Menopause and glucocorticoid use can put rheumatoid arthritis patients at risk of osteoporosis, and doctors need to keep in mind the particular needs of these patients when assessing and treating the disease, according to a January talk at the American College of Rheumatology Winter Symposium in Snowmass, Colorado.
Osteoporosis is undertreated generally, with only half of patients who qualify for a diagnosis receiving treatment, said Nancy Lane, M.D., a professor of medicine, rheumatology and aging research at the UC Davis Health System.
Rheumatoid arthritis, as an inflammatory illness, puts patients both at risk for localized and generalized bone loss, Dr. Lane told Rheumatology Network. Meanwhile, most rheumatoid arthritis patients are post-menopausal, compounding the risk.
“Patients with rheumatoid arthritis who are menopausal should be evaluated,” Dr. Lane said. “Their bone mass should be evaluated and treated if, one, they have osteoporosis defined by the T score of less than minus 2.5 at the spine or the time, or two, if they have low bone mass or osteopenia plus a risk factor.”
The algorithm used to determine the latter condition is FRAX, a World Health Organization tool that combines bone mineral density measurements with risk factors to determine the probability of a fracture in the next 10 years. If the risk is 20 percent or more for major osteoporotic fracture, or 3 percent or more for hip fracture, treatment is necessary, Lane said.
But there are particular considerations for patients with rheumatologic illness. Any patient on a bone-active agent can’t be assessed using FRAX, Dr. Lane said.
The first line of prevention against bone loss in rheumatology patients is the same as it is for anyone, Dr. Lane said: Calcium, vitamin D and exercise. For treatment, biphosphonates and other standards are generally safe for patients with rheumatologic illness, Lane said, though there is a theoretical risk if using TNF blockers and the monoclonal antibody denosumab at the same time.
“When I have treated patients with both compounds, I have not seen an increased risk of infection or loss of efficacy in either one,” Dr. Lane said. “But that is something to be a little concerned about.”
Glucocorticoid treatments may put rheumatology patients at increased risk of glucocorticoid-induced osteoporosis. The American College of Rheumatology has commissioned a Group Reading Assessment and Diagnostic Evaluation (GRADE) assessment, currently in progress, to develop new guidelines for preventing and treating osteoporosis caused by glucocorticoid drugs, Lane said. The results should be out for review by this summer.
“I am optimistic that the new set of revised guidelines will be very useful for clinicians and patients to improve bone health,” Dr. Lane said.