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Host  0:06  
Welcome to The Expert Series, brought to you by the Lupus Foundation of America. Through The Expert Series, our health education team brings you information and education about lupus to help you live better. Thank you for tuning in to today's episode. My name is Melissa, and I'll be your host. I'm very excited to welcome Dr. Ummara Shah, who will be speaking with us today about the importance of bone health. Dr. Shah is a rheumatologist who has a special clinical interest in lupus. She is an associate professor in the Department of Medicine at the University of Rochester. She also leads clinical trials in lupus, and is involved in education of lupus patients at the University of Rochester. We're delighted to have you join us today, Dr. Shah. 

Dr. Shah  0:51  
Thank you. My pleasure for joining. And thank you very much for the invite.

Host  0:56  
Oh, thank you. We're so happy to have you. So let's just get started. I want to start with the basics. As an inflammatory disease, does lupus affect the bones? And if so, how so?

Dr. Shah  1:11  
Yes, so lupus does certainly affect the bones. You know, so as a rheumatologist, I'm a bit partial to bones, I think they're very important. And I think it's important to be vigilant about general bone health or skeletal health in general, as our bones serve a very important function. However, I think it's kind of even more important in persons with lupus, for a few reasons. One reason is that several population studies have shown that persons with lupus are at higher risk for certain disorders such as osteoporosis. And because of that disorder, they're at higher risk for fractures, particularly weight-bearing joints, such as the hips and the spine. We know that the risk of fracture in patients with lupus is about five times that of what we see in the general population. And so let me just kind of speak a little bit about you know, what is osteoporosis. So, you know, it's always helpful to kind of think about the word itself. So osteo means bone, I think in Latin, and porous or perosa sounds very similar to porous. So like, you know, it means weak bones. And this is a condition that's basically defined by low bone density. And what we know is that low bone density can actually contribute to increased risk of kind of non-chromatic fractures or what we call fragility fractures. So these are fractures that can happen with very minimal trauma that normally would not cause a bone to fracture, but because of the low bone density, you know, can result in a fracture and, and we know that fractures of the spine or the hips can actually lead to other medical problems. I also mentioned a term called osteopenia, which is basically like another it's kind of a precursor to osteoporosis. So it is weak bones, but not as weak as we see with osteoporosis. But there is also an increased risk of fracture with osteopenia.

Host  3:02  
Oh, wow, okay, so. So it sounds like bone health, obviously, is something that's very important to everyone, not just people with lupus, but but particularly for people with lupus because there is a link between osteoporosis and lupus. Can you explain that? And are there certain medications that people take for lupus that can affect their bone health?

Dr. Shah  3:25  
Yes, definitely. Absolutely. So, you know, lupus is an autoimmune inflammatory condition. And we've seen with, not just with lupus, but other inflammatory disorders, that there's direct effects of the inflammation on the bone. And so you know, normally our bone is a is a tissue that's kind of always remodeling. And what I mean by that is, bone normally kind of goes through a process where it's building and it's breaking down. But with when there's inflammation, like particularly when in lupus, when we see inflammation in the joints, it can actually affect the bone that's near the joints. And we think that the inflammation kind of has direct effects on kind of like breaking down to the middle of the bone. And that kind of leads to weakening of the bones over time. So we've we've seen that folks with lupus who have maybe high disease activity or very active lupus are kind of more prone to developing weaker bones. 

Certain times, it's like lupus is affecting the kidneys. That can actually also be a risk factor for weakening of the bones because the kidneys playing an important role in certain hormones that help maintain bone strength. Additionally, when one has a Lupus flare, you know, it can often cause a lot of pain and fatigue and when one is feeling down and having a lot of pain, and one doesn't really want to engage in physical activity. So that kind of lack of physical activity also affected raw bone health and can lead to weakening of the bone. So we'll talk about that in a little bit. 

You asked about certain medications in lupus. So, you know, oftentimes, rheumatologists will use steroids. So that's usually a medication called prednisone or medrol or solu-medrol. These medications work very well to control lupus inflammation because they work pretty quickly. They're very effective. But unfortunately, sometimes they do have a side effect where they can weaken the bones. They do that in a few ways. One is, you know, bone is made up of several minerals, particularly calcium. And so steroids can actually affect absorption of calcium in the gut. And so then the bones don't have enough building blocks to build. And then we also think that steroids kind of affect that balance of building bone breaking down bone. And they actually have an effect where the breaking down of bone is accelerated when one is on steroids.

Host  5:52  
Okay, so it sounds like people with lupus are at risk of poor bone health from both the disease itself and sometimes from the medications that they take to control the flares. And it seems like it's something that people with lupus really do need to pay attention to. 

So there's another term that I saw and reading up on bone health for this episode, and it's avascular necrosis or AVN. Can you talk a little bit about AVN and the link between AVN and lupus?

