Does Psoriatic Arthritis and Psoriasis Increase Risk of Fracture Development?

Psoriatic arthritis (PsA) and psoriasis are linked to an increased risk for osteoporotic fracture development, according to research published in the Annals of the Rheumatic Diseases. 

Alexis Ogdie, MD, MSCE, of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, and colleagues, conducted a population-based cohort study in patients with either PsA or psoriasis, patients with rheumatoid arthritis (RA), and unexposed controls to determine the relationship between fracture risk, osteoporosis, and PsA or psoriasis diagnosis.  

More than 168,100 patients with either PsA (n=9788) or psoriasis (n=158,323; 148,809 mild and 8514 severe), 39,306 patients with RA, and 821,834 control patients were included in the study; patient data were gathered from the UK’s The Health Improvement Network (THIN) between 1994 and 2014. Baseline demographic information is shown in Table 1. 

Table 1. Baseline Demographics UK The Health Improvement Network (THIN) 1994-2014 

	PsA	Mild Psoriasis	Severe Psoriasis	RA	Control
Participants (n)	9788	149,809	8514	39,306	821,834
Age (years; mean ±SD)	49.74±14.09	46.67±17.43	49.29±15.18	58.71±15.33	50.18±17.47
Female Sex (%)	51.38%	53.38%	52.83%	69.20%	57.12%
Cohort Time* (years; mean ±SD)	6.17±4.67	6.37±4.80	5.50±4.19	6.29±4.67	6.75±4.87
*Time from index date to end date.
PsA = psoriatic arthritis; RA = rheumatoid arthritis.

Approximately 5% of patients with psoriasis were prescribed disease-modifying antirheumatic drug (DMARD) therapy; oral corticosteroids were prescribed in 17% of patients with PsA, 9% of patients with mild psoriasis, and 21% of patients with severe psoriasis. 

Other commonly prescribed medications included proton pump inhibitors and antidepressants. Patients with either mild or severe psoriasis were more likely to be current smokers, and patients with PsA or severe psoriasis showed higher rates of heavy alcohol use.

Patients with either PsA or psoriasis experienced an elevated risk for incident fracture (hazard ratio [HR]: 1.16; 95% CI, 1.06-1.27 for PsA vs HR: 1.07; 95% CI, 1.05-1.10 for mild psoriasis vs HR: 1.26; 95% CI, 1.15-1.39 for severe psoriasis). 

Patients with mild psoriasis also had an elevated risk for hip or vertebral fracture (HR: 1.13, 95% CI, 1.04-1.22 and HR: 1.17; 95% CI, 1.03-1.33, respectively), while patients with severe psoriasis had a substantially elevated vertebral fracture risk (HR: 2.23; 95% CI, 1.54-3.22). 

Summary and Clinical Applicability

“We found patients with PsA and psoriasis had an increased prevalence of risk factors for [osteoporosis] and fracture (eg, diabetes, alcohol abuse, smoking, depression, antidepressant use, corticosteroids, methotrexate, and cyclosporin),” the researchers noted.

“Fractures, in particular ostseoporotic fractures, are a major health concern that results in poor outcomes,” the researchers concluded, adding that osteoporosis is largely underdiagnosed. “Screening and management of [osteoporosis] should still be considered for patients with psoriasis and PsA using guidelines available for the general population.”

Study Limitations