BOSTON, Massachusetts—The management of osteoporosis in rheumatoid arthritis (RA) patients is improving (at least in one large academic practice), according to a new study in the December 15 issue of Arthritis Care & Research,¹ but much remains to be done. Daniel H. Solomon, MD, MPH, an associate physician at Brigham and Women's Hospital, in Boston, Massachusetts, compared results of a 2004 chart review to those from a similar review conducted in 1999.

"This appears to be a modest improvement over results from 5 years ago," Dr. Solomon writes.

Chart review of 193 RA patients

The researchers reviewed the records for 193 RA patients, 99 (51%) of whom had not used glucocorticoids in the prior 2 years, and 94 of whom had used the therapy. The investigators defined osteoporosis management as having undergone a bone mineral density (BMD) test or received osteoporosis medications during the prior 24 months. Since RA itself is a risk factor for osteoporosis, patients who were not taking steroids were also included in the study.

Slightly less than half of these RA patients (48%) had received a bone mineral density (BMD) test or medication for osteoporosis in the preceding 24 months. Osteoporosis care was more commonly undertaken for RA patients who had used steroids than for those who had not (64% of patients taking >e;5 mg prednisone for >e;3 months versus 38% of patients not taking steroids, P = .002).

This is an improvement over the 1999 study, which found osteoporosis management for only 51% of RA patients who were taking steroids versus 64% in the current study.² The 13% difference between 1999 and 2004 is not statistically significant, which Dr. Solomon explains is partly because so few patients in the recent study had taken >e;5 mg prednisone for >e;3 months. Comparing the 1999 and 2004 cohorts was also complicated by differences in inclusion criteria. For example, patients were required to have paid one visit to a rheumatologist in 1999, compared with the two visits required in 2004.

Gender, age 50–64, RA duration, prior fractures increase chance for osteoporosis care

Osteoporosis management was more common in women than in men in the 2004 cohort. Patients aged 50–64 were more likely to have received osteoporosis management than their older or younger counter parts (P <.001). Patients who had RA for longer periods of time and those with more comorbid conditions were also more likely to undergo BMD testing or to receive medication, the study showed. 

RA patients with a prior fracture or diagnosis of osteoporosis were much more likely to have received management, the study showed (P <.001). Patients taking higher doses of glucocorticoids were also more likely to receive osteoporosis management.

Why the modest increase?

Dr. Solomon attributes the improvements seen between 1999 and 2004 to several factors, including the American College of Rheumatology's recommendations for the treatment of glucocorticoid-induced osteoporosis published in 2001, generally increased physician and/or patient awareness of osteoporosis, and trials demonstrating the efficacy of bisphosphonates in treating glucocorticoid-induced osteoporosis. He notes that several new doctors joined the practice in the years between the two studies, which also might have contributed to the change.

Some improvement, but more needed

Ethel S. Siris, MD, the Madeline C. Stabile Professor of Clinical Medicine and director of the Toni Stabile Osteoporosis Center at Columbia University Medical Center in New York City, is not certain that the new findings can be generalized to private practices across the map. "Maybe this study suggests that things are getting better, but I am not sure if you look at practices in the middle of the country that we will find such a suggestion of improvements," she told CIAOMed.

"At least in some places more people are being evaluated and treated for glucocorticoid-induced osteoporosis. It is still inadequate, with some evidence of improvement, and we must continue to educate and work with rheumatologists to encourage them to follow the ACR guidelines on BMD testing, to appropriately manage RA patients who go on steroids, and to pay attention to the fact that RA is a risk factor for osteoporosis," Dr. Siris said.  "A lot more has to happen before we can say we adequately take care of these RA patients who are at risk for fracture."

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References

1. Solomon DH,  Katz JN, Cabral D, et al. Osteoporosis management in patients with rheumatoid arthritis: evidence for improvement. Arthritis Care Res. 2006;55:873–877.
2. Solomon DH, Katz JN, Jacobs JP, et al. Management of glucocorticoid-induced osteoporosis in patients with rheumatoid arthritis: rates and predictors of care in an academic rheumatology practice. Arthritis Rheum. 2002;46:3136–3142.