Dr. Shah  6:25  
Of course, yeah. So AVN stands for avascular necrosis. Avascular means lack of blood, necrosis means like cell death in science. So literally, what this term means is, you know, lack of blood supply and death. And so what it is, it's a condition where, sometimes certain, because of inflammation, the there's certain bones kind of like the bones that make up the hip joint, or the shoulder joint, or the knee joint commonly are affected with AVN. And what happens is for there's some sort of insult to the blood supply of these areas, and that part of the bone doesn't get enough blood supply. And so it actually dies and gets damaged. And in the early phases, this can actually be the asymptomatic, one may not really even know that this is happening. It can be, you know, not painful, but over time, because that bone isn't getting enough blood supply, it can kind of lead to, you know, collapse of that part of the bone. And that can lead to pain, particularly with weight bearing. And it can lead to kind of what we call secondary arthritis. 

And how it's linked with lupus is in a few ways. One I just talked about steroids. So we have seen that there's increased risk of AVN with steroid usage, I think sometimes the risk of this really kind of depends on the individual. And unfortunately, we don't really have ways of predicting who will develop this. But sometimes steroid use can actually lead to AVN. And another way that lupus can be linked with AVN is that that it can be a direct result of the inflammation that we see from lupus. So sometimes it's seen when someone has a lot of inflammation from lupus. In particular, it's seen when there's this other condition called antiphospholipid antibody syndrome. This is a condition that sometimes overlaps with lupus, and it's characterized by a propensity to develop blood clots. And we know that folks who have this condition overlapping with lupus, or if they have the autoimmune markers for this condition, that they might be at higher risk for developing this AVN.

Host  8:40  
Is AVN common in people with lupus or is it a less common condition?

Dr. Shah  8:46  
It's, it's, I am not exactly sure of the percentage. It's not not extremely common. I have to say that I when I do see, I think it's more common in in relation to people who are taking steroids to control their disease. I think it's less likely, you know, directly due to lupus. Usually when I see it, I think more commonly it's because it's a side effect of the steroid usage.

Host  9:13  
Okay, that makes sense. So osteoporosis and osteopenia, however, they're more common than than AVN. 

Dr. Shah  9:23  
Yeah, yeah, they're definitely more common. And, you know, they're also it's also pretty common condition in the general population. I think they say about like, 5 million Americans over the age of 50 have osteoporosis. So it's kind of like a public public health worry as well.

Host  9:43  
Yeah. Okay. So are there signs of osteoporosis and osteopenia that people can look out for? How is it diagnosed?

Dr. Shah  9:54  
Yeah, so I would say osteoporosis is considered to be like a silent disorder. And the same goes with osteopenia. There's really not any symptoms that one would experience with having these conditions really, you know, we hope to kind of diagnose osteopenia and osteoporosis and before it leads to a fracture, certainly, you know, someone has osteoporosis and they didn't know it and they had a fracture, then they would have a lot of pain from the fracture. So in that way, there are symptoms from it. But most of the time, you'd like to diagnose it before it leads to the fracture. And really, there's not any symptoms associated with it. And so what we mostly do is we there are screening tests for osteoporosis, if we think someone might be at high risk for that. There are certain imaging studies, something called a bone density test. This is kind of basically like a specialized X-ray that's done of the spine, of the lower part of the spine and the hips. And it basically gives us a score of how dense or porous the bones may be. And this is usually recommended for people over age 50. But it might be done in people younger than that, if they have other risk factors.

Host  11:08  
Okay, so if you do have these risk factors, or if you're diagnosed with osteopenia, which then--sorry, I just want to clarify osteopenia is an early form of osteoporosis, so osteopenia can lead to osteoporosis, but doesn't always. 

Dr. Shah  11:24  
That is correct. 

Host  11:24  
Yes or no? Yes. Okay. I just want to make sure that I'm getting the terms right. So if I, if I'm, you know, diagnosed with osteopenia, or even osteoporosis through a routine check, are there lifestyle changes that I can make that a person at risk of, of either osteopenia or osteoporosis can make to lower their risk and improve their bone health?

Dr. Shah  11:50  
Absolutely, there's a lot of things that one can do to kind of lower the risk of developing osteoporosis, or prevent the osteopenia from worsening. So there's certain like healthy, healthier lifestyle measures that one can do. So I think it's always best to avoid smoking cigarettes, or if one is already smoking cigarettes to think really, you know, seriously about quitting. That would not only positively impact bone health, but also a lot of other medical conditions as well. Excessive alcohol intake is actually also associated with low bone density. So kind of, you know, that's kind of something that when identified, you know, lowering alcohol intake to just the daily recommended amounts would be the best thing to do. There's some reports that excessive caffeine intake can also impact bone health negatively, because caffeine sometimes interferes with absorption of calcium. 

