease Transcript
“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”
Corinne: Hello! My name is Corinne Rutkowski and I’m here today with one of the country’s leading experts, rheumatologist Dr. Diana Sandler, to explore the relationship between osteoporosis and psoriasis, and why you may be at higher risk for developing this bone disease. Dr. Sandler is a rheumatologist at Endeavor Health in Chicago where she is also the Director of the Bone Health Center. She’s also a board member of the National Psoriasis Foundation. As a third year medical student at New York Institute of Technology College of Osteopathic Medicine, this is definitely a topic I’m interested in. Welcome Dr. Sandler! It’s a pleasure having you on Psound Bytes™.
Dr. Sandler: Thank you kindly. It's an honor to be here with you today.
Corinne: Let’s start our discussion with learning more about osteoporosis. Could you please tell us what is osteoporosis or osteopenia?
Dr. Sandler: Both osteoporosis and osteopenia tell us there's less bone density than in a young, healthy adult. That's how we compare them as to young, healthy adults. And we use bone density as a way to calculate risk of major bone fractures. And by major we mean big bones. So an arm, a hip, or a pelvis breaking could mean that later in life we can have less quality of life or life expectancy. So it's really the big bones from minimal impacts such as falling on ice. That's what we really worry about in fractures.
Corinne: And how would someone know they have osteoporosis? Are there any early symptoms prior to a bone fracture or is it more of a “silent” disease?
Dr. Sandler: So osteoporosis is a silent disease. There is no pain or other symptoms. However, if you had a major bone fracture or multiple fractures from minor injury, for example falling on ice that could be a sign that the bones are not as strong as they need to be. So if you broke a big bone like a hip or a wrist or an arm falling just from your standing height, that is concerning cause a person should be able to fall, get up and walk away. Of course, the most common way people find out is through their regular screening. Such as postmenopausal women at age 65 are recommended to get their first bone density test. Other risk factors particularly relevant to this audience are inflammation. So, for example, inflammation of the joints and gut, frequent steroid use, family history of osteoporosis, and especially if a parent broke a hip. So all of that would make us consider screening a person sooner to see if we can prevent a major fracture.
Corinne: And given your response, how is osteoporosis different from osteoarthritis? You know, many of us are familiar with osteoarthritis and often confuse it with osteoporosis.
Dr. Sandler: That is a question I wish more people would ask. So “osteo” refers to bone in Latin, and “arth” actually refers to joints. “Itis”, as you may know means inflammation. “Porosis” means something as porous or has holes in it. So when we combine it, osteoarthritis means disease of inflammation of the bone and joints, for example psoriatic arthritis. What we commonly think of as joint pain. Osteoporosis tells us that the bone is too porous. There's not enough of it to protect us from a break during a fall. The two are often confused, but they do go together because if a person has inflammation or arthritis a lot of times they will also have osteoporosis because inflammation is bad for bone.
Corinne: Thank you for that distinction Dr. Sandler. That’s good to know. And what is the diagnosis process like for osteoporosis? Is a bone density test needed to confirm the diagnosis and if so, when or how should that test be done? Is the test more of a prevention strategy?
Dr. Sandler: You'll often hear of a bone density scan or a DEXA is the other name for it, and it is a very simple, quick and painless test. So a patient will lay on a table with a pillow underneath their knees and a low dose X-ray arm moves over the patient for a few minutes and you're done. It's all open, not like a closed MRI at all, and usually lasts under 30 minutes. And so the test can give some interesting information. The question the test is answering is how far is your bone density compared to that of a young, healthy adult? As I always tell my patients, you know, your highest bone density you're ever going to have is age 20 to 30 and it all rolls downhill from there. The question is how far down did you roll and how fast did you do it? So there is a measure that the test gives you, known as a T score, which can be either normal (if it's within one standard deviation of normal bone), and the risk of fracture is low, and we don't worry about it. Osteopenia is when your bone density is between 1 to 2 1/2 standard deviations away from normal or lower than normal. So -1 to -2.4, and osteoporosis is what you’re called if you're 2.5 standard deviations or further away from normal. And again if you're normal, then the risk of fracture is low. You should be able to fall, bounce back up, and run away. In osteopenia, the risk of big fracture can still be low, moderate, or high. And that's where your doctor will help you decide do you need medicine early or not. And osteoporosis by definition means that the risk of major fracture is high and that treatment is warranted or at least a discussion. Typically, bone densities are done about two to five years apart, depending on the treatment path decided.
