Does This Patient Have Osteoporosis?
No, this patient does not have osteoporosis—the diagnosis is osteopenia (low bone mass). The lowest T-score is -2.2 at the left total hip, which falls in the osteopenic range (T-score between -1.0 and -2.5), not the osteoporotic range (T-score ≤ -2.5) 1, 2.
Diagnostic Criteria Applied
The diagnosis is based on the lowest T-score from any measured site, which in this case is -2.2 at the left total proximal femur 1, 2. According to WHO classification:
- Normal bone density: T-score ≥ -1.0 1, 2
- Osteopenia (low bone mass): T-score between -1.0 and -2.5 1, 2
- Osteoporosis: T-score ≤ -2.5 1, 2
- Severe osteoporosis: T-score ≤ -2.5 plus one or more fragility fractures 3
Review of All Measured Sites
The T-scores at each anatomic site confirm osteopenia without reaching the osteoporosis threshold 1:
- Left femoral neck: -1.7 (osteopenia) 1
- Right femoral neck: -1.5 (osteopenia) 1
- Left total hip: -2.2 (osteopenia, lowest score) 1
- Right total hip: -1.9 (osteopenia) 1
- Lumbar spine L1-L4: -1.1 (osteopenia) 1
Important Clinical Context
This patient has multiple significant risk factors for osteoporosis that warrant close monitoring and potential treatment consideration 1:
- Rheumatoid arthritis: A recognized medical condition that adversely affects BMD 1
- Family history: Relative with hip fracture increases fracture risk 1
- Significant weight loss: 65 pounds lost, which can accelerate bone loss 1
- Methotrexate use: Long-term medication known to adversely affect BMD 1
The FRAX score shows 12% 10-year probability of major osteoporotic fracture and 0.7% hip fracture risk, which are relatively low but should be interpreted in context of the patient's rheumatoid arthritis 1, 2.
Positive Finding: Significant BMD Improvement
The comparison to the previous scan shows substantial increases in BMD at all sites 1:
- Right hip: 8.1% increase 1
- Right femoral neck: 27.7% increase 1
- Left hip: 8% increase 1
- Left femoral neck: 23.4% increase 1
- Lumbar spine: 13.7% increase 1
These improvements exceed the least significant change thresholds reported for this facility, indicating real bone density gains rather than measurement variability 1, 2.
Treatment Considerations Despite Osteopenia Diagnosis
Although this patient does not meet the T-score criterion for osteoporosis, treatment should be strongly considered based on the following algorithm 1, 2:
High-Risk Features Present:
- Rheumatoid arthritis is an established secondary cause of osteoporosis requiring evaluation 1
- T-score approaching -2.5 at the left total hip (-2.2) 1
- Multiple risk factors including family history and significant weight loss 1
Treatment Decision Framework:
The American College of Physicians recommends making treatment decisions for osteopenic patients based on fracture risk profile, patient preferences, and medication benefits/harms 1. For this patient:
- Continue current vitamin D supplementation 1
- Ensure adequate calcium intake (>1000 mg/day) 4
- Consider pharmacologic treatment given rheumatoid arthritis and borderline T-score 1
- Discuss bisphosphonates or denosumab as first-line options if treatment is pursued 3
Monitoring Recommendations
Follow-up DXA scanning should occur in 2 years given the patient's risk factors and rheumatoid arthritis, rather than the typical 2-3 year interval 1. For patients with inflammatory arthritides or those on medications affecting BMD, annual or biennial monitoring is appropriate 1.
Important caveat: BMD should not be measured at the radius in patients with rheumatoid arthritis due to local juxta-articular bone loss that results in falsely low readings 1.
Secondary Causes Evaluation
The report correctly notes that secondary causes for bone loss should be evaluated, as the etiology of low BMD cannot be determined by BMD measurement alone 1. Given this patient's rheumatoid arthritis and methotrexate use, the low bone density is likely multifactorial 1.