What is the most appropriate screening test for a 43-year-old woman with hypertension (high blood pressure) and rheumatoid arthritis (RA), given her family history of hip fracture at a young age and normal recent mammogram and Pap smear results?

DEXA Scan is the Most Appropriate Screening Test for This Patient

The most appropriate screening test for this 43-year-old woman with rheumatoid arthritis is a dual-energy X-ray absorptiometry (DEXA) scan (option A).

Rationale for DEXA Scan Recommendation

Risk Factor Assessment

This patient has multiple significant risk factors for osteoporosis:

• Rheumatoid arthritis: A major independent risk factor for osteoporosis and fractures

  • Patients with RA have 2.25 times higher risk of bone fracture compared to those without RA 1
  • RA patients experience hip fractures at a significantly younger age (70.6 vs 76.1 years) 2

• Corticosteroid use: Even short courses for RA flares increase fracture risk

  • Glucocorticoid use is a key factor in the FRAX risk assessment tool 3

• Family history: Mother with hip fracture at age 50

  • Early parental hip fracture is a strong predictor of future fracture risk

Guideline Support

The USPSTF recommends screening for osteoporosis in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factors (B recommendation) 3, 4. This patient meets this criterion based on her multiple risk factors.

According to the ACR Appropriateness Criteria, DEXA is indicated for:

• Women with RA at any age 3
• Individuals with a history of maternal hip fracture 3
• Individuals on corticosteroid therapy 3

Why Other Options Are Not Appropriate

1. Mammogram (option B): The patient had a normal mammogram last year. According to ACR guidelines, annual screening mammography is recommended for average-risk women beginning at age 40 3. Since she had a normal mammogram last year, this is not the most urgent screening test at this time.

2. Plain radiographs of the hips (option C): Not sensitive enough for osteoporosis screening and not recommended by any guidelines for initial assessment of bone density.

3. Pap smear (option D): The patient had a normal Pap smear last year and has never had an abnormal Pap. Current guidelines do not recommend annual Pap testing, making this unnecessary at this time.

Implementation Considerations

DEXA Testing Protocol

• Measure BMD at the lumbar spine, proximal femur, and if indicated, the distal one-third radius 3
• Results will be reported as T-scores:
  • Normal: T-score > -1.0
  • Osteopenia: T-score between -1.0 and -2.4
  • Osteoporosis: T-score ≤ -2.5 3

Risk Assessment

• FRAX tool should be used to calculate the 10-year probability of major osteoporotic fracture
• Treatment is recommended when:
  • T-score ≤ -2.5, or
  • 10-year probability of hip fracture ≥ 3%, or
  • 10-year probability of major osteoporotic fracture ≥ 20% 3

Special Considerations for RA Patients

• RA patients have a higher incidence of osteoporotic fractures across all age groups and anatomic sites 5
• The risk of vertebral fractures (RR = 2.93) and hip fractures (RR = 2.41) is particularly high 1
• Fall risk is also increased in women with RA (54% vs 44% in controls), further elevating fracture risk 6
• Early intervention is critical as RA patients with hip fractures have higher complication and mortality rates 2

By identifying osteoporosis or osteopenia early through DEXA scanning, appropriate interventions can be initiated to reduce fracture risk and improve this patient's long-term morbidity, mortality, and quality of life outcomes.