Should postmenopausal women with rheumatoid arthritis who are starting corticosteroid treatment be screened for osteoporosis? A cost-effectiveness analysis

Objective. To evaluate the cost-effectiveness of different strategies for preventing corticosteroid-induced osteoporosis. Methods. Simulated cohorts of postmenopausal women with rheumatoid arthritis (RA) starting corticosteroid treatment were examined. A Markov decision analysis model was developed to compare different management strategies, including watchful waiting, screen and treat, and empirical treatment. Treatment thresholds for the screen and treat strategy were varied from bone mineral density (BMD) T scores < -1.0 to BMD T scores < -4.0. Results. Compared with a watchful waiting approach, the incremental cost-effectiveness ratio for a strategy of screen and treat with alendronate at a BMD T score of < -1.0 was $92,600 per quality-adjusted life year (QALY) gained. This result was sensitive to the cost and efficacy of osteoporosis therapy and, importantly, to the treatment threshold. At a treatment threshold of a BMD T score < -2.5, the incremental cost-effectiveness ratio of screening and treating was $76,100 per QALY. None of these results differed substantially for women taking estrogen replacement therapy. Conclusion. The incremental cost-effectiveness ratio of a strategy of screening and treating postmenopausal female RA patients with BMD T scores of < -1.0, Compared with watchful waiting, was greater than that of other well-accepted medical interventions. The cost-effectiveness ratios were more acceptable when a T score treatment threshold of < -2.5 was used. These conclusions are limited by the lack of data on fracture and treatment efficacy in corticosteroid-treated patients.