Abstract

     In this chapter, we emphasize among rheumatoid arthritis (RA) patients, whom and how to screen for osteoporosis. We highlight certain modalities, advancements in technology, secondary osteoporosis workup, and laboratory testing as well as their caveats. Finally, we discuss current guidance on how to direct the laboratory and radiology testing in the context of the individual patient with RA to guide and select from the osteoporosis treatment options currently available.

Introduction

     Rheumatoid arthritis (RA) is associated with double the risk of fracture when compared to the general population [1]. Unfortunately, osteoporosis screening and treatment rates are low in RA and may be due to the lack of clear guidelines for this high-risk population [2]. In this review, we collate the existing evidence to provide an evidence-based guide to osteoporosis screening and treatment for people with RA.

     There are no RA-specific guidelines for osteoporosis screening which likely contributes to the low rates of osteoporosis screening and detection in this high-risk population [2]. To provide evidencebased screening recommendations for people with RA, we combine recommendations from the 2014 National Osteoporosis Foundation (NOF) [3] and the 2017 American College of Rheumatology (ACR) glucocorticoid-induced osteoporosis (GIOP) guidelines [4]. The 2014 NOF guideline states that adults with a diagnosis (such as RA) or taking a medication (such as glucocorticoids (GCs)) should be screened. This recommendation does not apply to healthy young males or premenopausal females without fracture history. There is an additional statement to screen post-menopausal females and males over 50 with clinical risk factors for fracture. We use this statement to base our recommendation to screen all people with RA aged 50 and above [3]. The 2017 ACR GIOP guideline recommends bone mineral density (BMD) screening for anyone 40 years and older who are taking
۲٫۵ mg prednisone equivalents per day for 3 months or longer [4]. It also provides guidance for BMD testing for people under 40 years of age with significant risk factors such as prior fracture or exposure to very high doses of GCs [4].

Conclusions

     Early case detection and screening in RA patients is critical, especially in those with high ACPA positivity, prolonged RA disease duration, significant GC exposure, or history of low trauma fracture. While there is a need for more RA-specific studies and RA-focused bone health guidelines, we advocate for the clinician to risk stratify based on existing guidelines to aid in shared decision-making with patients and choosing the appropriate osteoporosis agent for fracture prevention.