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Logo of annrheumdAnnals of the Rheumatic DiseasesCurrent TOCInstructions for authors
Ann Rheum Dis. Dec 2002; 61(12): 1085–1089.
PMCID: PMC1753963

Clinical decision rules in rheumatoid arthritis: do they identify patients at high risk for osteoporosis? Testing clinical criteria in a population based cohort of patients with rheumatoid arthritis recruited from the Oslo Rheumatoid Arthritis Register


Background: Preliminary clinical criteria based on age, inflammation, and immobility have been proposed to identify which patients with rheumatoid arthritis (RA) should be examined by dual energy x ray absorptiometry (DXA) to diagnose osteoporosis. The three item criteria have not been evaluated in male patients with RA or in the entire female RA population.

Objectives: (1) To test the proposed criteria in a cohort of men and women thought to be representative of the entire underlying RA population. (2) To develop clinical decision rules, which could be applied to all patients with RA irrespective of corticosteroid use.

Methods: Clinical and demographic data were collected from a total of 287 representative patients with RA (235 (82%) women, 52 (18%) men, age range 25.3–73.1 years) from the Oslo RA register (completeness 85%). Bone mineral density (BMD) was measured in spine L2–4 (anterior-posterior view) and femoral neck by DXA. The criteria were applied and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

Results: Mean age (SD) for the women and men with RA was 56.8 (11.0) years and 61.5 (10.2) years; disease duration was 15.5 (9.5) years and 14.7 (8.6) years. Of the women 163 (69%) were postmenopausal. One hundred and seventeen (50%) women and 28 (54%) men fulfilled the three item criteria. For the diagnosis of osteoporosis (T score ≤-2.5) using the original three item criteria sensitivity in women and men was 74% and 67%, specificity 57% and 50%, PPV 32% and 29% and NPV 89% and 83%, and including weight and ever use of corticosteroids in a five item criteria sensitivity increased to 82% and 83%, specificity decreased to 45% and 45%, PPV was 29% and 31%, and NPV was 90% and 90% respectively.

Conclusion: The novel five item criteria (age, weight, inflammation, immobility, and ever use of corticosteroids) are a more accurate tool to identify patients with RA and osteoporosis than the original three item criteria (age, inflammation, and immobility). The clinical decision rules have an acceptable sensitivity and provide a practical tool for the doctor to identify patients with RA who should have a DXA measurement performed.

