Impact of Rheumatoid Arthritis and Its Management on Falls, Fracture and Bone Mineral Density in UK Biobank

Abstract

Objectives: Rheumatoid arthritis (RA) is a systemic chronic inflammatory disease which presents with polyarthritis in addition to extra-articular manifestations. Historically, studies have shown a link between RA and adverse musculoskeletal outcomes but these studies were reported before the widespread use of biologic therapies. The aim of this study was therefore to investigate associations between RA, RA medications and bone mineral density, falls and fractures, using UK Biobank data. Methods: Diagnosis of RA was made using Hospital Episode Statistics (HES) ICD-10 coding. We assessed RA relationships with estimated bone mineral density (eBMD) from heel quantitative ultrasound measurements, self-reported falls (in last year) and HES recorded fracture, adjusted for age, ethnicity, BMI, smoking status, and physical activity. Results: Of 502,543 participants, 3849 (1.4%) of women and 1643 (0.7%) of men had a diagnosis of RA. Median age of the participants was 57 years (IQR 50-63) in women and 58 (IQR 50-64) in men. RA was associated with lower eBMD (men: β −0.244, 95% CI −0.378, −0.110 p < 0.001; women: β −0.217, 95% CI −0.297, −0.138 p < 0.001) a reported fall in the last year (men: OR 1.54, 95% CI 1.26, 1.87 p < 0.001; women: OR 1.36, 95% CI 1.19, 1.56 p < 0.001) and fracture in women (OR 1.76, 95% CI 1.43, 2.16 p < 0.001). Corticosteroid therapy in men (β −0.934, 95% CI −1.565, −0.304 p = 0.004) and disease modifying anti-rheumatic drug (DMARD) use in both sexes (men: β −0.437, 95% CI −0.761, −0.112 p = 0.008; women: β −0.243, 95% CI −0.421, −0.065 p = 0.007), but not biologic therapy, were associated with a lower eBMD with RA. Conclusions: RA was associated with lower eBMD, increased falls and fracture. Corticosteroid and DMARD therapy, but not biologic therapy, were associated with lower eBMD.

Bone Loss, Osteoporosis, and Fractures in Patients with Rheumatoid Arthritis: A Review

“…It was expected to find the same risk factors for a fracture in the RA population and the general population. Patients with incident vertebral deformities or peripheral fractures are significantly older [ 16 , 22 ], had lower BMD, higher disability and more often a previous fracture and a higher cumulative steroid [ 11 , 15 , 20 ], frequent falls [ 35 ], low body mass index (BMI), alcohol abuse, smoking [ 28 ], risk factors resulting from the disease itself such as the intensity of the inflammation and disability [ 29 , 36 , 40 ], duration of the disease [ 1 , 37 ], and cachexia [ 18 ].…”

“…The DMARDs reduce the inflammation and by the way are associated with a reduced bone loss in RA patients [ 40 ]. In some studies, BMD is decreased in RA according to corticosteroid usage, especially at the lumbar spine in both females and males with RA, and in those who are current users of steroids [ 1 , 9 , 11 ] with an increased risk of fracture [ 21 ].…”

“…During the last three decades, many studies have shown that besides the joint inflammation and destruction, bone mass in patients with rheumatoid arthritis (RA) is lower than in the matched non-RA population [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ] and the risk of osteoporosis is increased [ 8 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. Similarly, the incidence of osteoporotic fractures is high [ 6 , 11 , 12 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ] even when compared to the general population of the same age and sex [ 5 , 9 , 15 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 ]. Osteoporosis-related fragility fractures represent one of the most severe complications in RA patien...…”

Rheumatoid arthritis and bone health

“…DMARDS and biologics have not been convincingly associated with bone loss and increased fracture risk, over and above that due to the RA itself. 9 In contrast, oral and parenteral corticosteroids have been clearly shown to rapidly increase fracture risk. The relationship appears continuous such that there is no safe lower dose of corticosteroid below which fracture risk is not increased.…”

Translating the Strengthening and Stretching for Rheumatoid Arthritis of the Hand Programme from clinical trial to clinical practice: An effectiveness–implementation study

“…It affects 1.4% of women and 0.7% of men in the UK. 1 RA commonly affects the hands and manifests as pain, swelling, stiffness and muscle weakness resulting in difficulty with everyday tasks and affecting quality of life. [2][3][4] The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme is a tailored and progressive 12-week exercise programme designed to improve hand function in people with RA affecting their hands and wrists.…”