Bones are constantly being formed and resorbed in our bodies. As we get older, our bones become less dense as formation does not keep up with loss. This can lead to osteoporosis, a condition characterized by weakened bones and a greater risk of fractures. As many as 20% of women and 5% of men older than 50 will break a bone due to osteoporosis. After menopause, women are at a higher risk of osteoporosis because they no longer produce enough estrogen to keep their bones as healthy as when they were younger. Additionally, people who take medications such as steroids for an extended period are more likely to experience bone loss.
Cristina Brunet, MD, is an associate professor of medicine (rheumatology) at Yale School of Medicine (YSM) and director of the Arthritis and Rheumatology clinic for the Yale New Haven Health Interventional Immunology Center in North Haven, Conn. She treats patients with inflammatory diseases, such as rheumatoid arthritis and lupus, and those with osteoporosis, and has a strong interest in the clinical teaching of rheumatology trainees.
How did you start your osteoporosis clinic at Yale?
Before I joined the Yale faculty, I spent ten years at a practice with my efforts divided between treating patients with rheumatic diseases and those with bone health issues. During that time, I became certified to interpret and report bone density (DXA) studies. On joining YSM, I continued to monitor and manage bone health in patients I saw in rheumatology clinics. I also designated one of my clinical sessions to evaluate and manage bone health and bone loss, which is now an osteoporosis clinic for patients with rheumatic diseases at the Yale New Haven Health Interventional Immunology Center in North Haven.
Why is it important to monitor bone health in your patients with rheumatic diseases?
Patients with inflammatory diseases, such as rheumatoid arthritis, other types of inflammatory arthritis, and lupus, often have bone loss. Rheumatologists sometimes prescribe steroids, which increase the risk of bone loss and fracture, to control inflammatory symptoms in the transition to better therapies.
As rheumatologists, we recognize this and recommend preventive strategies to minimize bone loss. We also refer our patients for DXA studies to assess their fracture risk and to inform treatment plans to prevent fractures. We naturally want to prevent fractures, to intervene before a fracture occurs.
How have you focused on bone health and osteoporosis in your clinical teaching?
I have developed a five-session program to introduce concepts of DXA interpretation and monitoring, risk factor assessment and modification, non-pharmacologic interventions including behavioral and lifestyle changes, optimizing diet and supplementation, and management of prescription therapies when needed. In the coming year, my goal is to further apply this curriculum in our rheumatology training program, making it easily accessible to our trainees.
What led you to create a bone health curriculum for rheumatology fellows?
I realized in working with our rheumatology fellows that no formal training existed for them in bone health and the management of osteoporosis. I developed a bone health curriculum because, as rheumatologists, we see patients with inflammatory arthritis and other inflammatory conditions associated with bone loss and often prescribe medications such as steroids for inflammatory symptoms, although these medications can increase fracture risk. The curriculum will teach fellows the basics of evaluating bone health and preventing and treating bone loss to reduce the risk of fracture. I hope to train our fellows to manage both the rheumatic diseases and related bone health issues in the patients for whom they will continue to care throughout their careers.
Can osteoporosis be reversed?
Bone loss is reversible in some cases. With our therapies, we hope to increase bone mass, but at a minimum, we hope to preserve bone density and prevent further bone loss.
What preventive strategies do you recommend to minimize the risk of bone loss and fracture?
It's inevitable that all of us will develop bone loss in life, which is partly due to aging and inactivity or, for women, loss of estrogen. First, we take into account multiple clinical factors that can contribute to bone loss and increased fracture risk. We also evaluate DXA to see if the patient is at risk for fracture based on bone loss or low bone density.
We formulate recommendations that include intake of calcium, supplementation of vitamin D, other minerals, and lifestyle changes, for example smoking cessation, and participation in an exercise program that's well-rounded and includes strengthening, stretching, weight-bearing, and balance work. We instruct patients in strategies to prevent falls. We consider when it's appropriate to prescribe medication to add to that program of supplementation and lifestyle changes to reduce the risk of fracture.
The Section of Rheumatology, Allergy and Immunology is dedicated to providing care for patients with rheumatic, allergic and immunologic disorders; educating future generations of thought leaders in the field; and conducting research into fundamental questions of autoimmunity and immunology. To learn more about their work, visit Rheumatology, Allergy & Immunology.