Bone Density Assessment and Management in Inflammatory Arthritis

Initial Diagnostic Evaluation

The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis recommends performing DXA at diagnosis of inflammatory arthritis at the lumbar spine and total hip for all adult patients, with additional forearm measurement in rheumatoid arthritis patients 1, 2
Use T-score < -2.5 to diagnose osteoporosis in patients over 50 years old, and Z-score < -2.0 to define "low bone mass" in patients under 50 years 3
Measure serum calcium and 25(OH) vitamin D levels at baseline in all patients with active inflammatory disease, and check for vitamin D deficiency 4

Calculate FRAX score with femoral neck BMD to estimate 10-year fracture probability in adults ≥ 40 years, and consider glucocorticoid use and other risk factors 5, 6
Very high fracture risk is defined as: prior osteoporotic fracture(s), BMD T-score ≤ -3.5, FRAX 10-year major osteoporotic fracture ≥ 30% or hip ≥ 4.5%, or high-dose glucocorticoids (≥ 30 mg/day for > 30 days) 6

Repeat DXA testing every 1-3 years in adults < 40 years with high-risk factors, and every 2-3 years in adults ≥ 40 years whether treated or untreated 5
Perform clinical fracture risk reassessment every 12 months, including glucocorticoid dose, falls assessment, new fractures, height measurement, and muscle strength testing 5, 6

All patients should receive universal interventions, including calcium 1,000-1,200 mg/day, vitamin D 600-800 IU/day, weight-bearing exercise, smoking cessation, and alcohol limitation 4, 5, 6
Pharmacologic treatment thresholds depend on fracture risk stratification, with very high-risk patients warranting immediate treatment with anabolic agents like teriparatide 6