Osteoporosis Care for RA Patients Found Suboptimal, Declining Save

Fewer than half of rheumatoid arthritis (RA) patients at a risk of fracture sufficient to warrant guideline-recommended osteoporosis treatment received appropriate care, according to a large study of U.S. osteoarthritis (OA) and RA patients.

The study, published online in Arthritis Care & Research, found that despite a higher risk of osteoporosis and fracture, RA patients were no more likely than OA patients to be treated or screened for osteoporosis according to the management recommendations of the American College of Rheumatology (ACR) 2010 guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) or the broader guidelines of the National Osteoporosis Foundation (NOF), which target all risk groups regardless of steroid use.

"Besides this suboptimal osteoporosis care, we also showed that the relative risk of undergoing osteoporosis treatment or [bone mineral density] screening has been decreasing since 2008 in RA and OA patients," wrote Kaleb Michaud, PhD, of the University of Nebraska Medical Center in Omaha, and colleagues. They noted that RA is associated with double the risk of osteoporosis, even at younger ages, thanks to accelerated aging, hormonal changes, physical disability, and inflammation-associated osteoclast activation.

Michaud has previously reported on this continuing treatment gap despite frequent recommendations over the past two decades that rheumatologists assess bone mineral density in at-risk patients. "With reduction in steroid use, we hope to see a reduction in fracture and osteoporosis risk, but there is still an inherent increase in risk that comes from having RA," he told MedPage Today. "As in many other conditions, screening can create uncertainty about who is responsible for ensuring this screening is done -- i.e., the rheumatologist, primary care physician, or other specialist. We hope the study's findings will help in the ongoing conversation about these roles for best clinical care of patients with RA."

The observational study followed osteoporosis care in 11,669 RA and 2,829 OA patients registered in the Wichita-based National Data Bank (NDB) of Rheumatic Diseases longitudinal study during 2003-2014. The mean age and gender composition in the RA group were 59.3 years and 80.4%, respectively, and in the OA group, 65.8 years and 82.6%. In the RA group, 66.3% of the patients had used glucocorticosteroids, versus 25.7% in the OA group.

With care defined as drug therapy (excluding calcium/vitamin D) or screening (OPTS, osteoporosis treatment or screening); treatment was assessed at enrollment and every six months and included bisphosphonates, raloxifene, teriparatide, and hormone-replacement therapy. The 10-year major fracture probability was assessed by FRAX, an approach based on demographic and clinical risk factors but without reference to bone mineral density.

During a median 5.5 years of follow-up, OPTS was reported in 67.4% of RA and 64.6% of OA patients overall. But of those requiring treatment according to the ACR 2010 GIOP guidelines, only about 55% overall reported osteoporosis medication use – 48.4% of RA patients and 17.6% of OA patients.

And although at greater risk, RA patients were no more likely to undergo OPTS than OA patients were: hazard ratio of 1.04 (95% CI 0.94-1.15). Adjusted models showed a significant downward trend for OPTS after 2008 in both groups of patients. Factors associated with receiving osteoporosis care in RA patients included older age, postmenopausal status, previous fragility fracture or diagnosis of osteoporosis, any duration of glucocorticoid treatment, and biologic use.

"Despite the importance of implementing GIOP guideline recommendations, our findings suggest that focusing only on glucocorticoid-receiving RA patients would overlook nearly 1 of every 5 patients not treated with glucocorticoids but also deemed to be high-risk and for whom osteoporosis treatment would be indicated based on the 2014 NOF guideline," Michaud and colleagues wrote.

Interestingly, RA patients treated with biologic disease-modifying antirheumatic drugs (bDMARDs) were more likely to be tested for bone mineral density but not more likely to be treated for osteoporosis: "These patients might have higher disease activities and more glucocorticoid-exposure prior to bDMARDs, which may explain the better screening," the investigators wrote.

They pointed to the need to clarify patient- and provider-related factors driving suboptimal management and develop effective interventions and reduce the burden of osteoporotic fractures. "Considering the increased osteoporosis and fracture risk in RA patients regardless of glucocorticoid use, development of an RA-specific osteoporosis prevention and management guideline might be helpful in covering all high-risk groups, optimizing the care and decreasing the health impact of osteoporosis complications in RA."

Regarding study limitations, the authors cited the voluntary recruitment of patients and physicians to the NDB, and hence the potential for reduced generalizability to all RA patients owing to participation bias created by a better-educated and disease-conscious sample. Another limitation was the self-reporting of fractures and trauma, opening the door to misclassification errors. Michaud et al also cautioned that the ACR's 2010 GIOP guidelines did not cover certain glucocorticoid-using risk and age groups, and even the expanded 2017 guidelines are not as extensive as their NOF counterparts, which are applicable to all fracture risk groups beyond users of glucocorticoids.

Funding for the study was partly provided by a Rheumatology Research Foundation Investigator Award to Michaud. One of the co-authors reported receiving support from a VA Merit Award and the National Institutes of Health. No conflicts of interest were reported. 

This article originally appeared August 13, 2017 on MedPage Today.