But one of the main ways I think that one can really improve their bone health is actually physical activity. We know that weight-bearing exercises are actually a very effective way for preventing the bones from getting weaker. And it's a really effective way for building bone density. And so really, what we recommend for physical activity is some form of weight-bearing exercise. It doesn't really have to be excessive, you know, walking counts, yoga count, you know, weightlifting, you know, even just a few pounds. And really, we've recommended about like 30 minutes a few times a week, like three to four times a week can be very effective for, you know, helping prevent worsening bone density. And not to mention, you know, a lot of other benefits as well. 

Host  13:35  
Right, so those are ways that people can help keep their bones strong. But if you are diagnosed with osteoporosis, what are then some ways to prevent the fractures and broken bones if you if you know that, that you are at risk of those fractures? And then I'll add a second question on to that, because what should you do if your doctor considers you at risk for falling? Because I would think falling is one of the major ways that people break bones.

Dr. Shah  14:06  
Yeah, yeah, definitely. Um, so I think besides being physically active, you know, bones are made up of minerals. So another aspect that's really important to bone health is actually making sure that you're getting an adequate intake of calcium, which is one of the main building blocks for bone and making sure that you have enough vitamin D, which is an a vitamin that's really important for good bone health. So there are daily recommended amounts of how much calcium you should be getting in your diet in a day. So it's anywhere from 1000 milligrams to 1200 milligrams a day. And that can either be via like food, usually it's like low-fat dairy that's high in calcium, one serving of low-fat dairy, whether that's like an ounce of cheese or yogurt has about 300 milligrams. So anywhere from about like three to four servings of something like that in a day would be really good. If if you find that maybe those foods are not something that you really liked to eat, then, you know, taking calcium supplements is also a good way to ensure that you're getting enough calcium on that your bones need. 

We also recommend good intake of vitamin D. And so normally, we recommend taking at least like 800 units of vitamin D. I often will end up checking vitamin D levels on my patients and making sure that they you know, have a normal good levels of that. 

Other things to kind of prevent falls is you know, a, you know, kind of screening for any conditions that might lead to falls. So sometimes you know, getting your eyes checked or your hearing checked, because those other senses are really important for your body to be aware of your surroundings and prevent falls. Another really helpful tip is to wear proper footwear, you know, making sure that you're not wearing high-heeled shoes, so the shoes should be like low heeled, they should have a good grip. If you live in a cold icy area like I do, during the winter time making sure that you have shoes that have, you know, non slip off holes. 

Certainly at home, there are some things that you should do to prevent any potential fall. So if you have any slippery rugs on making sure that they're kind of patted down, making sure that there's no wires that one can trip on. And that to ensure also like, you know, proper lighting, so you kind of know where you're walking.

Host  16:27  
Yeah, I would say that's important for all of us to fall down the stairs in the dark. So I want to go back to asking about the supplements. And I think I know the answer to this, because you already sort of answered it. But then I have a follow up that, you know, is it safe for people with lupus to take supplements to help prevent poor bone health. And then when choosing a supplement, is there anything that you know, people should look out for or you know, try to make sure that they're getting in a supplement?

Dr. Shah  17:01  
Yeah. So I think it's always a good idea to discuss which supplements you're taking with your physician or provider, good bone health, the supplements that we really focus on are like calcium, and vitamin D. And, you know, I think that you should always discuss with your doctor that you're taking an adequate amount of calcium and that you're not taking too much, because there are some concerns that sometimes calcium supplements have been linked to other medical problems. But for the most part, we find that an adequate intake of calcium, within the limits of the daily recommended amount is actually safe. And same goes for vitamin D, vitamin D is a fat soluble vitamin. And so usually, if you take too much of it, it can actually reach high levels, which can kind of be harmful for one's health. But this is an easily obtainable blood tests that your doctor can check to make sure that you know your levels are within a good range. But for the most part, these are very important for good bone health. And I often do recommend them to my lupus patients who are worried about, you know, low bone density, and they've been shown to be safe. 

Host  18:12  
Great, thank you. That's really helpful. So I just have one more question to ask. We've gotten so much great information. You know, you had mentioned earlier about osteoporosis as a public health issue and the recommendations for people over 50. And it is true that we tend to think of osteoporosis as a--and bone problems in general--as issues that that happened to older people. But are children and younger people with lupus also at risk for these types of diseases and poor bone health.