Corinne: I see, so who is more likely to develop osteoporosis? It is an equal opportunity disease or does it affect women more than men? If so, why?
Dr. Sandler: Women after menopause are higher risk than men because they no longer have their hormones to support bone health. So a woman may naturally lose about 2 to 3% of bone per year each year after menopause. Other risk factors include toxins to bones such as excessive alcohol, smoking, chemotherapy, hormone deprivation. So we see that in men who are getting treated for prostate cancer sometimes or women with breast cancer get aromatase inhibitors. Inflammation is a huge risk factor for osteoporosis, as are the steroids that we often use to treat the inflammation, and the either oral or injectable steroids are a high risk factor for losing bone. Low calcium and vitamin D intake due to diet or poor absorption are also risks as well as family history. Again, if a parent fractured a hip, we really worry more about that patient.
Corinne: And Dr. Sandler, you already mentioned some factors that play a role in the risk of osteoporosis. Are there any other risks associated with development that we should know about?
Dr. Sandler: So low activity when patients get under 7,000 steps per day also leads to lower bone quality. We are humans who are meant to move. We're not meant to sit in one place all day. So if you're sitting most of your day and you're getting under those 7,000 steps per day, the body says, why would I maintain this organ that takes so much energy? I'm just not going to bother.
Corinne: That's a good message everyone needs to hear. So I’m curious, is it possible to have osteoporosis or osteopenia and psoriatic arthritis together? What's the risk of osteoporosis for someone who has psoriasis?
Dr. Sandler: So I did a project with a resident last year where we went through the literature review and we found over 80 articles on this topic and unfortunately there's really no consensus whether patients with psoriasis only, meaning skin disease only, have an increased risk of osteoporosis. But of course certainly if you have other risk factors besides psoriasis, such as smoking or steroid use, that'll put you at risk just like we talked about. A lot more clear, though, for patients who have psoriatic arthritis because that's a sign of whole body or is what we call systemic inflammation where the inflammation is present everywhere. As I tell my patients the inflammatory arthritis you feel it in the joints, but the inflammation's everywhere so we have to be careful. And in those patients particularly, I would not wait until age 65 in women to screen them. I would do a bone density probably as soon as five years after menopause and for men significantly sooner than the recommended age 70 as well, because those patients are at higher risk for losing bone quicker. Let's face it, anyone with inflammation or inflammatory joint disease, also will find it hard to exercise regularly, so we do become more seated ducks and we've talked about exercise is very important. We know that psoriatic disease is a family of immune disease and it's closely related to inflammatory bowel disease such as Crohn's, which besides causing inflammation in the body also can cause a problem for absorbing nutrients leading to lower bone density because then you're not getting the calcium and the vitamin D that you need. So it's really a multi-factor problem.
Corinne: So Dr. Sandler, we know bone remodeling plays a role in psoriatic arthritis. Can you please explain the role of osteoclast and osteoblasts in osteoporosis? And is that possibly the connection between the two diseases?
Dr. Sandler: Yes. So here's a little bit of physiology. Here's a crash course in bone density. There are three types of cells that create bone. Osteoclast or C for cleaving. These cells break the bone down. Osteoblast, as in B for building which build the bone back up and then we have osteocytes which used to be osteoblasts, but they build up all this bone around themselves and now their only job is to maintain it. Our bones sustained impact from stress every day from our normal activities such as walking or playing sports. So bone should be and is in a constant state of turnover. The osteoclast and they come down and break old or injured bone down and then the osteoblasts get called in to lay down new healthy bone. And so the bone is constantly turning over. It is a very complicated balance of signaling and communication between these cells. It's tremendous to actually think about and when that balance is broken or one side is more active than the other, usually the osteoclasts outpace the osteoblast. You break the bone faster than you build it. Then we get the problem with bone quality and quantity.
Corinne: That's really interesting and a great way to explain the process.
Dr. Sandler: Thank you.
Corinne: I’m curious, is it possible to decrease the risk of osteoporosis by treating the inflammation associated with psoriasis and psoriatic arthritis?
