Does Psoriatic Arthritis and Psoriasis Increase Risk of Fracture Development?

X-ray image of femoral neck fracture, AP view
X-ray image of femoral neck fracture, AP view
A population-based cohort study compared patients with psoriatic arthritis, psoriasis, and rheumatoid arthritis with matched comparators to determine fracture risk associated with the conditions.

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
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
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.

High-Yield Data Summary

  • Risk for osteoporosis and fracture were elevated in patients with either psoriatic arthritis or psoriasis.

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

  • When using diagnosis codes, there is a risk for outcome misclassification
  • A secondary definition for fracture was used, requiring osteoporosis therapy to address osteoporotic fractures
  • Disease manifestations, activity, and use of biological DMARDs are not available in the THIN database
  • Researchers were unable to account for some lifestyle factors, such as immobility, or laboratory factors like vitamin D


Dr Ogdie has received support from an investigator-initiatied research grant from Pfizer, has consulted for both Novartis and Pfizer, and has received payment for continuing medical education work related to PsA. Dr Takeshita has an investigator-initiated research grant from Pfizer and has received payment for continuing medical education work related to psoriasis. Dr Gelfand has served as a consultant for Abbvie, AstraZeneca, Celgene, Coherus, Eli Lilly, Janssen Biologics (formerly Centocor), Sanofi, Merck, Novartis, Endo, Valeant, and Pfizer, has received research grants from Abbvie, Amgen, Eli Lilly, Janssen, Novartis, Regeneron, and Pfizer, and has received payment for continuing medical education work related to psoriasis.

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Ogdie A, Harter L, Shin D, et al. The risk of fracture among patients with psoriatic arthritis and psoriasis: a population-based study [published online January 16, 2017]. Ann Rheum Dis. doi: 10.1136/annrheumdis-2016-210441