Dr. Shah  18:45  
Yes, absolutely. Yeah. So I mean, I think I did mention that, you know, the age 50 of the cut off. But I think with my lupus patients, I also always take it into consideration, even if they're younger than that, I think, particularly with like children and adolescents. You know, one thing to keep in mind for them is that normally, our skeletons reach their peak bone mass around late 20s and early 30s. And so really, you know, young people are...they're growing. And so I think if there's probably should be, you know, kind of more attention to this for young folks to make sure that they're getting the proper building blocks to ensure that they get, you know, peak that they reached the best peak bone density. But I would say that, you know, everything else kind of applies also to younger people to make sure that, you know, they're getting enough physical activity, enough calcium, vitamin D. If they're, you know, on certain medications for lupus, such as steroids, you know, discussing with their provider about ways to kind of prevent any sort of complications due to low bone density. 

Host  19:52  
Great, thank you. So as I said, that was my last question. We're out of time and out of questions. So I do want to thank you again, Dr. Shah for talking with us about bone health and lupus. We really appreciate you sharing your time and expertise. 

We invite those of you listening to check out past episodes of The Expert Series by visiting lupus.org/theexpertseries, where you can also subscribe to get alerts when podcasts are released. If you have lupus-related questions, you can reach out to the health education specialists by email at lupus.org/healtheducator or by phone at 1-800-558-0121. You can also find information on understanding and living with lupus at our National Resource Center on lupus at lupus.org/resources. Finally, we'd love to hear from you. If you have any questions or comments or topics that you would like to see covered, please email us at info@lupus.org Thank you and have a wonderful day

• Episode 1: Managing and Preventing Flares
• Episode 2: Financing Your Medical Care
• Episode 3: Tips for Managing Medication Side Effects
• Episode 4: Diet and Lupus: Separating Fact and Fiction
• Episode 5: Lupus and Brain Fog
• Episode 6: Lupus and Men
• Episode 7: Complementary and Alternative Medicine
• Episode 8: Clinical Trials and Lupus
• Episode 9: Lupus 101
• Episode 10: Exercise and Lupus
• Episode 11: Lupus Lab Work and Blood Tests 

• Episode 1: Skin Lupus - Beyond the Butterfly Rash  
• Episode 2: Becoming a Self-Advocate
• Episode 3: Lupus and Heart Health
• Episode 4: Lupus and the Kidneys
• Episode 5: Preparing for a Doctor's Appointment
• Episode 6: Childhood Lupus and Mental Health
• Episode 7: Vaccine Safety and Lupus
• Episode 8: 5 Common Questions About Diagnosing Lupus
• Episode 9: Planning for Pregnancy with Lupus
• Episode 10: Lupus and Eye Health

• Episode 1: Lupus Foundation of America Health Educators and Resources
• Episode 2: Fatty Acids and Lupus
• Episode 3: Mental Health and Wellness During a Time of Uncertainty
• Episode 4: Telehealth and Lupus
• Episode 5: Reproductive Health and Lupus
• Episode 6: The Impact of Racial Trauma on Mental Health
• Episode 7: Kidney Health and Lupus
• Episode 8: The Importance of Support
• Episode 9: Trust and Participation in Research
• Episode 10: Advice from the Community

• Episode 1: Lupus and Physical Activity
• Episode 2: Top Questions about Skin and Hair
• Episode 3: Managing Your Journey with Lupus Nephritis
• Episode 4: Improving Health Visits for People with Lupus
• Episode 5: Could It Be Lupus?
• Episode 6: Men’s Health and Special Considerations with Lupus
• Episode 7: Making it Work with Lupus
• Episode 8: 2021 Lupus Treatment Research Updates
• Episode 9: Lupus Myths and Realities  (podcast in Spanish)
• Episode 10: Diet, Nutrition, and Kidney Health
• Episode 11: Caring for Caregivers
• Episode 12: Winter Wellness

• Episode 1: Medication Management
• Episode 2: The heart and lupus
• Episode 3: Recursos Financieros Para Personas Hispanas/Latinas con Lupus (Financial Resources for Hispanics/Latinos with lupus)
• Episode 4: Lupus and Antiphospholipid Syndrome (APS)
• Episode 5: Self-care & self-management for people with lupus
• Episode 6: Fertility and reproductive health
• Episode 7: Participating in Clinical Trials
• Episode 8: Lupus and the Eyes
• Episode 9: Respuestas de nuestra educadora de la salud
• Episode 10: Health Disparities and Social Determinants of Health
• Episode 11: Lupus and bone health
• Episode 12: Step therapy and access to medications
• Episode 13: Remission: Can my lupus go away?

• Episode 1: Invisible symptoms of lupus
• Episode 2: Visible Symptoms of Lupus
• Episode 3: Lupus in the LGBTQ+ Communities
• Bonus Episode: The Awakening: When lupus looks like mental illness
• Episode 4: Lupus and Teens
• Episode 5: Stress and Stress Management
• Episode 6: Lupus and Cancer

• Episode 1: Lupus Nephritis
• Episode 2: Race-free eGFR Calculations and Implications for People Living With Lupus Nephritis