Dr. Sandler: Yes, so as we already said, inflammation is bad for bone and the reason that our osteoclasts, the ones that break the bone down, actually come from the immune system and they're actually the immune system cells that used to be part of the immune system itself known as macrophages. And so when there is inappropriate or prolonged inflammation, such as with psoriatic arthritis or other types of inflammation, these osteoclasts they get over stimulated and they do their job more vigorously than they should. They kind of get signaled by their old mothership, and so they have more activity than they should. When we get steroids to treat this inflammation that also decreases bone density, and it blocks vitamin D and calcium absorption in the gut, kind of giving you a double whammy. Finally when you see a patient in the state of inflammation you realize how exhausted they are. I mean, the fatigue is incredible. It's kind of like running a marathon you can't train for. And so it's very rare to see somebody eating well enough to get calcium and vitamin D or exercise when they're inflamed and all of that now we know, is bad for bone.
Corinne: Absolutely. And what are the treatments that you typically recommend for osteoporosis? Do you prescribe bisphosphonates which slow the breakdown of the bone?
Dr. Sandler: So treatment always depends on the patient. It's always an individualized response. If it's someone I anticipate that will need steroids for a long time or at high dose, I would put them on a bisphosphonate early, even without getting a bone density scan because I know that the steroids will start to break the bone down. So we try to prevent the problem before it ever happens, and when they're done with the steroids, I will probably remove the bisphosphonate early. For American College of Rheumatology Guidelines in 2023 recommend preventative use of bisphosphonates in a patient who's going to be using Prednisone 30mg per day or more over a period of 30 days. Or if they're getting more than 5 grams of Prednisone or equivalent per year. So if I'm meeting someone in the office who's had seven or eight Medrol dose packs, I will seriously think about putting them on bone density medicine early because you really want to prevent that breakdown, instead of waiting for them to get to osteoporosis to treat them. Otherwise, if we're already at high risk for fracture in osteopenia, so something called the FRAX score, which is also reported on bone density is high, so a risk of fracture is high, or they're already in osteoporosis then we do recommend treatment. And now we have medicines that not only prevent the bone from breaking down, we also have bone density medicines that help build the bone back up and the duration of treatment can be short. It can be long. It can be continuous, but it really depends on what the patient needs at that point in time.
Corinne: Again, that’s really interesting. I’m so glad there's a way to help build bone back a little bit. So how important is vitamin D or calcium in the prevention of osteoporosis? Could taking supplements help prevent the disease? And what recommendations do you have for someone who is allergic to dairy (or lactose intolerant)?
Dr. Sandler: So I always tell my patients, you cannot build a house without bricks. No medicine can work if the body does not have the material to build new bone. So we humans typically need about 1200 milligrams of calcium per day. But it's important that it gets divided into small portions because we only absorb 6 to 700 milligrams of calcium at a time. So if you're going to take a supplement with 1000 milligrams of calcium, you're just going to have expensive urine with 400 milligrams of calcium in it. I still think that diet is best because man is not yet, or maybe not ever will be smarter than nature. So I really try to get my patients to get their calcium from the food. If you have a dairy allergy or intolerance, almond milk, oat milk, soy milk, calcium fortified with vitamin D in orange juice are also fine ways to get it. Some of my patients have even discovered lactose free yogurt and I really love fermented foods for my patients because they tend to have lots of probiotics and are thought to be anti-inflammatory and you would absorb the calcium better that way. I typically check vitamin D for my patients twice a year. Once in the late fall because we might need to bump it up going into winter. And once in the spring, in case we can back off of it if they're gotten enough going into summer. Typically, again for Chicago, an average person will need 3 to 4000 international units per day throughout the year to maintain their vitamin D in optimum range.
Corinne: That’s great advice. Now we talked about exercise earlier. What activities strengthen the muscles and bones to help slow the progression of osteoporosis?
Dr. Sandler: Walking is excellent. Walking with a weighted vest is better if it doesn't hurt your back.
So I tell my patients you can buy a weighted vest from one of the online retailers or wherever you like it. And if it doesn't hurt you, walking with it may actually make you a lot more efficient with weight bearing exercise. If you want the cheap option, find the old backpack in your closet and put a couple of cans of tuna or water bottles in it, and you can walk with it that way. Resistance training is a great way to keep up muscle mass and remind your bones that they have a job to do.
