Future Fragility Fracture Linked to Rheumatoid Arthritis-Specific Risk Factors

Future major fragility fractures were associated with disease-specific risk factors among patients with early-stage RA.

Future major fragility fractures were associated with disease-specific risk factors among patients with early-stage rheumatoid arthritis (RA); utilization of a treat-to-target (T2T) strategies and restored functional capacity during early disease phases may help prevent these fractures, according to study findings published in BMC Rheumatology.

Investigators assessed the relationship between RA-associated risk factors during the first 2 years of patient follow-up and major fracture occurrence, and aimed to determine whether the effects of these fractures were independent of bone mineral density (BMD).

An observational cohort study was conducted, comprised of patients from urban and rural Sweden with newly diagnosed RA. Included patients had symptom duration of 1 year or less and were naïve to glucocorticoids and disease-modifying anti-rheumatic drugs. The main study outcome was first major fragility fracture.

A total of 2557 patients were included in the study (mean age, 58.1 years; 67% women) with a median follow-up duration of 10.3 years.

Fractures occurred among 352 (13.8%) patients, corresponding to a rate of 13/1000 patient-years during follow-up. Fractures occurred primarily in the hip (n=152), wrist (n=101), or shoulder (n=63).

The findings emphasize the importance of T2T strategy and restored function in early arthritis to reduce fracture risk.

Patients with vs without fractures tended to be older, women, and more likely to have prior fractures, hypertension, osteoporosis, and lower body mass index (BMI). Patients with fractures were more likely to be underweight at baseline while those without were more likely have a BMI of at least 30 kg/m2.

A total of 602 patients were measured for baseline BMD. Among these, a proportional risk reduction for major fragility fractures was associated with a BMI of at least 30 kg/m2 at baseline, attainment of Disease Activity Score for 28 joints (DAS28)-remission or low disease activity at month 6 of treatment initiation (sustained for up to 2 years), and Health Assessment Questionnaire (HAQ) scores of 0.5 or less (sustained for up to 2 years).

A proportional risk increase for major fragility fractures was associated with a baseline BMI of 20 kg/m2 or less, baseline, 6-month, and 1-year DAS28 scores, and cumulative DAS28 scores over 2 years; additionally, erosion score progression at 2 years, rheumatoid factor presence, HAQ score (specifically, HAQ ≥1 at 6 months and 1 year), and a trend for anti-citrullinated protein antibodies (ACPA) positivity were associated with increased risk for fracture.

Independent of disease activity, patients who used glucocorticoids (GC) had an increased estimated risk for fracture, specifically among those with higher GC-dosages at follow-up and a higher cumulative dosage over 2 years. No differences in fracture outcomes were associated with exposure to GC, following adjustment for BMD.

Effects of DAS28-remission, higher BMI, and low HAQ scores attained at 6 months following treatment initiation and sustained for up to 2 years were independent of low BMD, as were ACPA positivity, rheumatoid factor presence, and erosion score progression at 2 years.

This study was limited by its observational design and lack of baseline BMD data.

The study authors concluded, “The findings emphasize the importance of [T2T] strategy and restored function in early arthritis to reduce fracture risk.”

References:

Ajeganova S, Andersson M, Forslind K, et al. Long-term fracture risk in rheumatoid arthritis: impact of early sustained DAS28-remission and restored function, progressive erosive disease, body mass index, autoantibody positivity and glucocorticoids. a cohort study over 10 years. BMC Rheumatol. Published online August 7, 2023. doi:10.1186/s41927-023-00347-6