Objective: Peripheral bone mineral density (BMD) may be decreased in early rheumatoid arthritis (RA) but it is unknown whether BMD loss emerges before arthritis is clinically apparent. We aimed to study whether BMD loss occurs in patients with clinically suspect arthralgia (CSA), and whether it is associated with progression to clinical arthritis and magnetic resonance imaging (MRI)-detected subclinical inflammation.Method: Patients with CSA had arthralgia for amp;lt;1year and were at risk of progressing to RA according to their rheumatologists. At baseline, a 1.5T MRI was performed of unilateral metacarpophalangeal, wrist, and metatarsophalangeal joints, and scored on synovitis, bone marrow oedema, and tenosynovitis;. summing these features yielded the total MRI inflammation score. Digital X-ray radiogrammetry (DXR) was used to estimate BMD on two sequential conventional hand radiographs (mean interval between radiographs 4.4months). The change in BMD was studied; BMD loss was defined as a decrease of 2.5mg/cm(2)/month. Patients were followed for arthritis development for a median of 18.4months.Results: In CSA patients (n=108), change in BMD was negatively associated with age (=-0.03, p=0.007). BMD loss in CSA patients was associated with arthritis development [adjusted for age hazard ratio (HR)=6.1, 95% confidence interval (CI) 1.7 to 21.4] and was most frequently estimated in the months before clinical arthritis development. The total MRI inflammation scores were associated with the change in BMD (adjusted for age =-0.05, p=0.047). The total MRI inflammation score and BMD loss were both independently associated with arthritis development (HR=1.1, 95% CI 1.1 to 1.2, and HR=4.6, 95% CI 1.2 to 17.2, respectively).Conclusion: In CSA patients, severe BMD loss is associated with MRI-detectable subclinical inflammation and with progression to clinical arthritis.