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Selected References

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  • Haugeberg G, Uhlig T, Falch JA, Halse JI, Kvien TK. Bone mineral density and frequency of osteoporosis in female patients with rheumatoid arthritis: results from 394 patients in the Oslo County Rheumatoid Arthritis register. Arthritis Rheum. 2000 Mar;43(3):522–530. [PubMed]
  • Haugeberg G, Uhlig T, Falch JA, Halse JI, Kvien TK. Reduced bone mineral density in male rheumatoid arthritis patients: frequencies and associations with demographic and disease variables in ninety-four patients in the Oslo County Rheumatoid Arthritis Register. Arthritis Rheum. 2000 Dec;43(12):2776–2784. [PubMed]
  • Gough AK, Lilley J, Eyre S, Holder RL, Emery P. Generalised bone loss in patients with early rheumatoid arthritis. Lancet. 1994 Jul 2;344(8914):23–27. [PubMed]
  • Eggelmeijer F, Papapoulos SE, van Paassen HC, Dijkmans BA, Valkema R, Westedt ML, Landman JO, Pauwels EK, Breedveld FC. Increased bone mass with pamidronate treatment in rheumatoid arthritis. Results of a three-year randomized, double-blind trial. Arthritis Rheum. 1996 Mar;39(3):396–402. [PubMed]
  • Verhoeven AC, Boers M. Limited bone loss due to corticosteroids; a systematic review of prospective studies in rheumatoid arthritis and other diseases. J Rheumatol. 1997 Aug;24(8):1495–1503. [PubMed]
  • Lems WF, Dijkmans BA. Should we look for osteoporosis in patients with rheumatoid arthritis? Ann Rheum Dis. 1998 Jun;57(6):325–327. [PMC free article] [PubMed]
  • Nolla JM, Fiter J, Gómez-Vaquero C, Alegre JJ, Valverde J, Roig-Escofet D. Value of clinical factors in selecting postmenopausal women with rheumatoid arthritis for bone densitometry. Ann Rheum Dis. 2001 Aug;60(8):799–801. [PMC free article] [PubMed]
  • Saito JK, Davis JW, Wasnich RD, Ross PD. Users of low-dose glucocorticoids have increased bone loss rates: a longitudinal study. Calcif Tissue Int. 1995 Aug;57(2):115–119. [PubMed]
  • Saag KG, Koehnke R, Caldwell JR, Brasington R, Burmeister LF, Zimmerman B, Kohler JA, Furst DE. Low dose long-term corticosteroid therapy in rheumatoid arthritis: an analysis of serious adverse events. Am J Med. 1994 Feb;96(2):115–123. [PubMed]
  • Kvien TK, Glennås A, Knudsrød OG, Smedstad LM, Mowinckel P, Førre O. The prevalence and severity of rheumatoid arthritis in Oslo. Results from a county register and a population survey. Scand J Rheumatol. 1997;26(6):412–418. [PubMed]
  • Kvien TK, Haugeberg G, Uhlig T, Falch JA, Halse JI, Lems WF, Dijkmans BA, Woolf AD. Data driven attempt to create a clinical algorithm for identification of women with rheumatoid arthritis at high risk of osteoporosis. Ann Rheum Dis. 2000 Oct;59(10):805–811. [PMC free article] [PubMed]
  • Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum. 1980 Feb;23(2):137–145. [PubMed]
  • Kroot EJ, Nieuwenhuizen MG, de Waal Malefijt MC, van Riel PL, Pasker-de Jong PC, Laan RF. Change in bone mineral density in patients with rheumatoid arthritis during the first decade of the disease. Arthritis Rheum. 2001 Jun;44(6):1254–1260. [PubMed]
  • Lydick E, Cook K, Turpin J, Melton M, Stine R, Byrnes C. Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care. 1998 Jan;4(1):37–48. [PubMed]
  • Cadarette SM, Jaglal SB, Kreiger N, McIsaac WJ, Darlington GA, Tu JV. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. CMAJ. 2000 May 2;162(9):1289–1294. [PMC free article] [PubMed]
  • Haugeberg Glenn, Ørstavik Ragnhild E, Uhlig Till, Falch Jan A, Halse Johan I, Kvien Tore K. Bone loss in patients with rheumatoid arthritis: results from a population-based cohort of 366 patients followed up for two years. Arthritis Rheum. 2002 Jul;46(7):1720–1728. [PubMed]
  • Sambrook P, Raj A, Hunter D, Naganathan V, Mason R, Robinson B. Osteoporosis with low dose corticosteroids: contribution of underlying disease effects and discriminatory ability of ultrasound versus bone densitometry. J Rheumatol. 2001 May;28(5):1063–1067. [PubMed]
  • Wolfe F, Pincus T. The level of inflammation in rheumatoid arthritis is determined early and remains stable over the longterm course of the illness. J Rheumatol. 2001 Aug;28(8):1817–1824. [PubMed]
  • Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D. Guidelines for diagnosis and management of osteoporosis. The European Foundation for Osteoporosis and Bone Disease. Osteoporos Int. 1997;7(4):390–406. [PubMed]
  • Cadarette SM, Jaglal SB, Murray TM, McIsaac WJ, Joseph L, Brown JP. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA. 2001 Jul 4;286(1):57–63. [PubMed]
  • Dargent-Molina P, Poitiers F, Bréart G. In elderly women weight is the best predictor of a very low bone mineral density: evidence from the EPIDOS study. Osteoporos Int. 2000;11(10):881–888. [PubMed]
  • Mazess RB, Barden H. Bone density of the spine and femur in adult white females. Calcif Tissue Int. 1999 Aug;65(2):91–99. [PubMed]
  • Thompson JM, Modin GW, Arnaud CD, Lane NE. Not all postmenopausal women on chronic steroid and estrogen treatment are osteoporotic: predictors of bone mineral density. Calcif Tissue Int. 1997 Nov;61(5):377–381. [PubMed]

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