A 52-year-old woman with known rheumatoid factor-positive rheumatoid arthritis comes to the physician for routine follow-up. She currently takes 7.5 mg methotrexate weekly with good response. She has minimal morning stiffness and good exercise tolerance. The patient's last flare 2 years ago was treated with a short course of prednisone. Her other medications include folic acid daily and naproxen occasionally for joint pain. She has a 30-pack-year smoking history. There is no family history of cancer or heart disease. Her blood pressure is 133/82 mm Hg and pulse is 75/min. Her BMI is 18 kg/m². There are mild deformities affecting small joints of both hands with no active synovitis. Lungs are clear to auscultation. Abdominal examination shows no organomegaly. There are no skin rashes. Laboratory results are as follows: Liver function tests are within normal limits. Which of the following is the best next step in management of this patient?

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11ec193a_9930_26f4_853d_3b294f46b400_MD0002_00 This patient has risk factors for osteoporosis, including rheumatoid arthritis, current smoking, and low body weight. The appropriate age to begin osteoporosis screening is 65. However, most guidelines recommend that testing should begin earlier if the patient has 1 or more risk factors for osteoporosis. Bone mineral density (BMD) testing, in conjunction with fracture risk assessment, is recommended for osteoporosis screening. Dual-energy x-ray absorptiometry (DXA) is the most widely used technique to assess BMD and predict osteoporotic fracture. Hip DXA can accurately predict hip fracture risk, but the lumbar spine is the best location for monitoring as it has less variability and shows earlier response to therapy than the hip. Osteoporosis screening of high-risk women < age 65 may lead to earlier medical therapy and improved fracture risk/outcomes. Testing can be repeated every 2 years if the risk factors persist. (Choices B and D) Anti-TNF antagonists have been associated with development of heart failure and can also increase the risk of reactivation tuberculosis. As a result, patients require tuberculin skin testing and assessment of left ventricular ejection prior to starting therapy. However, this patient appears stable on methotrexate and does not need anti-TNF therapy at this time. (Choice C) N-telopeptide is a bone turnover marker reflecting bone resorption and formation. However, these markers can sometimes be elevated in normal subjects and are generally not used to decide for/against BMD testing. N-telopeptide can be used for assessing treatment efficacy earlier than the next BMD testing, which is often years later. (Choice E) Methotrexate therapy requires monitoring with serum creatinine and CBC to evaluate for renal toxicity and bone marrow suppression. Urine microalbumin excretion is not necessary in this patient with a normal creatinine. Educational objective: The appropriate age to begin osteoporosis screening is 65. However, most guidelines recommend that testing should begin earlier if the patient has 1 or more risk factors for osteoporosis. Bone mineral density testing with dual-energy x-ray absorptiometry is the most widely used technique. __________ References: Screening for osteoporosis: U.S. preventive services task force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/21242341) Population screening for osteoporosis risk: a randomised control trial of medication use and fracture risk. (http://www.ncbi.nlm.nih.gov/pubmed/19565176)

A 52-Year-Old Woman with Known Rheumatoid Factor-Positive Rheumatoid Arthritis Comes