Corinne: How do you feel about step walking machines like those you see for use under the desk? Is that a viable option?
Dr. Sandler: Any exercise is better than no exercise, assuming it does not give you harm. So if you're walking, if you're moving, if you're causing the motion to happen, it's all a positive as far as I'm concerned. I don't have an opinion on machines that vibrate you or add pressure, because it's somebody else doing the work, and that's usually not ever proven to be helpful.
Corinne: Great information. And what precautions do you recommend as we grow older and are more prone to falls in the development of osteoporosis?
Dr. Sandler: So fall precautions, fall precautions, and more fall precautions. So unclutter the house, remove small rugs. Give away all your tchotchkes. Give away the extra chairs that are standing around for no reason. The queen is not coming for dinner. I tell all my patients to have plenty of lighting in the bathroom and the hallways that turns on automatically when it's dark and at night. I tell all my patients mark your stairs with bright tape, particularly the ones that lead to the basement if that's where your laundry is. Use a walker if anyone said use the walker, then you use the walker. Salt your driveway liberally and often, and watch the curbs after leaving the restaurant. That is how I meet my patients. They either miss the bottom step to the laundry going down carrying a basket. They slip down black ice in their driveway to get their mail. Or they missed a curb after a restaurant. So watch those things very carefully. Personally, in my practice, I refer every patient I see for osteoporosis to physical therapy, even patients who are physical therapists, I refer to physical therapy. Patients who have a personal trainer, I refer to physical therapy. Because they do an amazing job assessing your balance, working on your stability, and they teach you proper weight bearing exercises to reduce risk of fracture. Not all exercise is safe in osteoporosis, and that's their job is to see what it is you want to do, what it is you're capable of doing, especially if you have arthritis or some limitations and they give you a planned regimen, and I love that about physical therapy.
Corinne: Yes, I agree physical therapists are amazing!
Dr. Sandler: They're a joy.
Corinne: For sure. Thank you, Dr. Sandler, for being here today for such an interesting discussion about osteoporosis. I learned quite a bit. It's so important to be aware of the risks associated with osteoporosis and how to prevent the disease early on. Do you have any final comments you'd like to share with our listeners?
Dr. Sandler: Yes, please always remember you are not alone. We are here to help you. Having said that, these are also post COVID times, so wait times I'm sure you've noticed are very long for anything medical. Doctors are in short supply. Studies and tests are scheduling very far away. So I strongly tell all my patients this, call your doctor early, ask for referrals early if you think that you'll need them. If the wait times seem too long, they say “you can see the doctor in three months”, I tell my patients say “yes, thank you. I will take that visit. Please put me on your wait list if someone cancels”. Plan your travel and your social calendar and your family functions around your medical care. Don't cancel appointments. Show up and get them done. Because the wait times might even get longer before they get better. And so it's always so upsetting for a patient to miss a visit, call back and say, “OK, Now I'm ready”. But now their appointment is rescheduled 4 months down and they didn’t get their medicine refill or something else happened. So today, if you think you'll need something before the end of the year before everybody else has met their deductible or is leaving for their snowbird vacation or is going back to school, please, please schedule everything early. Your three month visit, your six month visit, your nine month visit, make sure you're picking up your medicine before it runs out. These are tough times in medicine. There are not enough of us to care for patients unfortunately. So please plan ahead, and plan early.
Corinne: That's a great reminder. Thank you for that message.
Dr. Sandler: My pleasure. But it really is sincere. I actually have my patients schedule all their visits for the rest of the year because if one gets cancelled, they at least have the next one coming up or it's a lot easier to switch them with somebody than it is to give them a new appointment if they haven't had one.
Corinne: Thank you again Dr. Sandler for our discussion today about osteoporosis and psoriasis. It’s been such a pleasure having you on Psound Bytes™. For our listeners, please share this episode link with anyone you know who may be at risk of developing osteoporosis. For more information about psoriasis and psoriatic arthritis contact our Patient Navigation Center at education@psoriasis.org. And finally, thank you for listening to Psound Bytes™!
We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.
This transcript has been created by a computer and edited by an NPF Volunteer.
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